epidemiology of hiv/aids in the indianapolis transitional grant area: 2014
TRANSCRIPT
EPIDEMIOLOGY OF HIV/AIDS IN THE INDIANAPOLIS TRANSITIONAL
GRANT AREA: 2014
Objective• To provide the Ryan White Planning Council with
information necessary for priority setting
Topics• Epidemiology
• The Indianapolis Transitional Grant Area (TGA)
• HIV incidence
• HIV mortality/deaths
• HIV prevalence
• Co-morbidities
• Measures of HIV health outcomes
Epidemiology
Epidemiology – The study of:
Epidemiology - Terminology• Incidence
• Rate of new diagnoses per 100,000 people per year
• Prevalence• Proportion of people living with a disease/injury from among those
at risk; reported as per 100,000 people
• Mortality• Rate of death caused by a disease/injury per 100,000 people per
year
• Rate Ratio• Comparison of a rate among two or more groups
The Indianapolis Transitional Grant Area
(TGA)
TGA Location & Population
• Ten Central Indiana counties with a 2014 estimated population of just over 1.84 million1
TGA Population 1990-2014
Source: U.S. Census Bureau1,2,3
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
500,000
750,000
1,000,000
1,250,000
1,500,000
1,750,000
2,000,000
Marion Hamilton Hendricks Johnson Hancock MorganBoone Shelby Putnam Brown
5.7% increase since 2009
84% of TGA residents live in four counties
TGA Population Center88% of the TGA population4
TGA Demographics
Sex Age
TGA Demographics
TGA Race/Ethnicity
The population of Marion County is more diverse
than that of the TGA overall, with 26.9% Black, 9.7% Hispanic, and about
the same percentage Asian/PI and Other
HIV Incidence
HIV/AIDS Incidence
Late diagnoses decreased from 27.4% in 2013 to 19.9% in 2014
New Diagnoses Cases* Rate
TGA Rate
(2013)
U.S. Rate**
(2013)5
HIV 241 13.2 13.2 15.0AIDS 124 6.8 6.7 8.4*N missing ≈ <5**Includes the TGA
A late HIV diagnosis occurs when an AIDS diagnosis is reported within 90 days of an initial HIV diagnosis
No significant change in HIV or AIDS incidence from 2013 to 2014
Annual HIV Incidence by Time to AIDS: 1982-2014
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
0
50
100
150
200
250
300
350
Late Diagnosis (AIDS < 91 Days) Conversion 91-365 DaysHIV non-AIDS for > 1 Year
HIV
Dia
gnos
es (N
)
N missing ≈ <5
HIV Incidence by County
No significant change by county between 2013 to 2014
HIV incidence is 11.6 times higher in Marion County residents
County Cases% of Total Rate
RR [95% CI]: to Others
Marion 216 89.6% 23.3 11.6 [6.5-20.8]Hamilton 13 5.4% 4.4 NSOthers* 12 5.0% 2.0 -RR [95% CI]: = Rate ratio and 95% confidence interval*N missing ≈ <5NS = Not statistically significant
Morgan County data missing but thought to be <5 cases
HIV Incidence by Gender
No significant change by gender between 2013 to 2014
Men were diagnosed with HIV at a rate 4.4 times that of women
Gender Cases% of Total Rate
RR [95% CI]: to Female
Female <48 <19.9% 4.9 -Male 194 80.5% 21.8 4.4 [3.2-6.1]Transgender <5 <2.1% UNK -RR [95% CI]: = Rate ratio and 95% confidence intervalN missing ≈ <5
HIV Incidence by Race/Ethnicity
No significant change by race/ethnicity 2013 to 2014
Racial/ethnic minorities, especially African Americans,
experience increased risk of HIV infection
Race/ Ethnicity Cases
% of Total Rate
RR [95% CI]: to White
Asian/PI 6 2.5% 12.4 NSBlack 128 53.1% 46.2 8.3 [6.2-11.0]Hispanic 26 10.8% 22.0 3.9 [2.5-6.1]Other 6 2.5% 16.1 2.9 [1.3-3.6]White 75 31.1% 5.6 -RR [95% CI]: = Rate ratio and 95% confidence interval N missing ≈ <5NS = Not statistically significant
Asian/PI Black Hispanic Other White0.0
10.020.030.040.050.060.070.080.0
MaleFemale
Race/Ethnicity
Rate
per
100
,000
HIV Incidence by Race/Ethnicity and Sex
N missing ≈ <5
HIV Incidence by Age
No significant change by age between 2013
and 2014
Young adults 20-34 continue to be at most risk of HIV, with rates at least double those of other age groups
Age (Yrs.) Cases% of Total Rate
<15 <5 0.4% <1.015-19 18 7.5% 14.920-24 57 23.7% 48.425-34 86 35.7% 32.935-44 38 15.8% 15.345-64 39 16.2% 8.365+ <5 0.8% <1.0
N missing ≈ <5
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
0
50
100
150
200
250
300
350
<15 15-19 20-24 25-34 35-44 45-64 65+
HIV
Dia
gnos
es (N
)
Annual HIV Incidence by Age (Yrs.) at Diagnosis: 1982-2014
N missing ≈ <5
HIV Incidence by Age and Sex
<15 15-19 20-24 25-34 35-44 45-64 65+0.0
10.020.030.040.050.060.070.080.090.0
MaleFemale
Age at Diagnosis (Yrs.)
Rate
per
100
,000
N missing ≈ <5
HIV Incidence by Exposure/Risk
No significant change by exposure/risk 2013 to 2014
Men who have sex with men (MSM) bear the greatest burden
of HIV in the TGA
Exposure/Risk Category Cases% of Total Rate
Male-to-Male Sexual Contact* 141 58.5% 362.6Injection Drug Use 9 3.7% 0.5Heterosexual Contact 70 29.0% 3.9Not Reported/Identified 21 8.7% 0.6* Rate based on estimate of men with a lifetime history of sexual contact with another man of 4.6% Black and 5.8% other men 15+ years of age6
N missing ≈ <5
HIV Incidence by U.S. Nativity Status
Foreign-born residents of the TGA experience a risk approximately 3.3 times that of native-born residents
U.S. Nativity Status Cases
% of Total Rate
RR [95% CI]: to Native-
BornForeign-Born 39 16.2% 35.7 3.3 [2.3-4.7]Native 178 73.9% 10.8 -Unknown 24 10.0% UNK -RR [95% CI]: = Rate ratio and 95% confidence intervalN missing ≈ <5
HIV Mortality
2013 HIV Mortality & All Deaths of People Living with HIV/AIDS during 2014
- HIV deaths are directly attributable to HIV/AIDS- All deaths are those of PLWH/A regardless of cause
AreaHIV Deaths (2013) All Deaths (2014)
N Rate N RateMarion County 23 2.5 35 3.8TGA - - 50 2.7Indiana (excl. TGA) 54 1.0 - -U.S. 6,955 2.2 - -Morgan County deaths missing
Reported deaths are subject to revision as it is standard practice to report 18 months behind any given period to allow for reporting lag
HIV Prevalence
HIV/AIDS Prevalence
No significant change in HIV or AIDS prevalence 2013 to 2014
Status Cases* Rate TGA Rate
(2013)U.S. Rate**
(2012)5
HIV 2,589 142.0 139.0 129.4AIDS 2,863 157.0 154.5 162.1Total 5,452 299.0 293.5 291.5*N missing ≈ 53 **Includes the TGA
HIV/AIDS Prevalence: 2000-2014
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
HIV (non-AIDS) AIDSEstimated Undiagnosed
HIV
Dia
gnos
es (N
)
r = .987, p < .001
Morgan County data missing since 2011. Prevalence in Morgan County at EOY 2014 thought to be 53 total
HIV Prevalence by County
County Cases% of Total Rate
Marion 4,751 87.1% 511.8Putnam 67 1.2% 178.6Brown 21 0.4% 139.8Johnson 141 2.6% 96.9Hendricks 135 2.5% 87.7Morgan * * *Hancock 54 1.0% 75.4Hamilton 214 3.9% 72.1Boone 41 0.8% 67.8Shelby 28 0.5% 62.6
No significant change by county between 2013 and
2014
More than 87% of TGA residents living with HIV
reside in Marion County
*Morgan County data missing but thought to be N=53 (76 per 100,000)
HIV Prevalence by County
Marion
PutnamBrown
Johnson
Hendricks
Morgan
Hancock
Hamilton
Boone
Shelby
0.0
100.0
200.0
300.0
400.0
500.0
600.0
Rate
per
100
,000
*
*Morgan County data missing but thought to total 53 for a rate of 76.0 per 100,000
*Morgan County data is missing but prevalence was estimated using RISE and ISDH data and is estimated to total 53
HIV Prevalence by Gender
No significant change by gender between 2013 to 2014
Men have a risk 4-5 times that of women in the TGA
Gender Cases% of Total Rate
RR [95% CI]: to Female
Female 1,018 18.7% 109.1 -Male 4,370 80.2% 490.8 4.5 [4.2-4.8]Transwomen 47 0.9% UNK -Transmen 17 0.3% UNK -RR [95% CI]: = Rate ratio and 95% confidence interval N missing ≈ 53
HIV Prevalence by Race/Ethnicity
No significant change by race/ethnicity 2013 to 2014
Racial/ethnic minorities, especially African Americans,
experience increased risk of HIV
Race/ Ethnicity Cases
% of Total Rate
RR [95% CI]: to White
Asian 113 2.1% 233.1 1.3 [1.1-1.6]Black 2,343 43.0% 845.6 4.7 [4.4-4.9]Hispanic 396 7.3% 334.9 1.8 [1.7-2.1]Other 165 3.0% 441.5 2.4 [2.1-2.8]White 2,435 44.7% 181.4 -RR [95% CI]: = Rate ratio and 95% confidence interval N missing ≈ 53
HIV Prevalence by Race/Ethnicity and Sex
Asian/PI Black Hispanic Other White0.0
200.0
400.0
600.0
800.0
1,000.0
1,200.0
1,400.0MaleFemale
Race/Ethnicity
Rate
per
100
,000
N missing ≈ 117 (53 from Morgan County and 64 transgender PLWH/A)
HIV Prevalence by Current Age
No significant change by age between 2013
and 2014
Adults 35-64 account for most PLWH/A in the
TGA
Age (Yrs.) Cases% of Total Rate
<15 31 0.6% 7.915-19 33 0.6% 27.420-24 243 4.5% 206.125-34 940 17.2% 359.935-44 1,246 22.9% 502.645-64 2,727 50.0% 578.365+ 228 4.2% 106.9N missing ≈ 53
A significant increase in prevalence among those 20-44 years of
age has occurred since 2010 (r = .95, p < .05,)
HIV Prevalence by Age and Sex
<15 15-19 20-24 25-34 35-44 45-64 65+0.0
200.0
400.0
600.0
800.0
1,000.0
1,200.0MaleFemale
Current Age (Yrs.)
Rate
per
100
,000
N missing ≈ 117 (53 from Morgan County and 64 transgender PLWH/A)
Exposure/Risk Category Cases% of Total Rate
Male-to-Male Sexual Contact* 3,143 57.6% 8,082.4Injection Drug Use 565 10.4% 31.0Heterosexual Contact 1,056 19.4% 59.2Other 75 1.4% 4.1Not Reported/Identified 613 11.2% 33.6*Rate based on estimate of men with a lifetime history of sexual contact with another man of 4.6% Black and 5.8% other men 15+ years of age6
N missing ≈ 53
HIV Prevalence by Exposure/RiskNo
significant change from
last year
MSM bear the greatest burden of HIV in the
TGA with a known
prevalence of about
8.1%
Based on CDC estimates, about 18% of MSM are HIV-positive. Moreover, while 14% of PLWH/A are unaware of their status
overall, 34% of HIV-positive MSM are unaware of their status.8
HIV Prevalence by U.S. Nativity Status
The proportion of foreign-born TGA residents infected with HIV is about twice that of native-born residents
U.S. Nativity Status Cases
% of Total Rate
RR [95% CI]: to Native-
BornForeign-Born 603 11.1% 552.1 2.0 [1.8-2.2]Native 4,553 83.5% 275.8 -Unknown 296 5.4% UNK -RR [95% CI]: = Rate ratio and 95% confidence interval N missing ≈ 53
Co-morbidities
Foreign-Born• Almost 1 in 6 newly diagnosed with HIV in the TGA during
2014 was foreign-born and this group had 3.3 times the risk of native-born residents
• More than 1 in 10 PLWH/A in the TGA are foreign-born, a prevalence twice as high as among the native-born
• Special considerations• Linguistic services
• Health insurance
• Social support structure
• Cultural stigma/beliefs
• Fear
Aging
Better therapies Longer lives
• 54% of PLWH/A in the TGA are 45+ years of age
• People living with AIDS at 50+ have needs as complicated as a geriatric patient
• Special considerations9
• Weakened immune system
• Increased risk of adverse events and drug interactions
Photo credit: Jeremy Swain, Ending Homelessness in London
• Among PLWH/A, 347 were homeless or insecurely housed at some point during 201310,11,12
• Research suggests that 10%-16% of all PLWH/A in some communities are homeless at any given time13
• Special considerations• Case finding
• Public assistance
• Permanent housing
• Priority of medical care
Homelessness
Recent Incarceration• 157 PLWH/A have a known history of incarceration
• Special considerations• Employment and housing
• Retention in care throughout and after the transition
• Substance abuse
• Trouble navigating the health care system
Mental Health & Substance Abuse• Approximately 2,726 PLWH/A suffer from mental health
issues according to the 50% estimate found in the National HIV/AIDS Strategy16
• 40% of PLWH/A are estimated to have substance abuse issues and 13% are thought to experience both substance abuse and mental health issues16
• To complicate matters…• Marion County, home to 4,751 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)17
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 underweight18
Mycobacterium tuberculosis (TB)• During 2014, 59 TGA residents were diagnosed with
active TB, of these six were HIV positive• PLWH/A in the TGA were at least 8 times more likely to be
diagnosed with active TB than HIV-negative residents (RR 20.7, 95% CI: 8.2-52.0)
• Special considerations• Screening
• Diagnostic
• Treatment
Viral Hepatitis• Approximately 545 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 Services14
• 1,363-1,636 PLWH/A are thought to be co-infected with hepatitis C based on the 25%-30% estimate of the National Alliance of State and Territorial AIDS Directors15
Chlamydia• 11,581 chlamydia diagnoses were reported in the TGA
during 2014• At least 129 diagnoses were among HIV-positive residents for a
rate of 2,265.9 per 100,000 [95% CI: 1,910.4-2,685.9]
• HIV-positive residents were about 3.6 times more likely [95% CI: 3.0-4.3] to receive a chlamydia diagnosis than HIV-negative residents
HIV-chlamydia co-infection is thought to be grossly underestimated due to low screening rates – PLEASE screen, diagnose and treat PLWH/A and their partner(s) for chlamydia
Gonorrhea• 3,695 gonorrhea diagnoses were reported in the TGA
during 2014• At least 162 diagnoses were among HIV-positive residents for a
rate of 2,845.6 per 100,000 [95% CI: 2,444.5-3,310.3]
• HIV-positive residents were about 14.6 times more likely [95% CI: 12.5-17.1] to receive a gonorrhea diagnosis than HIV-negative residents
HIV-gonorrhea co-infection is thought to be underestimated – Please screen, diagnose and treat PLWH/A and their partner(s) for gonorrhea
Early Syphilis• 202 early syphilis diagnoses were reported in the TGA
during 2014• At least 87 diagnoses were among HIV-positive residents for a rate
of 1,528.2 per 100,000 [95% CI: 1,240.7-1,881.1]
• HIV-positive residents were at least 183 times as likely [95% CI: 183.1-318.7] to be diagnosed with early syphilis than HIV-negative residents
Early syphilis includes primary, secondary and early latent stages of infection
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
Measures of HIV Health Outcomes
HIV Treatment Cascade
• Developed by Dr. Edward Gardner and colleagues19 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
19
“HIV screening without linkage to care “confers little or no benefit to the patient” – Branson, et al., 2006 20
Benefits of Improving Linkage Into and Retention in Care
• Delayed linkage and poor engagement in care are associated with:19,20
• 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
Use of a Treatment Cascade, as Illustrated by the CDC21
Continuum of Care Definitions (TGA)Measure Denominator NumeratorEstimated Prevalence
Estimated number of persons living with HIV on 31-Dec-2014, including those undiagnosed/unaware2
Diagnosed Persons living with HIV on 31-Dec-2014, including those undiagnosed/unaware
Number diagnosed
Linked to Care Persons newly diagnosed with HIV during 2014
Number with ≥1 CD4 or viral load test within 90 days
Retained in Care
Persons with an HIV diagnosis and ≥1 CD4 or viral load test in the first six months of 2013
Number with ≥1 CD4 or viral load test in each 6-month period of 2013 and 2014, with ≥60 days between the first in a 6-month period and the last in the subsequent period
Prescribed ART
Persons with an HIV diagnosis and ≥1 CD4 or viral load test in 2014
Number prescribed HIV antiretroviral therapy
Suppressed Viral Load
Persons with an HIV diagnosis and ≥1 CD4 or viral load test in 2014
Number with HIV viral load <200 copies/mL at last 2014 HIV viral load test
Continuum of Care Definitions (U.S.)Measure Denominator NumeratorEstimated Prevalence
Estimated number of persons living in the U.S. with HIV on 31-Dec-2011, including those undiagnosed/unaware
Diagnosed Persons living in the U.S. with HIV on 31-Dec-2011, including those undiagnosed/ unaware
Number diagnosed
Linked to Care
Persons ≥13 in any of 18 U.S. states or District of Columbia (D.C.) that require reporting of all CD4 and viral load tests and newly diagnosed with HIV during 2011
Number with ≥1 CD4 or viral load test within 90 days of diagnosis
Retained in Care
Persons ≥13 in any of 18 U.S. states or D.C. that require reporting of all CD4 and viral load tests and diagnosed with HIV by year-end 2009 and alive at year-end 2010
Number with ≥2 CD4 or viral load tests ≥90 days apart during 2010
Prescribed ART
Persons living in the U.S. with HIV on 31-Dec-2010
Number prescribed HIV antiretroviral therapy
Suppressed Viral Load
Persons ≥13 in any of 18 U.S. states or D.C. that require reporting of all CD4 and viral load tests and HIV diagnosed by year-end 2009, alive at year-end 2010, and ≥1 CD4 or viral load test during 2010
Number with HIV viral load <200 copies/mL at last 2010 HIV viral load test
National HIV/AIDS Strategy Objectives
• 90% of HIV-positive residents diagnosed and aware of their status
• 85% of newly diagnosed individuals linked to care within 90 days
• 80% retained in care• 20% increase in the number of PLWH/A with suppressed
viral loads
Estimated Number of Undiagnosed/Unaware PLWH/A
• Current estimated proportion of PLWH/A while undiagnosed/unaware is 14.0% of known prevalence22
HIV/AIDS Prevalence 5,452HIV Prevalence 2,589AIDS Prevalence 2,863Undiagnosed/Unaware 894
Estimated Total PLWH/A 6,346
Continuum of Care
Estimated Prevalence
Diagnosed Linked to Care
Retained in Care
Prescribed Antiretroviral
Therapy
Suppressed Viral Load
100.
0%
86.0
%
76.1
%
47.7
%
47.7
%
81.4
%100.
0%
86.0
%
78.9
%
62.4
%
48.8
%
79.1
%
100.
0%
86.0
%
79.8
%
50.8
%
45.3
%
68.6
%
MSA 2014 MSA 2013 U.S.
Perc
ent o
f All
PLW
H
Community Viral Load• Mean HIV viral load is based on the last test result during
each year analyzed for all PLWH/A who had at least one viral load test
• Results reported as <20 or >10,000,000 copies/mL were set to 20 and 10,000,000 copies/mL, respectively, to reflect the detectable range of lab instruments
• Community viral load = CVL
2010 (N=3,201)
2011 (N=3,392)
2012 (N=3,569)
2013 (N=3,802)
2014 (N=3,887)
05,000
10,00015,00020,00025,00030,00035,00040,000
33,33637,351 35,747 36,383
23,822
HIV
RN
A Co
pies
/mL
Mean Community Viral Load, Indianapolis TGA: 2010-2014
Analysis of variance between CVLs during 2010-2014 was not significant, F(4,17850) = 1.04, p = .3836, ηp2 = .0002
Morgan County data are missing
Mean Community Viral Load by County, Indianapolis TGA: 2014
Analysis of variance for the effect of residence county on mean CVLs during 2010-2014 was not significant F(8, 17850) = .77, p = .6318, ηp2 = .0003
0
10,000
20,000
30,000
10,200
445
6,868 6,865
22,616
17,520
25,852
3,807 2,052
HIV
RN
A Co
pies
/mL
Morgan County data are missing
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 Panel23
• CLOSE 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=1170890
Vision for the National HIV/AIDS Strategy16
“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.”
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
References1 U.S. Census Bureau. (2015). Annual Estimates of the Resident Population: April 1, 2010 to July 1, 2014. U.S. Census Bureau, Population Division. Release dates: For the United States, regions, divisions, states, and Puerto Rico Commonwealth, December 2014; For counties and Puerto Rico municipios, March 2015.2 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, 2013. Retrieved from http://www.cdc.gov/hiv/pdf/g-l/hiv_surveillance_report_vol_25.pdf#Page=216 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.pdf8 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/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/guidelines10 Indiana University Public Policy Institute. (2013). 2013 Point-in-time count: Identifying the most vulnerable homeless in Indianapolis. Retrieved from http://policyinstitute.iu.edu/uploads/PublicationFiles/HomelessCount_2013_WEB.pdf
References11 U.S. Department of Housing and Urban Development. (2014). HOPWA performance profile - Formula grantee: City of Indianapolis. Retrieved from https://www.hudexchange.info/resource/reportmanagement/published/HOPWA_Perf_GranteeForm_00_INDI-IN_IN_2013.pdf12 Marion County Public Health Department. (2014). Ryan White Information Services Enterprise (RISE). Indianapolis: Ryan White Services Program.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-hiv14 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/15 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.pdf16 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.pdf17 Marion County Public Health Department. (2014). Community health assessment of Marion County: 2014. Retrieved from http://health.mchd.com/18 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/
References19 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/ciq24320 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.htm21 Centers for Disease Control and Prevention. (2013). Linkage to and retention in HIV medical care. Retrieved from http://www.cdc.gov/hiv/prevention/programs/pwp/linkage.html22 Centers for Disease Control and Prevention. (2014). Monitoring selected national HIV prevention and care objectives by using HIV surveillance data - United States and 6 dependent areas - 2012. HIV Surveillance Supplemental Report, 19(3). Retrieved from http://www.cdc.gov/hiv/pdf/surveillance_Report_vol_19_no_3.pdf23 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