HIV Care Continuum Persons Living With HIV, Georgia, 2012

Persons with HIV Engaged in Selected Stages of the Continuum of Care, United States Percent Hall et al. XIX International AIDS Conference, 2012 ART, antiretroviral therapy

Georgia Care Continuum Methodology, Persons Living With HIV (PLWH), 2012 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 risk 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 Estimated percentage prescribed ART derived from the Medical Monitoring Project (MMP) Georgia sample Viral suppression (VS) = VL<200 copies/ml in most recent VL All percentages are percent of total number of persons diagnosed with HIV

Special consideration: linkage to care within 3 months for prevalent population HIV reporting began in Georgia 2004; CD4 and viral load (VL) measurements are not available before this date Linkage to care proxy is CD4 or VL within 3 months of diagnosis date Linkage is missing for 54% of Georgia’s prevalent HIV population and therefore not represented here Linkage to care data are included in the New Diagnoses 2011 slide set for persons diagnosed in 2011

Special Consideration: people living with HIV, diagnosed in 2011 Linkage to care = CD4 or VL within 3 months of diagnosis For persons diagnosed in 2011, the first CD4 or VL represents linkage to care CD4 or VL within the first 3 months of diagnosis is excluded from the engagement and retention in care measurements To allow 12 months for engagement and retention in care and viral suppression, only persons diagnosed by 09/30/2011 and followed through 12/31/12 are included

Adults and adolescents living with HIV, Georgia, 2012 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 Prescribed ART derived from MMP sample Viral suppression (VS) = VL<200 copies/ml Estimated undiagnosed based on CDC projections for proportion undiagnosed nationally

Adults and adolescents living with HIV, by sex, Georgia 2012 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 Prescribed ART derived from MMP sample Viral suppression (VS) = VL<200 copies/ml Excludes 270 cases for whom sex was not reported

Adults and adolescents living with HIV, by race/ethnicity, Georgia, 2012 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

Adult and adolescent males living with HIV, by race/ethnicity, Georgia 2012 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 *American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <2% of males living with HIV in Georgia and are grouped with those of mixed or unknown race/ethnicity

Adult and adolescent females living with HIV, by race/ethnicity, Georgia 2012 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 American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <1% of adults living with HIV in Georgia and are grouped with those of mixed or unknown race/ethnicity N= 8,926 N= 492 N= 1303 N= 994

Adults and adolescents living with HIV by current age (years), Georgia 2012 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

Adult and adolescent males living with HIV by current age (years), Georgia 2012 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

Adult and adolescent females living with HIV by current age (years),Georgia 2012 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

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

Adult and adolescent males living with HIV, by transmission category, Georgia 2012 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. *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

Adult and adolescent females living with HIV, by transmission category, Georgia 2012 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. *IDU = 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

Black MSM* living with HIV, by current age (years), Georgia 2012 Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 15,657 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. *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

White MSM* living with HIV, by current age (years), Georgia 2012 Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 8,071 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. *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

Hispanic/Latino MSM* living with HIV, by current age (years), Georgia 2012 Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 1,670 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. *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

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

Viral suppression (VS) among adults and adolescents engaged and retained in care, by sex, Georgia 2012 *N= number retained in care Adults and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012, 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 N* = 13,160 N* = 4,298 N* = 71

Viral suppression (VS) among adult and adolescent males engaged and retained in care, by race/ethnicity, Georgia 2012 *N= number retained in care Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, 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 *American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <2% of males living with HIV in Georgia and are grouped with those of mixed or unknown race/ethnicity N* = 11,236 N* = 893N* =4,490 N* =2,078

Viral suppression (VS) among adult and adolescent females engaged and retained in care, by race/ethnicity, Georgia 2012 *N= number retained in care Adult and adolescent females >= age 13, diagnosed by 09/30/2011, living 12/31/2012, 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 *American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <2% of males living with HIV in Georgia and are grouped with those of mixed or unknown race/ethnicity N* = 186 N* = 3,350 N* = 432 N* = 330

Viral suppression (VS) among adults and adolescents engaged and retained in care, by current age (years), Georgia 2012 *N= number retained in care Adult and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012, 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 N* = 639N* = 2,568 N* = 7,265N* = 3,486N* = 6,436

Viral suppression (VS) among adult and adolescent males engaged and retained in care, by current age (years), Georgia 2012 *N = number retained in care Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, 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 N* = 436N* = 1,987 N* = 3,223 N* 4,992 N* = 2,522

Viral suppression (VS) among adult and adolescent females engaged and retained in care, by current age (years), Georgia 2012 *N= number retained in care Adult and adolescent females >= age 13, diagnosed by 09/30/2011, living 12/31/2012, 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 N* = 200 N* = 570 N* = 1,157 N* = 1,149 N* = 952

Viral suppression (VS) among adult and adolescent males engaged and retained in care, by transmission category**, Georgia 2012 *N= number retained in care; Males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, 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 **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 N* = 9,787 N* = 801 N* = 741 N* = 830N* 1,001

Viral suppression (VS) among adult and adolescent females engaged and retained in care, by transmission category**, Georgia 2012 *N= number retained in care; Females >= age 13, diagnosed by 09/30/2011, living 12/31/2012, 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 **HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection IDU = Injection drug use Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified N* = 3,129N* = 907 N*= 262

Viral suppression (VS) among Black MSM engaged and retained in care, by current age (years), Georgia 2012 *N= number retained in care Adult and adolescent Black MSM >= age 13, diagnosed by 09/30/2011, living 12/31/2012, 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 N* = 670N* = 2,658N* = 344N* = 136 N* = 68

Viral suppression (VS) among White MSM engaged and retained in care, by current age (years), Georgia 2012 *N= number retained in care Adult and adolescent White MSM >= age 13, diagnosed by 09/30/2011, living 12/31/2012, 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 N* = 39N* = 319N* = 849 N* = 136 N* = 68

Viral suppression (VS) among Hispanic/Latino MSM engaged and retained in care, by current age (years), Georgia 2012 *N= number retained in care Adult and adolescent H/L MSM >= age 13, diagnosed by 09/30/2011, living 12/31/2012, 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 N* = 23 N* = 200 N* = 344 N* = 253 N* = 74

Viral suppression (VS) among adults and adolescents engaged in care, Georgia, 2012, by diagnosis year Adults and adolescent s >= age 13, living 12/31/2012, current address Georgia = 46,495 Engaged in care >= 1 CD4 or VL in 2012 Viral suppression (VS) = VL<200 copies/ml

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 Cannot distinguish lack of prescription of ART, failure of ART adherence, or inappropriate medication choice Laboratory measures may be a poor proxy for engagement and retention in HIV care

Future analyses Monitoring the Care Continuum for both the prevalent population and by new diagnoses by year Advantages of monitoring the Care Continuum for new diagnoses: – Can measure linkage to care for new diagnoses – Excludes older cases who may have moved out of state – May be more sensitive for measuring effectiveness of interventions to improve testing, linkage, engagement and retention in care – Can measure time from diagnosis to viral suppression

Uncertainties Populations for which data are missing may be fundamentally different How to obtain data for transgender category How to improve completeness of reporting Data on ART use difficult to capture Understanding barriers to ART adherence Prioritizing further research

FOR MORE INFORMATION CONTACT: Georgia Department of Public Health HIV/AIDS Epidemiology Program