1. Impact of Age and Race on New HIV Infections among Men who have Sex with Men in Los Angeles County 2008-2010 Shoshanna Nakelsky, MPH Division of HIV and STD Programs Los Angeles County Department of Public Health 1

2. Overview Background –LAC Population –MSM –HIV Incidence Surveillance System Methods Results –New HIV cases diagnosed –HIV incidence estimates for young MSM Conclusions 2

3. Most populous county in U.S. – nearly 10M Area: 4,000 square miles City of LA (4M) plus 88 incorporated cities and unincorporated areas One of the most racially and ethnically diverse areas in U.S. Urban, suburban, and rural areas Los Angeles County 3

4. 2013 Estimated Number of Persons Living with HIV in Los Angeles County (LAC) (1) Estimate that 18.1% of HIV+ in LA County are unaware of their infection; from CDC estimate. (2) Of 4,200 notifications pending investigation, estimate about 2,000 who have detectable VL or confirmatory test to be unduplicated cases. Estimated ~ 58,000 living with HIV in LAC 45,500 10,500 2,000 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. 4

5. New HIV Diagnoses By Gender LAC, 2010 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. 5

6. New HIV Diagnoses by Age Group LAC, 2010 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. Age Group (years) 6

7. New HIV Diagnoses by Race/Ethnicity LAC, 2010 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. Race/Ethnicity 7

8. Mode of Transmission among Newly Diagnosed Cases, LAC 2010 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. MSM = Men who have sex with men; IDU = Injection drug use HET = heterosexual transmission risk 8

9. New HIV Diagnoses among MSM by Age Group, LAC 2010 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. Age Group (years) 9

10. Proportion of Young MSM (18-29 years) by Race, LAC 2010 BlackLatinoWhiteOther Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. 10

11. 11 HIV Incidence Surveillance (HIS) National effort developed and funded by the Centers for Disease Control and Prevention (CDC) Provides first reliable and scientifically valid estimates of newly acquired infections Estimates HIV incidence for those who: Test Early Test Late Never Test

12. 12 HIV Incidence Surveillance (2) Estimates the number and rate of new HIV infections Improves ability to allocate resources for prevention and care

13. Methods: Analysis Population Eligibility for inclusion in the estimation process: –Resided in LAC at the time of HIV diagnosis –Diagnosed in 2008-2010 –18-29 years of age –Male –Sex with males as a risk factor 13

14. Data Sources: Enhanced HIV/AIDS Reporting System (EHARS) Demographic Data –Age –Race/ethnicity –Mode of transmission –HIV/AIDS Diagnosis Data –HIV diagnosis date –AIDS diagnosis date –Proportion of cases diagnosed with AIDS within 6 months of HIV diagnosis (late detection) 14

15. –Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS) –HIV testing and treatment history History of previous negative test results Date of most recent negative test result Time between last negative and first positive test Data Sources: HIV Incidence Surveillance 15

16. Methods Rates calculated using: –Denominators for rates assumed 8.2% of males aged 18-29 years were MSM* –California State Department of Finance population estimates Lieb, 2011 16

17. Results: 2010 HIV Incidence Estimates 17

18. Rates and 95% CI of new HIV Infection among MSM by Age Group, LAC 2010 Rate per 1,000 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. Age Group 18

19. Proportion of Estimated HIV Infections in MSM aged 18-29 years by Race, LAC 2010 Black Latino White Other Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. 19

20. Estimated HIV Incidence Rates and 95% CI for YMSM age 18-29 years by Race, LAC 2010 Rate per 1,000 Race/Ethnicity Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. 20

21. Results: Combined Year HIV Incidence Estimates 21

22. Rate and 95% CI of new HIV Infection by Age Group, LAC 2008-2010 Rate per 1,000 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. Age Group 22

23. Rate of New HIV Infection among Young MSM by Race/Ethnicity and Age Group, 2008-2010 Rate per 1,000 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. Age Group (years) * *Rate for black MSM significantly different from other MSM. 23

24. Rate of new HIV Infection among Young MSM by Race/Ethnicity and Age Group, 2008-2010 Rate per 1,000 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. Age Group (years) * *Rate for black MSM significantly different from other MSM. 24

25. Key Findings In LAC, the rate of incidence among 13-17 year old MSM is low compared with 18-29 year old MSM. HIV incidence estimates confirm that MSM ages 18- 29 years are at the highest risk for new HIV infections The magnitude of the racial/ethnic disparity for young Black MSM compared with Whites and Latinos is largest for 18-24 year olds 25

26. Discussion 26

27. Possible Reasons for Increased Risk Among Black YMSM –Age of sexual debut –Increased partner age –Most likely to have Black partners –Decreased engagement in HIV care Undiagnosed HIV Infection Late Detection Less Retention in Care Less Viral Load Suppression Millett et al, 2012 27

28. Linkage to Care* Among MSM Reported with HIV, by Race/Ethnicity, LAC 2010 *Linked to care <3 months of diagnosis MSM diagnosed in 2010. ** Number of people diagnosed with HIV from 1/1/2010-12/31/2010 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. Age Group N=454**N=743** 28 % of cases

29. Viral Load Suppression* Among MSM Living with HIV Race/Ethnicity, LAC 2010 *Viral load suppression defined as VL <200. ** Number of people living with HIV at the end of 12/31/2010 Age Group Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012. N=1,111**N=15,638** 29 % of cases

30. Limitations Missing Data –Variation by Race/Ethnicity –Assumptions of Multiple Imputation Technique Sample Size Assumptions of Incidence Methodology –No Change in Testing Behavior 30

31. Conclusions The risk of new HIV infection among YMSM varies by both age and race/ethnicity Black MSM are at an increased risk of new HIV infection across age groups Black MSM, age 18-24 years, show most dramatic disparity in risk compared with Latino and White peers 31

32. Conclusions (cont’d) Research is needed to better understand contributing factors. Retention in care Quality of care Adherence to antiretroviral therapy 31

33. Acknowledgements Los Angeles County HIV Incidence Surveillance Team Trista Bingham, PhD Deanna Lewis Randi Kendrick Core HIV Surveillance Douglas Frye, MD Yunyin Hu Long Beach Health Department Pasadena Health Department Centers for Disease Control and Prevention 32

34. Thank You! For more information contact: Shoshanna Nakelsky HIV Incidence Surveillance Coordinator snakelsky@ph.lacounty.gov 213.351.8154 32