Ways to Analyze Data to Monitor Progress on the National HIV/AIDS Strategy Angelique Griffin, MS DC Department of Health HIV/AIDS, Hepatitis, STD and TB Administration June 3, 2012

A Public Health/Academic Partnership between the District of Columbia Department of Health and 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 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 in 2010 The goal is to reduce the number of new cases to 640 by 2015

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 per 100 people in 2010 The NHAS goal is to reduce this rate to 3.6 transmission per 100 people * 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 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 % in 2010 The 2015 goal is 85% 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 % in The goal is to increase this proportion to 80% 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 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 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 % in 2010 Though currently exceeding the NHAS goal, continued efforts are in place to have greater viral suppression among this high HIV prevalence group 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 % in 2010 Though currently exceeding the NHAS goal, continued efforts are in place to have greater viral suppression among this high HIV prevalence group 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 % in 2010 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, †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 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 VS Achieved VS (n=648)Did not Achieve VS (N=340) CharacteristicN (%) Sex Male444 (68.5)240 (70.6) Female204 (31.5)100 (29.4) Age at HIV Diagnosis (24.5)106 (31.2) (26.5)92(27.1) (30.1)104(30.6) ≥50122 (18.8)38 (11.2) Race/Ethnicity White89 (13.7)54 (15.9) Black508 (78.4)268 (78.8) Hispanic38 (5.9)11 (3.2) Other*13 (2.0)7 (2.1) Risk Factor MSM263 (40.6)127 (37.4) IDU88 (13.6)51 (15.0) MSM/IDU19 (2.9)12 (3.5) Heterosexual201 (31.0)114 (33.5) Risk not identified77 (11.9)36 (10.6) Insurance Public295 (45.5)149 (43.8) Private132 (20.4)66 (19.4) No coverage45 (6.9)30 (8.8) Unknown176 (27.2)95 (27.9)

Clinical Characteristics by Achievement of VS Characteristic Achieved VS (n=648) Did not Achieve VS (N=340) N (%) Diagnostic Status HIV (not AIDS) 415 (64.2)256 (75.3) AIDS231 (35.8)84 (24.7) CD4 Count at Diagnosis < (37.6)85 (25.4) (21.0)52 (15.5) > (40.8)196 (58.5) VL at Diagnosis Mean VL 185, ,826.8 Median VL22, ,444.0 Linkage to Care <3 Months460 (71.0)228 (67.1) 3-6 Months45 (6.9)25 (7.4) 6-12 Months41 (6.3)27 (7.9) 12+ Months102 (15.7)60 (17.7) Annual VL test rate At least 2 VL tests per year288 (44.4)33 (9.7) Less than 2 VL tests per year360 (55.6)307 (90.3) Continuous Care Yes207 (31.9)76 (22.4) No441 (68.1)264 (77.6)

Predictors of Achieving Viral Suppression CharacteristicOR95%CIaOR†95%CI Age at HIV Diagnosis 13-29referent (0.89, 1.77)1.09(0.74, 1.62) (0.89, 1.76)1.13(0.77, 1.66) ≥502.14(1.38, 3.32)2.09(1.29, 3.39) Risk Factor MSMreferent IDU0.83(0.56, 1.25)0.60(0.37, 0.99) MSM/IDU0.77(0.36, 1.62)0.60(0.26, 1.40) Heterosexual0.85(0.62, 1.16)0.61(0.39, 0.93) Risk not identified1.03(0.66, 1.62)0.83(0.49, 1.39) Diagnostic Status HIV (not AIDS) referent AIDS1.70(1.26, 2.28)1.92(1.34, 2.74) CD4 Count at Diagnosis < (1.56, 2.81) (1.34, 2.81)-- > 350 referent-- Annual VL test rate At least 2 VL tests per year7.44(5.03, 11.0)8.02(5.31, 12.11) Less than 2 VL tests per yearreferent Continuous Care Yes1.63(1.20, 2.21)1.01(0.71, 1.44) Noreferent

Median Number of Days to Viral Suppression Linkage to CareRetention 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