1. HIV Care Continuum, Georgia, United States, 2011 Presented to American Public Health Association, Annual Meeting Presented by Deepali Rane, MBBS, MPH, Epidemiologist Date: 4 th November, 2013

2. Presenter Disclosures Deepali Rane “No Relationships to Disclose”

3. Outline Overview of HIV statistics Georgia statewide Define and describe the HIV care continuum methodology Describe the HIV care continuum for persons living with and new diagnoses of HIV infection Discuss the HIV care continuum in Georgia by demographic characteristics and transmission category

4. Epidemic of HIV infection, Georgia, 1995 to 2011 Late testers=Persons diagnosed with stage 3, AIDS within one year of HIV diagnosis

5. WHAT IS THE HIV CARE CONTINUUM ?

6. Georgia Care Continuum Methodology, Persons Living With HIV infection (PLWH), 2011 Adults and adolescents are those aged >= 13 years Diagnosed by 09/30/2011 (Western Blot or Viral Load [VL]), including those missing race, sex, and/or transmission category Living as of 12/31/2012 Current address within Georgia Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml in most recent VL All percentages are percent of total number of persons diagnosed with HIV

7. Adults and adolescents living with HIV infection, Georgia, 2011 Adults and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 46,495 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml Note: All percentages are proportion of total number of persons living with HIV infection

8. Adults and adolescents living with HIV, by sex, Georgia, 2011 Adults and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012 Georgia = 46,495 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml Excludes 270 cases for whom sex was not reported Note: All percentages are proportion of total number of persons living with HIV infection in each category

9. Adults and adolescents living with HIV, by race/ethnicity, Georgia, 2011 Adults and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 46,495 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml *American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <2% of adults living with HIV in Georgia and are grouped with those of mixed or unknown race/ethnicity Note: All percentages are proportion of total number of persons living with HIV infection in each category

10. Adults and adolescents living with HIV infection by current age (years), Georgia, 2011 Adults and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 46,495 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml Note: All percentages are proportion of total number of persons living with HIV infection in each category

11. 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

12. Adult and adolescent males living with HIV, by transmission category*, Georgia, 2011 Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 34,510 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml *Multiple imputation is used to estimate number of persons in each transmission category. Note: All percentages are proportion of total number of persons living with HIV infection in each category

13. Adult and adolescent females living with HIV, by transmission category*, Georgia, 2011 Adult and adolescent females >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 11,715 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml *Multiple imputation is used to estimate number of persons in each transmission category Note: All percentages are proportion of total number of persons living with HIV infection in each category

14. Georgia Care Continuum Methodology, New Diagnoses of HIV infection, Georgia, 2011 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 date 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 All percentages are percent of total number of persons diagnosed with HIV

15. 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

16. Adults and adolescents diagnosed with HIV infection, Georgia, 2011 Adults and adolescents >= age 13, diagnosed 01/01/11 -12/31/11, Georgia = 2,885 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 = 1307 Note: All percentages are proportion of total number of persons diagnosed with HIV

17. Adults and adolescents diagnosed with HIV infection, by sex, Georgia, 2011 Adults and adolescents>= age 13, diagnosed 01/01/11 - 12/31/11, Georgia =2,869 Excludes 16 persons for whom sex was not reported 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 proportion of total number of persons diagnosed with HIV infection in each category N=2,214N=655

18. Adults and adolescents diagnosed with HIV infection, by race/ethnicity, Georgia, 2011 Adults and adolescents >= age 13, diagnosed 01/01/11 - 12/31/11, Georgia = 2,885 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 Other/Unknown include American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islanders and equal <2% of new diagnoses Note: All percentages are proportion of total number of persons diagnosed with HIV infection in each category

19. Adults and adolescents diagnosed with HIV infection, by age (years), Georgia, 2011 Adults and adolescents >= age 13, diagnosed 01/01/11 - 12/31011, Atlanta = 2,885 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 proportion of total number of persons diagnosed with HIV infection in each category N=655 N=786 N=649N=537 N=258

20. Adult and adolescent males diagnosed with HIV infection, by transmission category*, Georgia, 2011 Adult and adolescent males >= age 13, diagnosed 01/01/11 - 12/31/11, 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 Note: All percentages are proportion of total number of persons diagnosed with HIV infection in each category

21. Adults and adolescent females diagnosed with HIV infection, by transmission category*, Georgia, 2011 Adults and adolescent females >= age 13, diagnosed 01/01/11 - 12/31/11, 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 Note: All percentages are proportion of total number of persons diagnosed with HIV infection in each category N=81 N=411N=163

22. The HIV Care Continuum can help… 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 facilities Encourage improvement in surveillance data completeness (race, sex, transmission category)

23. Limitations Incomplete reporting Missing data for race/ethnicity, sex, and current address Lack of transmission category information Multiple imputation use 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 may lead to underestimation of engagement, retention and viral suppression Laboratory measures may be a poor proxy for engagement and retention in HIV care

24. Questions? Contact information: Deepali Rane, MBBS, MPH derane@dhr.state.ga.us Georgia Department of Public Health HIV/AIDS Epidemiology Program Suite 14-466 2 Peachtree St NW Atlanta GA 30303 404-657-2600 For more information on HIV Surveillance, Georgia, visit http://dph.georgia.gov/georgias-hivaids-epidemiology-surveillance-section For information on HIV Prevention, Georgia visit http://dph.georgia.gov/hiv-prevention-program