Ways to Analyze Data to Monitor Progress on the National HIV/AIDS Strategy

Angelique Griffin, MSDC Department of Health

HIV/AIDS, Hepatitis, STD and TB AdministrationJune 3, 2012

A Public Health/Academic Partnership between the

District of Columbia Department of Healthand

The George Washington University School of Public Health and Health Services

Department of Epidemiology and Biostatistics

Contract Number POHC-2006-C-0030  

REDUCING NEW INFECTIONS

Reducing New Infections

New record of 122,000 publicly supported HIV tests in 2011, up from 110,000 in 2010 and triple the 43,000 tests in 2007.

Distributed more than 5 million male and female condoms, a 10-fold increase from 2007.

Objective 1: Reduce the number of new infections by 25%

853 New HIV cases diagnosed and reported in 2009

835 in 2010

The goal is to reduce the number of new cases to 640 by 2015

DC2009 DC2010 DC20150

100

200

300

400

500

600

700

800

900 853 835

640

Number of Newly Diagnosed HIV Cases, by Year

Year of Diagnosis

Num

ber o

f New

ly D

iagn

osed

HIV

Cas

es

Objective 2: Reduce the HIV transmission rate, which is a measure of annual transmissions in relation to the number of people living with HIV,

by 30% 5.1 per 100 people in

2009

5.8 per 100 people in 2010

The NHAS goal is to reduce this rate to 3.6 transmission per 100 people

DC2009 DC2010 DC20150

1

2

3

4

5

6

7

5.1

5.8

3.6

Estimated Rate of HIV Transmission, by Year

Year

Rat

e pe

r 100

peo

ple*

* Estimate based on newly diagnosed HIV cases.

Objective 3: Increase the percentage of people living with HIV who know their

serostatus from 79% to 90%. Using data from the

CDC-funded NHBS study, DC is able to track the proportion of participants who know their HIV status

HET1 MSM2 IDU2 HET20%

10%

20%

30%

40%

50%

60%

70%

80%

90%

53%59%

70%

79%

Proportion of NHBS Participants who Knew HIV Status, by Cycle

NHBS Cycle

Prop

ortio

n of

Par

ticip

ants

Source: National HIV Behavioral Surveillance Data

INCREASING ACCESS TO CARE AND IMPROVING HEALTH OUTCOMES FOR PEOPLE LIVING WITH HIV

Increasing Access to Care and Improving Health Outcomes for People

Living with HIV Nearly 500 more persons living with HIV

obtained more health insurance coverage through expanded Medicaid eligibility.

Public-private partnership “Positive Pathways” developed new peer-based community health worker program to connect newly diagnosed persons with HIV into medical care.

Objective 4: Increase the proportion of newly diagnosed patients linked to clinical care within 3 months of their HIV diagnosis

from 65% to 85% Linkage to care

70% in 2009 76% in 2010

The 2015 goal is 85%

DC2009 DC2010 DC20150%

10%

20%

30%

40%

50%

60%

70%

80%

90%

70%76%

85%

Proportion of Newly Diagnosed HIV Cases Linked to Care within 3 months of

HIV diagnosis

Year of Diagnosis

Prop

ortio

n of

New

ly D

iagn

osed

Cas

es

Source: Name-based HIV surveillance and laboratory data

Objective 5: Increase the proportion of Ryan White HIV Program clients who are in continuous care (at least 2 visits for routine HIV medical care in 12 months at 3

months apart) from 73% to 80%

23% in 2009 35% in 2010.

The goal is to increase this proportion to 80%

DC2009 DC2010 DC20150%

10%

20%

30%

40%

50%

60%

70%

80%

90%

23%

35%

80%

Proportion of Ryan White Clients in Con-tinuous Care

Year

Prop

ortio

n of

Rya

n W

hite

Clie

nts

Source: Name-based HIV surveillance and laboratory data

Objective 6: Increase the number of Ryan White clients with permanent housing

from 82% to 86% In 2009, 70% of RW

clients had permanent housing, and 69% in 2010

DC2009 DC2010 DC20150%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

70% 69%

86%

Proportion of Ryan White Clients with Permanent Housing, by Year

Source: Ryan White Program/HOPWA

REDUCING HIV-RELATED HEALTH DISPARITIES

Reducing HIV-Related Health Disparities

Provided free STD testing for 4,300 youth ages 15 to 19 years old through the school based STD screening and community screening programs, up from 3,000 in 2010.

Removed more than 340,000 needles from the street, an increase from 317,000 in 2010, through the DC needle exchange programs despite one program closing during the year.

Launched first in the nation, HIV testing program at Department of Human Service Social Service center through a public-private partnership.  More than 200 persons were tested in first three days.

Objective 7: Increase the proportion of HIV diagnosed gay and bisexual men with

undetectable viral load by 20% 28% in 2009

39% in 2010

Though currently exceeding the NHAS goal, continued efforts are in place to have greater viral suppression among this high HIV prevalence group

DC2009 DC2010 DC20150%

5%

10%

15%

20%

25%

30%

35%

40%

45%

28%

39%

33%

Proportion of Gay/Bisexual Men with an Undetectable Viral Load, by Year

Source: Name-based HIV surveillance and laboratory data

Objective 8: Increase the proportion of HIV diagnosed Blacks with undetectable viral

load by 20% 25% in 2009

38% in 2010

Though currently exceeding the NHAS goal, continued efforts are in place to have greater viral suppression among this high HIV prevalence group

DC2009 DC2010 DC20150%

5%

10%

15%

20%

25%

30%

35%

40%

25%

38%

29%

Proportion of Black/African Ameri-can Cases with an Undetectable

Viral Load, by Year

Source: Name-based HIV surveillance and laboratory data

Objective 9: Increase the proportion of HIV diagnosed Latinos with undetectable

viral load by 20% 32% in 2009

41% in 2010

DC2009 DC2010 DC20150%

5%

10%

15%

20%

25%

30%

35%

40%

45%

32%

41%38%

Proportion of Hispanics/Latinos with an Undetectable Viral Load, by

Year

Source: Name-based HIV surveillance and laboratory data

Improving Coordination and Integration of Services

Mayor’s Commission on HIV/AIDS actions Letter sent to more than 4,000 doctors in DC highlighting the

District’s policy of offering routine HIV tests to all adults and adolescents.

Ongoing collaboration between DOH and the Department of Insurance, Securities and Banking to enforce District law on insurance reimbursement of HIV testing in emergency rooms.

Developed new fast track policy for homeless persons living with HIV and mental health and substance abuse conditions to receive coordinated services.

Under the national Program Collaboration and Service Integration (PCSI) initiative, HAHSTA creates new teams to assess program activities and align goals and objectives with National HIV/AIDS Strategy.

Objectives

To further characterize rates of viral suppression (VS) as they relate to: Linkage to care Continuity of care

To identify factors associated with achievement and maintenance of VS

20

• 16,721 reported living with HIV/AIDS in the District at the end of 2009

• Mean CVL 33,847 copies/ml

• DC is an intervention community in HPTN065 (the TLC Plus Study)

HIV/AIDS in the District of Columbia, 2009

Proportion of persons living with HIV/AIDS, by Ward, 2009

Continuum of Care for HIV Cases Diagnosed in the District of Columbia, 2005-2009

Diagnosed HIV Cases

Linked to HIV care by 12/31/2010

Received additional HIV care by 12/31/2010

Ever achieved viral suppression by

12/31/2010†

Maintained viral suppression through

12/31/2010‡

0

1,000

2,000

3,000

4,000

5,000

6,000

4,879

4,3473,729

2,730

1,391

58% Continuous

Care

42% Sporadic

Care

†At least one viral load test result prior to 12/31/2010 was ≤400 copies/mL.‡All subsequent viral load test results were ≤400 copies/mL.

Definitions Linkage to care:

Evidence of a CD4 or VL laboratory reported after initial diagnosis

Continuous care: 2 visits (CD4 or VL) within a 12-month

period at least 3 months apart Viral Suppression (VS):

Viral load (VL) <400 copies/ml Sustained VS:

All VL <400 copies/ml over the 12-month period after achieving VS

Methods Identified newly diagnosed HIV-infected

adults and adolescents diagnosed between 2006-2007 from DC DOH HIV/AIDS surveillance database Inclusion criteria: Had an initial detectable VL

followed by at least one additional VL test reported to DC DOH prior to 12/31/10

Calculated time to and maintenance of VS Conducted uni-, bi-, multivariate analyses

and survival analyses to assess predictors of VS and maintenance

Case Demographics by Achievement of VSAchieved VS (n=648) Did not Achieve VS (N=340)

 Characteristic N (%) N (%)Sex

Male 444 (68.5) 240 (70.6)Female 204 (31.5) 100 (29.4)

Age at HIV Diagnosis13-29 159 (24.5) 106 (31.2)30-39 172 (26.5) 92(27.1)40-49 195 (30.1) 104(30.6)≥50 122 (18.8) 38 (11.2)

Race/EthnicityWhite 89 (13.7) 54 (15.9)Black 508 (78.4) 268 (78.8)

Hispanic 38 (5.9) 11 (3.2)Other* 13 (2.0) 7 (2.1)

Risk FactorMSM 263 (40.6) 127 (37.4)IDU 88 (13.6) 51 (15.0)

MSM/IDU 19 (2.9) 12 (3.5)Heterosexual 201 (31.0) 114 (33.5)

Risk not identified 77 (11.9) 36 (10.6)Insurance

Public 295 (45.5) 149 (43.8)Private 132 (20.4) 66 (19.4)

No coverage 45 (6.9) 30 (8.8)Unknown 176 (27.2) 95 (27.9)

Clinical Characteristics by Achievement of VS

 CharacteristicAchieved VS

(n=648)Did not Achieve VS

(N=340)N (%) N (%)

Diagnostic StatusHIV (not AIDS)  415 (64.2) 256 (75.3)

AIDS 231 (35.8) 84 (24.7)CD4 Count at Diagnosis

< 200 242 (37.6) 85 (25.4)200 - 350 135 (21.0) 52 (15.5)

> 350 262 (40.8) 196 (58.5)VL at Diagnosis

Mean VL 185,883.5 266,826.8Median VL 22,583.5 18,444.0

Linkage to Care<3 Months 460 (71.0) 228 (67.1)3-6 Months 45 (6.9) 25 (7.4)

6-12 Months 41 (6.3) 27 (7.9)12+ Months 102 (15.7) 60 (17.7)

Annual VL test rateAt least 2 VL tests per year 288 (44.4) 33 (9.7)

Less than 2 VL tests per year 360 (55.6) 307 (90.3)Continuous Care

Yes 207 (31.9) 76 (22.4)No 441 (68.1) 264 (77.6)

Predictors of Achieving Viral Suppression Characteristic OR 95%CI aOR† 95%CIAge at HIV Diagnosis

13-29 referent30-39 1.25 (0.89, 1.77) 1.09 (0.74, 1.62)40-49 1.25 (0.89, 1.76) 1.13 (0.77, 1.66)≥50 2.14 (1.38, 3.32) 2.09 (1.29, 3.39)

Risk FactorMSM referentIDU 0.83 (0.56, 1.25) 0.60 (0.37, 0.99)

MSM/IDU 0.77 (0.36, 1.62) 0.60 (0.26, 1.40)Heterosexual 0.85 (0.62, 1.16) 0.61 (0.39, 0.93)

Risk not identified 1.03 (0.66, 1.62) 0.83 (0.49, 1.39)Diagnostic Status

HIV (not AIDS)  referentAIDS 1.70 (1.26, 2.28) 1.92 (1.34, 2.74)

CD4 Count at Diagnosis< 200 2.13 (1.56, 2.81) --

200 - 350 1.94 (1.34, 2.81) --> 350 referent --

Annual VL test rateAt least 2 VL tests per year 7.44 (5.03, 11.0) 8.02 (5.31, 12.11)

Less than 2 VL tests per year

referent

Continuous CareYes 1.63 (1.20, 2.21) 1.01 (0.71, 1.44)No referent

Median Number of Days to Viral Suppression

< 3 Months3 - 6 Months

6 - 12 Months> 12 Months

0

200

400

600

800

1000

1200

< 3 Months 3 - 6 Months6 - 12 Months > 12 Months

Timing of Linkage to Care

Num

ber o

f day

s to

VS

Continuous Care

Sporadic Care0

200

400

600

800

1000

1200

Continuous Care Sporadic Care

Retention in Care

Num

ber o

f day

s to

VS

Linkage to Care Retention in Care

VLs among Those Not Maintaining VS

Limitations

Unable to determine actual number of patient encounters Used routinely reported lab data as a

proxy All laboratories report to surveillance

system Do not have ARV data to accompany this

analysis VL <400 (undetectable VL) approximates

viral suppression

Conclusions More rapid linkage to care and retention in

continuous care led to more rapid achievement of VS

Analysis can help guide targeted interventions to increase linkage to care rates and treatment adherence

Acknowledgements

DC DOH HAHSTA Dr. Irshad Shaikh Tiffany West Dr. Gregory Pappas Dr. Yujiang Jia

GWU SPHHS Dr. Amanda Castel Sarah Willis Dr. Alan Greenberg Dr. Manya Magnus Dr. Irene Kuo Dr. James Peterson