HIV Care Continuum New Diagnoses, 2011, Georgia

Persons with HIV Engaged in Selected Stages of the Continuum of Care, United States Percent Hall et al. XIX International AIDS Conference, 2012 ART, antiretroviral therapy

Care Continuum Methodology, New HIV Diagnoses 2011, Georgia Adults and adolescents are those aged >= 13 years Diagnosed between 01/01/11 -12/31/11 Alive at least 15 months after diagnosis Residence at diagnosis and current address within Georgia Excludes 52 persons deceased within 15 months of diagnosis Linked to care = CD4 or VL within 3 months of diagnosis, excluding day of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis Retained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosis Estimated percentage prescribed ART derived from the Medical Monitoring Project (MMP) Georgia sample Viral suppression (VS) = VL<200 copies/ml in most recent viral load All percentages are percent of total number of persons diagnosed with HIV

HIV Care Continuum Methodology Confirmatory Diagnosis Date Months 0-3 after diagnosis Months 4-15 after diagnosis CD4 or Viral Load This person is: Linked YES Engaged YES Retained YES Virally suppressed YES Last viral load <200 copies/ml

HIV Care Continuum Methodology HIV Confirmatory Diagnosis Date Months 0-3 after diagnosis Months 4-15 after diagnosis CD4 or Viral Load This person is Linked YES Engaged YES Retained NO Virally suppressed YES “Engaged in care” is minimal engagement that indicates the person “touched” the medical system at least once during that 12 month period Last viral load undetectable CD4 or Viral Load

HIV Care Continuum Methodology HIV Confirmatory Diagnosis Date Months 0-3 after diagnosis Months 4-15 after diagnosis CD4 or Viral Load This person is Linked NO Engaged YES Retained YES Virally suppressed NO If no viral load done, it is assumed to be not suppressed CD4 done but no viral load done

Adults and adolescents diagnosed with HIV infection, Georgia, 2011 Adults and adolescents >= age 13, diagnosed 01/01/11 -12/31/11, Georgia = 2885 Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis Retained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosis Prescribed ART derived from MMP sample Viral suppression (VS) = VL<200 copies/ml in most recent viral load = 1307 Note: all percentages are proportion of total number of persons diagnosed with HIV in category

Adults and adolescents diagnosed with HIV infection, by race/ethnicity, Georgia, 2011 Adults and adolescents >= age 13, diagnosed 01/01/ /31/11, Georgia = 2885 Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis Retained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosis Viral suppression (VS) = VL<200 copies/ml in most recent viral load American Indian/Alaska Native, Asian, and Native Hawaiian/Other Pacific Islanders combined equal <2% of new diagnoses and are included in Other/Unknown

Adult and adolescent males diagnosed with HIV infection, by race/ethnicity, Georgia, 2011 Adult and adolescent males >= age 13, diagnosed 01/01/ /31/11, Georgia = 2214 Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis Retained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosis Viral suppression (VS) = VL<200 copies/ml in most recent viral load American Indian/Alaska Native, Asian, and Native Hawaiian/Other Pacific Islanders combined equal <2% of new diagnoses and are included in Other/Unknown

Adult and adolescent females diagnosed with HIV infection, by race/ethnicity, Georgia, 2011 Adult and adolescent females >= age 13, diagnosed 01/01/ /31/11, Georgia = 655 Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis Retained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosis Viral suppression (VS) = VL<200 copies/ml in most recent viral load American Indian/Alaska Native, Asian, and Native Hawaiian/Other Pacific Islanders combined equal <2% of new diagnoses and are included in Other/Unknown

Adults and adolescents diagnosed with HIV infection, by age, Georgia, 2011 Adults and adolescents >= age 13, diagnosed 01/01/ /31011, Atlanta = 2885 Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis Retained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosis Viral suppression (VS) = VL<200 copies/ml most recent viral load Note: all percentages are percent of total number of persons diagnosed with HIV in category N=655 N=786 N=649N=537 N=258

Transmission category definitions Multiple imputation was used to re-distribute transmission category where missing MSM = Male to male sexual contact IDU = Injection drug use MSM/IDU = Male to male sexual contact and injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

Adult and adolescent males diagnosed with HIV infection, by transmission category*, Georgia, 2011 Adult and adolescent males >= age 13, diagnosed 01/01/ /31/11, Georgia = 2214 Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis Retained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosis Viral suppression (VS) = VL<200 copies/ml in most recent viral load Multiple imputation was used to re-distribute transmission category where missing *MSM = Male to male sexual contact IDU = Injection drug use MSM/IDU = Male to male sexual contact and injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

Adults and adolescent females diagnosed with HIV infection, by transmission category*, Georgia, 2011 Adults and adolescent females >= age 13, diagnosed 01/01/ /31/11, Georgia = 655 Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis Retained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosis Viral suppression (VS) = VL<200 copies/ml in most recent viral load Multiple imputation was used to re-distribute transmission category where missing *IDU = Injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified N=81 N=411N=163

Adult and adolescent Black MSM diagnosed with HIV infection, by age, Georgia, 2011 Adult and adolescent males >= age 13, diagnosed 01/01/ /31011, Georgia = 1050 Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis Retained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosis Viral suppression (VS) = VL<200 copies/ml in most recent viral load Note: all percentages are percent of total number of persons diagnosed with HIV in category

The HIV Care Continuum can help us… Focus our efforts for linkage, retention and viral suppression. Identify groups at increased risk for dropping out of each step in the continuum. Monitor our progress in improvement of linkage, retention, and viral suppression. Identify disparities not only in prevalence but in care Evaluate efforts addressing specific populations with low viral suppression. Monitor efforts in improving viral suppression in specific counties, census tracts, zip codes and some specific facilities Encourage improvement in surveillance data completeness (race, sex, transmission category)

Stage of HIV disease at diagnosis Stage at diagnosis is defined by the first CD4 done within 3 months of diagnosis Stage 1 = CD4 >=500 Stage 2 = CD Stage 3 = CD4 <200 or OI Stage at diagnosis is unknown if no CD4 done within 3 months of diagnosis

Stage of disease by earliest CD4 count within 3 months of HIV diagnosis, adults and adolescents, Georgia, 2011 Adults and adolescents >= age 13, diagnosed 1/1/ /31/2011, Georgia = 2885 CD4<200 = Stage 3 disease (AIDS) Stage unknown = no CD4 within 3 months of diagnosis N=418N=649N=561N=1257

Stage of disease by earliest CD4 count within 12 months of HIV diagnosis, adults and adolescents, Georgia, 2011 Adults and adolescents >= age 13, diagnosed 1/1/ /31/2011, Georgia = 2885 CD4<200 = Stage 3 disease (AIDS) Stage unknown = no CD4 within 12 months of diagnosis N=484 N=632N=766 N=1003

Number and proportion of adults and adolescents by stage at diagnosis by earliest CD4 count within 3 and 12 months after diagnosis, by race/ethnicity, Georgia, 2011 Race/ Ethnicity N** Stage 1 CD4>500 Stage 2 CD Stage 3 CD4 <200 Stage Unknown CD4 Missing 3 mos. N (%) 12 mos. N (%) 3 mos. N (%) 12 mos. N (%) 3 mos. N (%) 12 mos. N (%) 3 mos. N (%) 12 mos. N (%) Black (13)244 (15)359 (22)444 (27)351 (22)404 (25)704 (44)524 (32) Hispanic/ Latino (10)18 (13)39 (27)43 (30)48 (33)50 (35)42 (29)33 (23) White27150 (18)54 (20)66 (24)78 (29)68 (25)76 (28)87 (32)63 (23) Other*/ Unknown (18)168 (20)185 (22)201 (24)94 (11)102 (12)424 (50)383 (45) Adults and adolescents >= age 13, diagnosed 1/1/ /31/2011, Georgia = 2885 CD4<200 = Stage 3 disease (AIDS) Stage Unknown = no CD4 within 3 or 12 months of diagnosis *American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <2% of adults diagnosed with HIV in Georgia, 2011 and are grouped with other/unknown race/ethnicity ** N = total number in this category

Stage of disease by CD4 count within 12 months of HIV diagnosis, adults and adolescents, by race/ethnicity, Georgia 2011 Adults >= age 13, diagnosed 1/1/ /31/2011, Georgia = 2885 CD4<200 = Stage 3 disease (AIDS) Stage Unknown = no CD4 within 12 months of diagnosis *American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <2% of adults diagnosed with HIV in Georgia, 2010 and are grouped with Unknown race/ethnicity N=1616 N=144 N=271 N=854

Number and proportion of adults and adolescents by stage at diagnosis using earliest CD4 count within 3 and 12 months after diagnosis, by sex, Georgia, 2011 SexN* Stage 1 CD4>500 Stage 2 CD Stage 3 CD4 <200 Stage Unknown CD4 Missing 3 mos. N (%) 12 mos. N (%) 3 mos. N (%) 12 mos. N (%) 3 mos. N (%) 12 mos. N (%) 3 mos. N (%) 12 mos. N (%) Male (15)385 (17)497 (22)579 (26)404 (18)464 (21)978 (44)786 (36) Female65581 (12)97 (15)151 (23)186 (28)152 (23)163 (25)271 (41)209 (32) Adults and adolescents >= age 13, diagnosed 1/1/ /31/2011, Georgia = 2869 CD4<200 = Stage 3 disease (AIDS) Stage Unknown = no CD4 within 3 or 12 months of diagnosis *N = total number in this category Excludes 16 cases for which sex was not reported

Stage of disease by CD4 count within 12 months of HIV diagnosis, adults and adolescents, by sex, Georgia, 2011 Adults and adolescents >= age 13, diagnosed 1/1/ /31/2011, Georgia = 2869 Excludes 16 cases for which sex was not reported CD4<200 = Stage 3 disease (AIDS) Stage Unknown = no CD4 within 12 months of diagnosis N=2214 N=655

Number and proportion of adult and adolescent males by stage at diagnosis by earliest CD4 count within 3 and 12 months after diagnosis, by transmission category*, Georgia, 2011 Trans- mission category N** Stage 1 CD4>500 Stage 2 CD Stage 3 CD4 <200 Stage Unknown CD4 Missing 3 mos. N (%) 12 mos. N (%) 3 mos. N (%) 12 mos. N (%) 3 mos. N (%) 12 mos. N (%) 3 mos. N (%) 12 mos. N (%) MSM (13)222 (16)319 (23)388 (28)267 (19)318 (23)616 (44)458 (33) IDU686 (9)7 (10)12 (18)15 (22)30 (44)31 (46)20 (29)16 (24) MSM/IDU367 (19) 8 (22) 9 (25)14 (39)12 (33) HET10110 (10)12 (12)20 (20)22 (22)44 (44)46 (46)27 (27)22 (22) Other (21)137 (22)138 (22)147 (24)56 (9)60 (10)301 (48)279 (45) Adult and adolescents males >= age 13, diagnosed 1/1/ /31/2011, Georgia = 2214 CD4<200 = Stage 3 disease (AIDS) Stage Unknown = no CD4 within 3 or 12 months of diagnosis Multiple imputation used to re-distribute transmission category where missing *MSM = Male to male sexual contact IDU = Injection drug use MSM/IDU = Male to male sexual contact and injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified **N = total number in this category

Stage of disease by earliest CD4 count within 12 months of HIV diagnosis, adult and adolescent males, by transmission category*, Georgia, 2011 Adults and adolescent males >= age 13, diagnosed 1/1/ /31/2011, Georgia = 2214 CD4<200 = Stage 3 disease (AIDS) Stage Unknown = no CD4 within 12 months of diagnosis Multiple imputation used to re-distribute transmission category where missing *MSM = Male to male sexual contact IDU = Injection drug use MSM/IDU = Male to male sexual contact and injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified N=1386 N=68 N=36

Number and proportion of adult and adolescent females by stage at diagnosis using earliest CD4 count within 3 and 12 months after diagnosis, by transmission category*, Georgia, 2011 SexN** Stage 1 CD4>500 Stage 2 CD Stage 3 CD4 <200 Stage Unknown CD4 Missing 3 mos. N (%) 12 mos. N (%) 3 mos. N (%) 12 mos. N (%) 3 mos. N (%) 12 mos. N (%) 3 mos. N (%) 12 mos. N (%) IDU8110 (12)13 (16)18 (22)21 (26)25 (31)27 (33)28 (35)20 (25) HET41152 (13)61 (15)102 (25)128 (31)107 (26)116 (28)150 (36)106 (26) Other16319 (12)23 (14)31 (19)37 (23)20 (12) 93 (57)83 (51) Adult and adolescent females >= age 13, diagnosed 1/1/ /31/2011, Georgia = 655 CD4<200 = Stage 3 disease (AIDS) Stage Unknown = no CD4 within 3 or 12 months of diagnosis Multiple imputation used to re-distribute transmission category where missing *IDU = Injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified **N = total number in this category

Stage of disease by CD4 count within 12 months of HIV diagnosis, adult and adolescent females, by transmission category*, Georgia, 2011 Adult and adolescent females >= age 13, diagnosed 1/1/ /31/2011, Georgia = 655 CD4<200 = Stage 3 disease (AIDS) Stage Unknown = no CD4 within 12 months of diagnosis Multiple imputation used to re-distribute transmission category where missing *IDU = Injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified N=81 N=163 N=411

Limitations Incomplete reporting Missing data for race/ethnicity, sex, and complete address at diagnosis Lack of transmission category information Estimation using multiple imputation to redistribute risk when missing Definition of heterosexual transmission (sexual contact with a known HIV infected partner or person with increased risk, i.e., MSM or IDU) Missing laboratory reports CD4 within 3 and 12 months of diagnosis yields high unknown stage in Georgia

Uncertainties Populations for which data are missing may be fundamentally different How to obtain data for transgender category How to improve completeness of reporting Data on ART use Understanding barriers to ART adherence Prioritizing further research

Viral suppression on most recent viral load, by stage of disease at or within 3 months of HIV diagnosis, adults and adolescents, Georgia, 2011 Adults and adolescents >= age 13, diagnosed 1/1/ /31/2011, Georgia = 2885 CD4<200 = Stage 3 disease (AIDS) Stage unknown = no CD4 within 3 months of diagnosis N=418N=649 N=561 N=1257

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