HIV Epidemiology Program: Epidemiology of HIV and AIDS in Los Angeles County Presentation to Public Health Commission October 28, 2010 Douglas M. Frye, MD, MPH Director, HIV Epidemiology Program

Mission Statement Collect, analyze, and disseminate HIV/AIDS surveillance and epidemiologic study data essential for the planning, implementation, and evaluation of programs and policies involving HIV care, prevention, education, and research in Los Angeles County

HIV EPI PROGRAM STAFFING Staff positions (49 total): –38 County employees –11 Temporary contract employees Lead Surveillance/Research Staff: –1 Medical Epidemiologist –3 Doctoral Level Epidemiologists –9 Masters Level Epidemiologists and Research Analysts –4 Public Health Nurses –1 PHN Supervisor

Department of Public Health Robert Kim-Farley Division Director Communicable Disease Control and Prevention Douglas Frye Director HIV Epidemiology Program Mario J. Pérez Director, Office of AIDS Programs and Policy Jonathan E. Freedman Chief Deputy Director for Department of Public Health Acute Communicable Disease Control & Public Health Laboratory Department of Public Health Jonathan E. Fielding Director and Health Officer L.A. County Board of Supervisors Sexually Transmitted Disease Control & Tuberculosis Control

DIRECTOR Data Acquisition ADMINISTRATION Data Analysis Special Projects Behavioral Epidemiology HIV EPI Organizational Chart Surveillance UnitsResearch Units

Current Program Surveillance and Epidemiologic Research Projects HIV Surveillance units –Data Acquisition Unit collects case reports –Data Analysis Unit enters data, analyzes it, distributes it to stakeholders –Enhanced Perinatal Surveillance Project Behavioral Epidemiology Unit –HIV Incidence and Resistant Strains Surveillance –National HIV Behavioral Surveillance Special Projects Unit –Medical Morbidity Monitoring Project

HIV and AIDS Reporting 1982: physicians and hospitals required to report confirmed and suspected cases of AIDS to local health department 2002: laboratories and providers required to report all non-AIDS HIV infections by code 2006: SB-699 signed into law; report by name 2008: AB-1045 signed into law; CD4 reporting by laboratories required 2009: CDC implements evaluation-HARS 2010: AB-2541 signed into law; HIV reporting allowed by secured electronic means for providers, labs and local health jurisdictions 2011: more changes in eHARS

Importance of Reporting HIV and AIDS for L.A. County HIV/AIDS epidemic in Los Angeles differs from the rest of the United States by gender, race/ethnicity, mode of exposure, Number of cases reported translates into state and federal dollars for prevention, education, care services for persons living with HIV in LA County Second highest (to NYC) morbidity for among urban areas in nation 5% of US and 35% of California cases

How Data Are Collected Active Reporting –HIV EPI personnel contact health care practitioners and review medical records in hospitals and clinics Passive reporting –health care practitioners, hospitals, and clinics report cases of AIDS without being reminded or contacted Electronic reporting –Labs and large providers report via secured network or by CD-ROM

Persons Living with HIV and AIDS in L.A. County

Estimated Number of Persons Living with HIV and AIDS in LAC (1) Estimate that 21.5% of HIV+ in LA County are unaware of their infection; modified from CDC estimate. (2) Of 6,700 notifications pending investigation, estimate >4,000 to be cases. (3) Estimate based on a 1:1 ratio of HIV (non-AIDS) to living AIDS cases and includes reported, named, coded, pending and unaware HIV and AIDS cases. Estimate ~ 62,800 living with HIV & AIDS in LAC (3) 24,650 16,000 13,500 4,150 4,500 Source: LAC HIV Epidemiology Program, reported as of 12/31/2009.

Number of Persons Living with HIV/AIDS, by Gender and Year, LAC, *Data is provisional due to reporting delay ( ) Source: HIV Epidemiology Program, LAC-DPH; data as of May 31, % 88%

Proportion of LAC PLWHA Cases by Race/ Ethnicity* & Diagnosis Year, *American Indian and Alaska Native are not presented here but consistently comprise <1% of cases. *Data are provisional due to reporting delay. Source: HIV Epidemiology Program, LAC-DPH; data as of December 31, 2009 White Hispanic Black Asian/PI 22% 39% 3% 36%

Persons living with HIV and AIDS in LAC, by Race/Ethnicity (N=44,450), 12/31/ % 35% 3% 39% <1% Source: HIV/AIDS Surveillance Summary, data as of 9/30/2010.

*Sometimes called “Prevalence Rate”; it is really a proportion. Persons Living with HIV and AIDS in LAC per 100,000 population by Race/Ethnicity * Source: HIV/AIDS Surveillance Summary, data as of Dec

Age (years) Source: HIV/AIDS Surveillance Summary, data as of 9/30/2010. Current Age of Reported Persons Living with HIV and AIDS in LAC, 2010 (N=43,829)

Men who have sex with men Heterosexual MSM IDUIDU **NRR = no reported risk. *Data are provisional due to reporting delay. Source: HIV Epidemiology Program, LAC-DPH; data as of December 31, 2009 Proportion of LAC PLWHA by Mode of Exposure and Calendar Year, * 17% 7% 64% 6% NRR** 5%

Persons living with HIV and AIDS in LAC, 2007, by Mode of Exposure, Adjusted (N=40,000) Source: HIV/AIDS Surveillance Summary, data as of Sept

Male (n=35,035) Female (n=4,968) *Persons who had no reported risk for HIV infection had been redistributed to a valid mode of exposure category based on the CDC method for distribution of reclassified cases. Source: HIV/AIDS Surveillance Summary, data as of September Adjusted Mode of Exposure for Persons Living with HIV/AIDS by Gender in LAC, December 2007

Persons Living with HIV and AIDS by Zip Code and Service Planning Area (SPA) in Los Angeles County, as of Dec. 31, 2009 (N=44,450) Source: HIV/AIDS Surveillance Summary.

Number, Percent, and Rate of Persons Living with HIV and AIDS by Service Planning Area (SPA) in Los Angeles County, as of Dec. 31, 2009 (N=44,450) Source: HIV/AIDS Surveillance Summary.

Source: HIV Epidemiology Program, LAC-DPH; data as of December 31, 2009 Percent of Newly Diagnosed Severe HIV Disease (AIDS) Cases Among Persons 50 Years and Older, by Year of Diagnosis Percent (%) 11% 17%

Percent Perinatal HIV Transmission by Birth Year, Los Angeles County, 1996 – 2009 Year of Birth Percent SB889 AB1676 AB682

Contact Information Douglas M. Frye (213) HIV Epidemiology Program Phone: (213) 351 –

Time, in months, between first learned of HIV+ status and AIDS Diagnosis, by Race/Ethnicity SHAS, LAC, (N = 672) Time (months) between HIV+ and AIDS Diagnoses Early detectionLate detectionVery late detection

Severe HIV Disease (AIDS) in L.A. County

AIDS cases from LA County HIV/AIDS Semiannual Surveillance Summary No. cases No. deathsNo. Living US 1,051, ,901468,577 CA* 153,901 86,396 67,505 LAC** 56,091 31,448 24,643 *Reported as of 04/30/2009 **Reported as of 12/15/2009

Number of Persons Living with AIDS by Calendar Year – LA County, Source: HIV/AIDS Surveillance Summary, data as of Dec ,643 * Data are provisional due to reporting delay.

Source: Centers for Disease Control and Prevention. 21% 48% 1% 29% <1%

Proportion of AIDS Cases by Race/ Ethnicity* & Diagnosis Year, , LA County *American Indian and Alaska Native are not presented here but consistently comprise <1% of cases. **Data are provisional due to reporting delay (2006). Source: HIV Epidemiology Program, LAC-DPH; data as of December 31, 2009 White Hispanic Black Asian/PI 22% 43% 4% 31%

Current Diagnosis (years) Current Age for Persons Living with Severe HIV Disease (AIDS) in LAC (N = 24,643) Source: HIV/AIDS Surveillance Summary, data as of Dec

Cumulative AIDS Rates (per 100,000) by Race/Ethnicity and Median Household Income* LA County, * At census tract-level Source: HIV Epidemiology Program, LAC/DPH Race/Ethnicity Income Overall Rate Rate White11 Low33 Middle14 High 5 African-American30 Low 35 Middle26 High20 Latino11 Low14 Middle 9 High 7 Asian/Native American 4 Low 6 Middle 5 High 2

HIV Incidence Monitoring diagnosed HIV does not tell us when a person was actually infected with HIV To find out who is getting infected now, need a test that identifies persons infected with HIV more recently – e.g. within the last year New “de-tuned” ELISA assay is less sensitive than ELISA and does not show positive for new infections, as there are fewer blood antibodies 25 states are working with CDC to pilot HIV incidence surveillance in the U.S.

Markers of HIV/AIDS Surveillance 1st confirmed positive HIV test CD4 Count s CD4 Count <200 Opportunistic Infection Death Viral Load Test s CORE HIV/AIDS SURVEILLANCE AIDS Recent HIV infection HIV Incidence Disease Progression

HIV Resistance Surveillance Prevalence of resistant HIV strains among persons diagnosed with HIV in LA County is currently unknown. HIV Epidemiology Program one of 14 sites working with CDC to conduct “Variant, Atypical and Resistant HIV Surveillance” for newly diagnosed cases of HIV infection Purpose of surveillance:  Estimate prevalence of mutations associated with HIV drug resistance ~ and ~  Investigate trends in transmission of drug-resistant strains of HIV Preliminary data indicate HIV resistance to one or more classes of antiretroviral drugs to be 23% in LA County Nationally, one-drug resistance: 4 – 20%

Los Angeles County Square Miles:4,086 Population:10.2 Million Latino/Hispanic 47% White 30% Asian/Pac Islander 13% African-American10% Native American1% Proportion of California Population: 29% Proportion of California HIV/AIDS Cases:35% SPA 6: South SPA 8: South Bay SPA 5: West SPA 2: San Fernando SPA 4: Metro SPA 3: San Gabriel SPA 1: Antelope Valley SPA 7: East SPA = Service Planning Area

VISION Accurate, timely and complete surveillance and epidemiologic information on the HIV epidemic in Los Angeles County is readily available and used effectively to reduce the spread and impact of HIV throughout the county HIV Epidemiology Program

Collect, analyze, and disseminate HIV/AIDS surveillance and epidemiologic study data essential for the planning, implementation, and evaluation of programs and policies involving HIV and AIDS care, prevention, education, and research in Los Angeles County MISSION HIV Epidemiology Program

Confidentiality of HIV Registry Data AIDS surveillance data protected under State law and Federal Assurance of Confidentiality CDC requires HIV/AIDS registry data in state and local health departments be maintained in physically secure environment with access limited to authorized personnel Patient names and identifying information reported to HIV Epidemiology Program are not sent to CDC or any other federal agency CDC does not collect identifying information (name, address, or phone number) Data not subpoenable

* Data are provisional due to reporting delay. Source: HIV/AIDS Surveillance Summary, data as of Dec Number of AIDS Cases by Year of Diagnosis – LA County,

Number of AIDS Deaths by Year of Death – LA County, Note: Data for are provisional due to reporting delay and that data are not shown. Source: HIV/AIDS Surveillance Summary, data as of Dec

Percent * Data are provisional due to reporting delay. Source: HIV/AIDS Surveillance Summary, data as of December AIDS Cases Percent by Gender and Year – LA County, 2004 – % 89%

Source: Center for Disease Control and Prevention. 5% 32% 19% 43%

Men who have sex with men Heterosexual MSM IDU IDU *Cases without reported risk redistributed using CDC protocol. Source: HIV Epidemiology Program, LAC-DPH; data as of December 31, 2009 Proportion of AIDS Cases by Adjusted Mode of Exposure and Year of Diagnosis , LA County* 13%7.4% 71% 7.4%

Persons living with HIV and AIDS in LAC, by Mode of Exposure (N=44,450)* **NRR = no reported risk. *Data are provisional due to reporting delay. Source: HIV Epidemiology Program, LAC-DPH; data as of December 31, 2009

Persons living with HIV and AIDS in LAC, by Gender (N=44,450) Source: HIV/AIDS Surveillance Summary, data as of Dec

27% 73%

Male (n=21,929) Female (n=2,714) Note: Persons with no reported risk for HIV infection redistributed to valid mode of exposure category based on the distribution of reclassified cases reported from Source: HIV/AIDS Surveillance Summary, data as of December Adjusted Mode of Exposure for Persons Living with AIDS, by Gender, LA County