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Epidemiology of HIV in the Indianapolis Transitional Grant Area: 2015 June 2, 2016 Tammie L. Nelson, MPH, CPH

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Presentation on theme: "Epidemiology of HIV in the Indianapolis Transitional Grant Area: 2015 June 2, 2016 Tammie L. Nelson, MPH, CPH"— Presentation transcript:

1 Epidemiology of HIV in the Indianapolis Transitional Grant Area: 2015 June 2, 2016 Tammie L. Nelson, MPH, CPH TNelson@MarionHealth.org

2 Objectives To identify trends in HIV incidence, prevalence, mortality, and health outcomes within the TGA To provide the Ryan White Planning Council with information necessary for priority setting and allocation To provide Planning Council subcommittees with relevant information

3 Epidemiology

4 Epidemiology – The study of:

5 Epidemiology - Terminology Incidence New diagnoses– Annual rate of new diagnoses per 100,000 of those at risk Prevalence Existing diagnoses – The number of previously diagnosed people per 100,000 (e.g., number of TGA residents living with HIV on 12/31/2014 who were still living in the TGA on 12/31/2015) Mortality Deaths due to a specific cause – Annual rate of deaths per 100,000 Rate Ratio Comparison of rates between two or more groups

6 The Indianapolis Transitional Grant Area (TGA)

7 TGA Location & Population Ten Central Indiana counties with a 2015 estimated population of 1.86 million 1 (6% increase since 2010) 2 3

8 TGA Population Center 88% of the TGA’s population in orange 4 46% reside inside Indianapolis city limits 1

9 TGA Demographics GenderAge

10 TGA Demographics TGA Race/Ethnicity The population of Marion County is more diverse than that of the TGA overall, with 27% African American, 10% Hispanic, and nearly 3% each of Asian/PI and Other

11 HIV/AIDS Incidence

12 New DiagnosesNo.Rate [95% CI * ]2014 Rate [95% CI * ] U.S. Rate ** (2014) 5 HIV22512.1 [10.7-13.8]13.1 [11.6-14.9]13.8 AIDS1246.1 [5.1-7.3]6.8 [5.7-8.1]6.6 *95% confidence interval **Includes the TGA No significant change in HIV or AIDS incidence from 2014 to 2015 HIV/AIDS incidence in the TGA are on par with national rates

13 HIV/AIDS Incidence HIV Diagnoses and Population Estimates in the Indianapolis TGA: 1990-2015

14 HIV/AIDS Incidence HIV Diagnoses by Time to AIDS in the Indianapolis TGA: 1990-2015

15 HIV Incidence by County Marion County HIV incidence was 4.5-11 times that of TGA counties outside of Marion and Hendricks CountyNo. % of HIV in TGARate [95% CI * ] RR [95% CI * ]: to Others Marion18582.2%19.8 [17.1-22.9]7.2 [4.6-11.3] Hendricks198.4%12.0 [7.7-18.8]4.4 [2.3-8.1] Others * 219.3%2.8 [1.8-4.2]1.0 * 95% confidence interval In 2015, Hendricks County HIV incidence was at least double that of TGA counties outside of Marion and Hendricks. Many Hendricks County diagnoses can be attributed to the Indiana Department of Corrections Reception & Diagnostic Center (Intake).

16 HIV/AIDS Incidence HIV Diagnoses by Year in Marion County (IN): 1990-2015

17 HIV/AIDS Incidence HIV Diagnoses by Year in Hendricks County (IN): 1990-2015

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20 HIV Incidence by Gender No significant change by gender between 2014 to 2015 Men were diagnosed with HIV at a rate of 4.5 to 9 times that of women GenderNo. % of HIV in TGARate [95% CI * ] RR [95% CI * ]: to Female Female<35<15.6%3.4 [2.4-4.7]1.0 Male19285.3%21.2 [18.4-24.5]6.3 [4.4-9.2] Transgender<5<2.2%-- *95% confidence interval

21 HIV/AIDS Incidence HIV Diagnoses by Sex at Birth in the Indianapolis TGA: 1990-2015

22 HIV Incidence by Race/Ethnicity No significant change by race/ethnicity 2014 to 2015 African Americans and residents of Hispanic ethnicity continue to experience increased risk of HIV infection Race/ EthnicityNo. % of HIV in TGARate [95% CI * ] RR [95% CI * ]: to White Asian/PI<5<2.2%NS Black11852.4%40.4 [33.7-48.3]7.5 [5.6-10.0] Hispanic2511.1%20.6 [14.0-30.4]3.8 [2.4-6.0] Other<10<4.4%NS White7432.9%5.4 [4.3-6.7]1.0 *95% confidence interval NS = Does not meet MCPHD standards for statistical significance

23 Age (Yrs.)No.% of HIV in TGARate [95% CI * ] <15<5<2.2%NS 15-19104.4%8.2 [4.4-15.1] 20-243917.3%32.1 [23.5-43.9] 25-348738.7%32.8 [26.6-40.5] 35-443716.4%14.8 [10.7-20.4] 45-543716.4%14.4 [10.5-19.9] 55-64125.3%5.4 [3.1-9.5] 65+<5<2.2%NS *95% confidence interval NS = Does not meet MCPHD standards for statistical significance HIV Incidence by Age No significant change by age between 2014 and 2015 Young adults 20-34 continue to be at most risk of HIV, with rates at least double those of other age groups

24 HIV/AIDS Incidence HIV Diagnoses by Age at Diagnosis in the Indianapolis TGA: 2001-2015

25 HIV Incidence by Exposure Category ExposureNo. % of HIV in TGARate [95% CI * ] RR [95% CI * ]: to Heterosexual MSM ^ 14661.9%277.2 [235.8-325.8]83.6 [61.9-112.9] IDU ^ 135.5%UNK Heterosex.6025.4%3.3 [2.6-4.3]1.0 Perinatal<5<2.2%-- Not Rptd.156.4%0.8 [0.5-1.3]0.2 [0.1-0.4] ^MSM=Male-to-male sexual contact (denominator estimated) 5 6 and IDU=Injection drug use Rows may total more than actual incidence due to report of multiple categories *95% confidence interval The percentage of new HIV attributable to IDU increased from 3.7% (N=9) to 5.5% (N=13) MSM continue to bear the greatest burden of HIV

26 HIV Incidence by U.S. Nativity Status Foreign-born residents of the TGA account for an estimated 6.3% of the TGA population and experienced HIV incidence about 2.5x that of native-born residents Nativity StatusNo. % of HIV in TGARate [95% CI * ] RR [95% CI * ]: to Native Born Foreign Born2811.6%24.0 [16.6-34.7]2.5 [1.7-3.8] Native Born16468.0%9.4 [8.1-11.0]1.0 Unk/Miss3313.7%- - *95% confidence interval

27 HIV Mortality and Death

28 HIV Mortality and All Deaths of PLWH/A AreaNo.Rate [95% CI * ]2014 Rate [95% CI * ] U.S. Rate ** (2013) 7 Mortality (Marion Only) 242.6 [1.7-3.8]2.5 [1.6-3.7]- Deaths (TGA) 623.3 [2.6-4.3]3.2 [2.4-4.1]5.1 *95% confidence interval **Includes the TGA No significant change in mortality or deaths from 2014 to 2015 The death rate of PLWH/A is on par with, or lower than, the 2013 national rate

29 Death of PLWH/A (Any Cause) Deaths of Indianapolis TGA Residents Living with HIV/AIDS, Regardless of Cause of Death, by Year: 2000-2015

30 HIV Mortality Deaths of Marion County (IN) Residents with HIV as the Underlying Cause of Death, by Year: 2000-2015

31 HIV Prevalence

32 Prevalence of Diagnosed HIV/AIDS No significant change in HIV or AIDS prevalence 2014 to 2015 StatusNo.Rate [95% CI * ] U.S. Rate (2013) 5 HIV2,774149.2 [143.8-154.9]129.4 AIDS2,900156.0 [150.4-161.8]165.7 Total5,674305.2 [297.4-313.2]295.1 *95% confidence interval

33 Total HIV/AIDS Prevalence Total Estimated Prevalence of HIV/AIDS in the Indianapolis TGA, by Year: 2000-2015

34 HIV Prevalence by County CountyNo. % of HIV in TGARate [95% CI * ] RR [95% CI * ]: to Shelby Marion4,88086.0%519.7 [505.3-534.4]9.2 [6.2-13.7] Putnam661.2%175.6 [138.1-223.3]3.1 [2.0-4.9] Brown160.3%106.8 [65.8-173.5]NS Johnson1592.8%106.3 [91.0-124.1]1.9 [1.2-2.9] Hendricks1592.8%100.5 [86.1-117.4]1.8 [1.2-2.7] Hancock541.0%74.5 [57.1-97.1]NS Hamilton2254.0%72.7 [63.8-82.8]NS Morgan470.8%67.5 [50.8-89.7]NS Boone420.766.3 [49.1-89.6]NS Shelby250.4%56.2 [38.1-83.0]1.0 *95% confidence interval No significant changes between 2014 and 2015

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37 HIV Prevalence by Gender No significant change by gender between 2014 to 2015 HIV prevalence among the TGA’s men was about 4.5 times that found among women GenderNo. % of HIV in TGARate [95% CI * ] RR [95% CI * ]: to Female Female1,07018.9%112.2 [105.7-119.1]1.0 Male4,53279.9%499.0 [484.7-513.7]4.4 [4.2-4.8] MtF551.0%UNK FtM160.3%UNK *95% confidence interval

38 HIV Prevalence by Race/Ethnicity No significant change by race/ethnicity 2014 to 2015 HIV prevalence continues to be higher among racial/ethnic minorities than among Caucasians in the TGA Race/ EthnicityNo. % of HIV in TGARate [95% CI * ] RR [95% CI * ]: to White Black2,44343.1%828.9 [796.8-862.2]4.6 [4.3-4.9] Other1693.0%Approx. 440.0Approx. 2.0 Hispanic4397.7%360.4 [328.3-395.7]2.0 [1.8-2.2] Asian/PI1332.3%229.9 [194.1-272.4]1.3 [1.1-1.5] White2,49043.9%180.5 [173.5-187.7]1.0 *95% confidence interval

39 HIV Prevalence by Current Age No significant changes between 2014 and 2015 Adults over 45 Yrs. of age account for more than 55% of the TGA’s PLWH/A Age (Yrs.)No.% of HIV in TGARate [95% CI * ] <15350.6%8.8 [6.4-12.3] 15-19300.5%24.6 [17.2-35.1] 20-242254.0%185.1 [162.5-210.9] 25-341,01017.8%379.7 [357.0-403.8] 35-441,23521.8%490.8 [464.3-518.9] 45-541,85432.7%718.4 [686.5-751.7] 55-641,00217.7%398.2 [374.3-423.6] 65+2825.0%125.8 [112.0-141.4] *95% confidence interval

40 HIV Prevalence by Exposure/Risk ExposureNo. % of HIV in TGA Rate [95% CI * ] per 100,000 or per 100(%) RR [95% CI * ]: to Heterosexual MSM ^ 3,55254.2%6.74% [6.53%-6.96%]71.5 [67.5-75.7] Heterosex.1,70626.1%94.3 [89.9-98.9]1.0 IDU ^ 5979.1%UNK Perinatal641.0%-- Other150.20.8 [0.5-1.3]NS Not Rptd.6149.4%33.0 [30.5-35.7]0.4 [0.3-0.4] ^MSM=Male-to-male sexual contact (denominator estimated) 5 6 and IDU=Injection drug use Rows may total more than actual incidence due to report of multiple categories *95% confidence interval Based on CDC estimates, about 18% of MSM are HIV-positive and as many as 34% of HIV-positive MSM are unaware of their status. 8

41 HIV Prevalence by U.S. Nativity Status HIV prevalence among foreign-born TGA residents is twice that of native-born residents Nativity StatusNo. % of HIV in TGARate [95% CI * ] RR [95% CI * ]: to Native Born Foreign Born66211.8%564.1 [522.9-608.6]2.1 [1.9-2.3] Native Born4,67582.4%268.4 [260.8-276.2]1.0 Unk/Miss3375.9%- - *95% confidence interval

42 Co-morbidities

43 Foreign-Born With a risk of about 2.5 times that of native-born residents, foreign-born residents of the TGA accounted for more than 1 in 10 newly diagnosed with HIV during 2015 Similarly, at least 1 in 10 PLWH/A in the TGA are foreign- born, experiencing a prevalence that is twice as high as among the native-born Special considerations Linguistic services Health insurance Social support structure Cultural stigma/beliefs Fear

44 Aging Better therapies  Longer lives 55.4% of PLWH/A in the TGA are 45+ years of age (up from 54% last year) Special considerations 9 Weakened immune system Increased risk of adverse events and drug interactions

45 Photo credit: Jeremy Swain, Ending Homelessness in LondonEnding Homelessness in London Among PLWH/A, between 202 and 324 were homeless or insecurely housed at some point during 2015 10,11,12 Research suggests that 10%-16% of all PLWH/A in some communities are homeless at any given time 13 Special considerations Case finding Public assistance Permanent housing Priority of medical care Homelessness

46 Recent Incarceration 8% of the TGA’s PLWH/A have a history of incarceration Special considerations Employment and housing Retention in care throughout and after the transition Substance abuse Trouble navigating the health care system

47 Mental Health & Substance Abuse Approximately 2,837 PLWH/A suffer from mental health issues according to the 50% estimate found in the National HIV/AIDS Strategy 14 40% of PLWH/A are estimated to have substance abuse issues and 13% are thought to experience both substance abuse and mental health issues 14 To complicate matters… Marion County, home to 86% of the TGA’s PLWH/A, is an underserved area for mental health services (population-to-provider ratio is only about two-thirds the average mental health staffing capacity in the state) 15

48 Food Insecurity 50% of PLWH/A are thought to struggle with food insecurity Food insecurity is a risk factor for mortality among people on HAART, especially those who are underweight 16

49 Mycobacterium tuberculosis (TB) During 2015, 63 TGA residents were diagnosed with active TB, one was HIV-positive 6%-10% of active TB diagnoses are among PLWH/A 17 Conversion from latent to active TB is 10 times more likely in PLWH/A (7%-10% risk each year) 18 Everyone newly HIV diagnosed should be tested for TB right away, and PLWH/A and at risk for TB should be tested annually. 19 Special considerations Screening Diagnostic HIV-TB synergy Treatment complications

50 Viral Hepatitis Approximately 568 PLWH/A are thought to be co-infected with hepatitis B based on the 10% estimate of the U.S. Department of Health and Human Services 20 Approximately 1,418 PLWH/A are thought to be co- infected with hepatitis C based on the 25% estimate of the National Alliance of State and Territorial AIDS Directors 21 Special considerations HIV co-infection triples the risk for HCV-related liver disease which is the leading cause of non- AIDS related death among PLWH/A 22 Current guidelines call for HCV screening in all PLWH/A (annually for those at increased risk) 23

51 Chlamydia 11,581 chlamydia diagnoses were reported in the TGA during 2014, at least 129 among PLWH/A 24 The chlamydia rate among PLWH/A was 2,266 per 100,000 [95% CI: 1,910-2,686], a rate 3-4 times higher [95% CI: 3.0-4.3] than that of HIV-negative residents C hlamydia co-infection among PLWH/A is thought to be grossly underestimated – PLEASE screen, diagnose and treat PLWH/A and their partner(s) for chlamydia

52 Gonorrhea 3,695 gonorrhea diagnoses were reported in the TGA during 2014, at least 162 among PLWH/A 24 The gonorrhea rate among PLWH/A was 2,846 per 100,000 [95% CI: 2,445-3,310], a rate 12-17 times higher [95% CI: 12.5-17.1] than that of HIV-negative residents C hlamydia co-infection among PLWH/A is thought to be grossly underestimated – PLEASE screen, diagnose and treat PLWH/A and their partner(s) for chlamydia

53 Early Syphilis 202 early syphilis (primary, secondary, and early latent) diagnoses were reported in the TGA during 2014, at least 87 among PLWH/A 24 The rate of early syphilis among PLWH/A was 1,528 per 100,000 [95% CI: 1,241-1,881], a rate at least 183 times higher [95% CI: 183.1-318.7] than that of HIV-negative residents

54 More on Sexually-Transmitted Infections HIV and STIs are commonly co-morbid conditions Special concerns STDs can increase the likelihood of contracting HIV As providers to residents with the highest risk, you can: Include routine screening as a function of HIV primary care Perform risk analyses – Assess risk behaviors of your patients Perform risk reduction - Alert your patients to the risks of STDs, especially when comorbid to HIV/AIDS, and offer periodic STD testing for each of your patients Treat - Diagnose and treat patients and their partner(s) Report – Provide thorough and accurate case reporting for better modeling of risk factors

55 Measures of HIV Health Outcomes

56 HIV Treatment Cascade (AKA: Continuum of Care Developed by Dr. Edward Gardner and colleagues 25 in March 2011 Model for use in identifying unmet needs, as well as discovery of where, across the continuum of care, clients are lost to follow-up “Improving control of HIV begins with enhanced detection and linkage to care” – Gardner, et al., 2011 25 “HIV screening without linkage to care “confers little or no benefit to the patient” – Branson, et al., 2006 26

57 Benefits of Improving Linkage Into and Retention in Care Delayed linkage and poor engagement in care are associated with: 25 26 Delayed/no receipt of anti-retroviral therapy (ART) Quicker progression to AIDS Drug resistance Increased morbidity (hospitalizations, opportunistic infections, emergency department visits, etc.) Increased mortality Increased risk of HIV transmission

58 National HIV/AIDS Progress Indicators 90% of HIV-positive residents aware of their status 85% of those newly diagnosed linked to care within 30 days (HAB measure remains 90 days for now) 90% retained in care 80% suppressed viral load

59 Continuum of Care Definitions MeasureDenominatorNumerator Estimated Prevalence Estimated number of persons living with HIV on 31-Dec-2015, including those undiagnosed/unaware DiagnosedEstimated prevalenceNumber diagnosed Linked to CareNumber newly diagnosed with HIV during 2015 Number with ≥1 CD4 or viral load test within 30/90 days In CareNumber with an HIV diagnosisNumber with ≥1 CD4 or viral load test during 2015 Retained in Care Number in careNumber with ≥2 CD4 or viral load tests performed 90+ days apart during 2015 Prescribed ART Number in careNumber prescribed HIV antiretroviral therapy Suppressed Viral Load Number in care with ≥1 viral load test during 2015 Number with HIV viral load <200 copies/mL at last 2015 HIV viral load test

60 Estimated Number of Undiagnosed PLWH/A Current estimated proportion of PLWH/A while undiagnosed/unaware is 12.8% of known prevalence 27 HIV/AIDS Prevalence5,674 HIV Prevalence 2,774 AIDS Prevalence 2,900 Undiagnosed/Unaware 833 Estimated Total PLWH/A 6,507

61 Continuum of Care 90% * 84% were linked to care within 90 days of diagnosis according to the previous definition

62 Community Viral Load Geometric means were used for comparisons of viral load Geometric means are always smaller than arithmetic means because the effect of very large values is diminished Geometric means are more stable from year to year All results are based on the last reported viral load test during 2015 for all residents with ≥1 viral load test Results were standardized such that: Results reported as 0 or <20 were set to half the lower limit of detection possible for the assay used according to CDC recommendations 28

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65 Community Viral Load by Gender Number and percent with suppressed viral load (<200 copies/mL) at last CY 2015 test, by gender GenderN % at <200 copies/mL Geometric Mean Viral Load 95% Confidence Interval (GM) Male3,16584.85954-64 Female78582.07171-85 MtF Transgender4484.1*68-154 FtM Transgender1586.7*53-167 * Point estimate suppressed due to wide confidence interval

66 Community Viral Load by Race/Ethnicity Number and percent with suppressed viral load (<200 copies/mL) at last CY 2015 test, by race/ethnicity Race/EthnicityN % at <200 copies/mL Geometric Mean Viral Load 95% Confidence Interval (GM) White1,82588.14944-54 Black1,67279.28373-95 Hispanic28988.24737-61 Asian/PI10487.5*32-71 Other12083.3*41-100 * Point estimate suppressed due to wide confidence interval

67 Community Viral Load by Age Number and percent with suppressed viral load (<200 copies/mL) at last CY 2015 test, by current age (Yrs.) Current Age (Yrs.)N % at <200 copies/mL Geometric Mean Viral Load 95% Confidence Interval (GM) <152777.8*32-385 15-192580.0*28-215 20-2415865.8*122-335 25-3472173.512399-153 35-4486585.15849-68 45-541,25187.84641-52 55-6471591.03934-45 65+20594.63327-42 Unk/Miss4353.5*348-4,804 * Point estimate suppressed due to wide confidence interval

68 Community Viral Load by County Number and percent with suppressed viral load (<200 copies/mL) at last CY 2015 test, by county of residence County of ResidenceN % at <200 copies/mL Geometric Mean Viral Load 95% Confidence Interval (GM) Boone3594.33318-61 Brown13100.02119-24 Hamilton17090.03828-51 Hancock4591.13922-71 Hendricks11580.9*45-118 Johnson10788.84530-68 Marion3,38884.06257-67 Morgan3083.3*28-207 Putnam4192.74221-84 Shelby2391.3*16-101 * Point estimate suppressed due to wide confidence interval

69 Community Viral Load by RWSP Status Number and percent with suppressed viral load (<200 copies/mL) at last CY 2015 test, by Ryan White HIV Services Program enrollment status RWSP Enrollment Status: CY 2015N % at <200 copies/mL Geometric Mean Viral Load 95% Confidence Interval (GM) Not Enrolled1,48181.47666-87 Enrolled Part of the Year1,29184.46153-69 Enrolled All Year ^ 1,238 87.64842-54 * Point estimate suppressed due to wide confidence interval ^ Experienced <30 day enrollment lapse during the year of interest

70 Improving Retention in the Cascade Guidelines for Improving Entry Into and Retention in Care and Antiretroviral Adherence for Persons With HIV: Evidence-Based Recommendations From an International Association of Physicians in AIDS Care Panel 29 C LOSE MONITORING AND INDIVIDUALIZED CARE Systematic monitoring of retention in care for all PLWH/A Intensive outreach for PLWH/A who are not engaged in care within six months Use of peer or paraprofessional patient navigators Summary of recommendations included. See appendix. Full published article at: http://annals.org/article.aspx?articleid=1170890http://annals.org/article.aspx?articleid=1170890

71 Vision for the National HIV/AIDS Strategy “The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.” 14

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74 Tammie L. Nelson, MPH, CPH Epidemiologist Health & Hospital Corporation Marion County Public Health Department 3901 Meadows Drive, H108 Indianapolis, IN 46205 Office: 317-221-3556 Fax: 317-221-4404 TNelson@MarionHealth.org

75 References 1 U.S. Census Bureau. (2016). Annual estimates of the resident population: April 1, 2010 to July 1, 2015. U.S. Census Bureau, Population Division. Release dates: For the United States, regions, divisions, states, and Puerto Rico Commonwealth, December 2015; For counties and Puerto Rico municipios, March 2016. 2 U.S. Census Bureau. (2002). Time series of Indiana intercensal population estimates by county: April 1, 1990 to April 1, 2000. Table CO-EST2001-12-18. Release date April 17, 2002. 3 U.S. Census Bureau. (2011). Intercensal estimates of the resident population for counties of Indiana: April 1, 2000 to July 1, 2010. Table CO-EST00INT-01-18. 4 Glenn, R. (2011). Demographics & trends: Indianapolis, Marion County & the Indianapolis region. Department of Metropolitan Development: City of Indianapolis. 5 Centers for Disease Control and Prevention. (2015). HIV surveillance report, 2014; Vol. 26. Retrieved from http://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-us.pdf http://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-us.pdf 6 Purcell et al. (2012). Estimating the population size of MSM in the U.S. to obtain HIV and syphilis rates. Open AIDS Journal; 6(S1: M6) 98-107. 7 Centers for Disease Control and Prevention. (2015). Deaths: Final data for 2013. National Vital Statistics Report, 64(2). Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdfhttp://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf 8 Centers for Disease Control and Prevention. (2015). HIV among gay and bisexual men: Fact sheet. Retrieved from http://www.cdc.gov/hiv/risk/gender/msm/facts/http://www.cdc.gov/hiv/risk/gender/msm/facts/ 9 U.S. Department of Health and Human Services. (2013). Guidelines for the use of antiretroviral agents in HIV-1- infected adults and adolescents. Retrieved from http://aidsinfo.nih.gov/guidelineshttp://aidsinfo.nih.gov/guidelines 10 Indiana University Public Policy Institute. (2015). 2015 Point-in-time count: Many families in Indianapolis not able to find shelter. Retrieved from http://www.chipindy.org/wp-content/uploads/2013/07/HomelessCount_2015_http://www.chipindy.org/wp-content/uploads/2013/07/HomelessCount_2015_ Web.pdf

76 References 11 U.S. Department of Housing and Urban Development. (2015). HOPWA performance profile - Formula grantee: City of Indianapolis. Retrieved from https://www.hudexchange.info/resource/reportmanagement/published/HOPWA_Perf_GranteeForm_00_INDI- IN_IN_2014.pdf https://www.hudexchange.info/resource/reportmanagement/published/HOPWA_Perf_GranteeForm_00_INDI- IN_IN_2014.pdf 12 Health & Hospital Corporation. (2016). Ryan White information services enterprise (RISE). Indianapolis: Ryan White HIV Services Program, Marion County Public Health Department. 13 Shubert, G. (2012). Mobilizing knowledge: Housing is HIV prevention and care. Available from https://www.slideserve.com/sibley/mobilizing-knowledge-housing-is-hiv-prevention-and-care-summary-of- research-presented-at-the-housing-and-hiv https://www.slideserve.com/sibley/mobilizing-knowledge-housing-is-hiv-prevention-and-care-summary-of- research-presented-at-the-housing-and-hiv 14 The White House Office of National AIDS Policy. (2010). National HIV/AIDS strategy for the United States. Retrieved from http://www.cdc.gov/hiv/strategy/pdf/nhas.pdfhttp://www.cdc.gov/hiv/strategy/pdf/nhas.pdf 15 Marion County Public Health Department. (2014). Community health assessment of Marion County: 2014. Retrieved from http://health.mchd.com/http://health.mchd.com/ 16 Weiser, S. D., Fernandes, K. A., Brandson, E. K., Lima, V. D., Anema, A., Bangsberg, D. R.,... Hogg, R. S. (2009). The association between food insecurity and mortality among HIV-infected individuals on HAART. J Acquir Immune Defic Syndr, 52(3): 342-349. doi: 10.1097/QAI.0b013e3181b627c2. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3740738/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3740738/ 17 Centers for Disease Control and Prevention. (2013). Staying healthy with HIV/AIDS: Potential related health problems: Tuberculosis. Retrieved from https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv- aids/potential-related-health-problems/tuberculosis/https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv- aids/potential-related-health-problems/tuberculosis/ 18 Centers for Disease Control and Prevention. (2013). Latent tuberculosis infection: A guide for primary health care providers. Retrieved from https://www.cdc.gov/tb/publications/ltbi/pdf/targetedltbi.pdfhttps://www.cdc.gov/tb/publications/ltbi/pdf/targetedltbi.pdf 19 Centers for Disease Control and Prevention. (2016). HIV and tuberculosis. Retrieved from http://www.cdc.gov/hiv/pdf/library/factsheets/hiv-tb.pdf http://www.cdc.gov/hiv/pdf/library/factsheets/hiv-tb.pdf

77 References 20 U.S. Department of Health and Human Services. (2014). Staying healthy with HIV/AIDS: Potential related health problems: Hepatitis. Retrieved from http://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential- related-health-problems/hepatitis/http://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential- related-health-problems/hepatitis/ 21 National Alliance of State and Territorial AIDS Directors. (2011). HIV and viral hepatitis co-infection. Retrieved from http://www.nastad.org/Docs/031236_HIV%20VH%20CoInfection%20Final.pdfhttp://www.nastad.org/Docs/031236_HIV%20VH%20CoInfection%20Final.pdf 22 Centers for Disease Control and Prevention. (2014). HIV and viral hepatitis. Retrieved from http://www.cdc.gov/hiv/pdf/library_factsheets_hiv_and_viral_hepatitis.pdf http://www.cdc.gov/hiv/pdf/library_factsheets_hiv_and_viral_hepatitis.pdf 23 U.S. Department of Health & Human Services. (2015). Guidelines for the use of antiretroviral agents in HIV-1- infected adults and adolescents: Considerations for antiretroviral use in patients with coinfections. Retrieved from https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/26/hiv-hcv https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/26/hiv-hcv 24 Indiana State Department of Health. (2015). Statewide investigation, monitoring and surveillance system (SWIMSS). 25 Gardner, E.M., McLees, M.P., Steiner, J.F., del Rio, C., and Burman, W.J. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52(6): 793-800. doi: 10.1093/cid/ciq243 26 Branson, B.M., Handsfield, H.H., Lampe, M.A., Janssen, R.S., Taylor, A.W., Lyss, S.B., and Clark, J.E. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Centers for Disease Control and Prevention: Atlanta. MMWR. 2006; 55(RR14): 1-17. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm 27 Centers for Disease Control and Prevention. (2015). Prevalence of diagnosed and undiagnosed HIV infection – United States: 2008-2012. MMWR, 2015(64): 657-662. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6424a2.htm?s_cid=mm6424a2_e http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6424a2.htm?s_cid=mm6424a2_e 28 Centers for Disease Control and Prevention. (2011). Guidance on community viral load: A family of measures, definitions, and method for calculation. Retrieved from http://www.ct.gov/dph/lib/dph/aids_and_chronic/surveillance/statewide/community_viralload_guidance.pdf http://www.ct.gov/dph/lib/dph/aids_and_chronic/surveillance/statewide/community_viralload_guidance.pdf

78 References 29 Thompson, M. A., Mugavero, M. J., Amico, K. R., Cargill, V. A., Chang, L. W., Gross, R.,... Nachega, J. B. (2012). Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: Evidence-based recommendations from an international association of physicians in AIDS care panel. Ann Intern Med. 2012;156(11): 817-833. doi: 10.7326/0003-4819-156-11-201206050-00419


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