1. Late HIV Diagnoses, Georgia, 2011-2012
This slide set is public domain. Slides may be downloaded and used in publications or presentations without concern for copyright infringement. Readers are encouraged to note all titles and footnotes carefully to ensure a complete understanding of displayed data. Acknowledgement of the Georgia Department of Public Health (DPH) as the source of the data and slide is appreciated. Changes may be made in formatting or deletion of footnotes, but DPH should be consulted before any change is made in content.
All data reported here are provisional and should be interpreted with caution. Although HIV reporting is mandated for health care providers and laboratory facilities, not all providers and laboratories may comply, resulting in missing data. Laboratory tests performed in other jurisdictions may not be reported to DPH and therefore would not be included in these analyses. In this report, missing data are indicated as unknown.
Missing laboratory report data do result in an underestimation of care and viral suppression. Nevertheless, by maintaining methodological consistency across reporting time periods, DPH hopes to use the HIV Care Continuum to monitor improvements in HIV linkage, retention in care and ultimately viral suppression.
Production of this slide set was made possible by the work of the DPH HIV/AIDS Epidemiology Section Core HIV surveillance staff, HIV Case Report Forms submitted by Georgia health care facility staff, HIV infection-related laboratory test results transmitted by laboratory facilities in Georgia, data matches with other public health programs, and the ongoing efforts of multiple individuals from public and private sector organizations dedicated to improving surveillance, prevention, testing, and care of persons living with HIV infection.

2. Background
Late HIV diagnosis is defined as first CD4 within 12 months of diagnosis <200 cells/ml
Late HIV diagnosis is associated with shorter lifespan compared to those with earlier diagnosis.
 It is estimated that persons with late HIV diagnosis have been living 8-10 years with HIV, but have been undiagnosed and untreated.
 Persons with late HIV diagnosis have twice the lifetime risk of transmitting HIV to others compared to those diagnosed early.1
Late HIV diagnosis is defined as first CD4 within 12 months of diagnosis <200 cells/ml
Late HIV diagnosis is associated with shorter lifespan compared to those with earlier diagnosis.
 It is estimated that persons with late HIV diagnosis have been living 8-10 years with HIV, but have been undiagnosed and untreated.
 Persons with late HIV diagnosis have twice the lifetime risk of transmitting HIV to others compared to those diagnosed early.1
1 Farnham, P.G., et al, J Acquir Immune Defic Syndr, Vo. 64, No. 2, Oct 1,2013.

3. Costs of Late Diagnosis
Lifetime direct medical costs and productivity losses for new HIV infections were estimated in 2002 as almost $1 million per person.2
The costs are likely much higher today largely because of increased medical expenses.
 The biggest cost, however, is in terms of new infections transmitted.
 Each person with late HIV diagnosis has an average lifetime risk of transmitted HIV to 1.4 others.1
Depending on risk behaviors, number of partners, concurrent STDs, lifetime transmission risk can be even higher.
Further, persons unaware of their HIV diagnosis have a higher annual rate of sexual transmission on HIV (9% vs. 0.4% per person per year).1
Lifetime direct medical costs and productivity losses for new HIV infections were estimated in 2002 as almost $1 million per person.2
The costs are likely much higher today largely because of increased medical expenses.
 The biggest cost, however, is in terms of new infections transmitted.
 Each person with late HIV diagnosis has an average lifetime risk of transmitted HIV to 1.4 others.1
Depending on risk behaviors, number of partners, concurrent STDs, lifetime transmission risk can be even higher.
Further, persons unaware of their HIV diagnosis have a higher annual rate of sexual transmission on HIV (9% vs. 0.4% per person per year).1
2 Hutchinson, A.B., et al. J Acquir Immune Defic Syndr, Vol 43, No. 4, December 1, 2006.

4. Stage of disease by earliest CD4 count within 12 months of HIV diagnosis, adults and adolescents, Georgia, 2011
Because no CD4 count within 12 months of diagnosis was reported in 1003 persons in Georgia in 2011, stage of disease at diagnosis is missing in 35%
At least 22% of persons diagnosed in 2011 and living in Georgia were Stage 3 (CD4 less than 200 cells/ml) at diagnosis
Because of the high proportion of missing, the 22% figure for persons with stage 3 disease (AIDS) at or within 12 months of diagnosis is a minimum and may be higher.
Almost half (49%) of people diagnosed in 2011 living in Georgia, for whom the initial CD4 count is known were either stage 2 or 3 at or within a year of initial diagnosis
N=484
N=766
N=632
N=1003
Adults and adolescents >= age 13, diagnosed 1/1/ /31/2011, Georgia = 2885
CD4<200 = Stage 3 disease (AIDS)
Stage unknown = no CD4 within 12 months of diagnosis

5. Stage of disease by earliest CD4 count within 12 months of HIV diagnosis, adults and adolescents, by race/ethnicity, Georgia 2011
N=1616
N=144
N=271
N=854
This figures represents the number and proportion of adults and adolescents by stage at diagnosis by earliest CD4 count 12 months after diagnosis in 2011, by race/ethnicity, living in Georgia
The highest proportion of late diagnosis is seen among Hispanic/Latinos, who had at least 35% at Stage 3 (AIDS) at or within 12 months of diagnosis
The highest proportion of Stage Unknown is found among persons for whom race/ethnicity was not reported (45%). American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <2% of adults diagnosed with HIV in Georgia, 2011 and are grouped with other/unknown race/ethnicity
Improved case reporting including race, sex and transmission category is critical to accurate characterization of the HIV Care Continuum in Georgia
Adults >= age 13, diagnosed 1/1/ /31/2011, Georgia = 2885
CD4<200 = Stage 3 disease (AIDS)
Stage Unknown = no CD4 within 12 months of diagnosis
*American Indian/Alaska Native, Asian and Native Hawaiian/Pacific Islander groups together constitute <2% of adults diagnosed with HIV in Georgia, 2010 and are grouped with Unknown race/ethnicity

6. Stage of disease by earliest CD4 count within 12 months of HIV diagnosis, adult and adolescent males, by transmission category*, Georgia, 2011
N=1386
N=68
N=36
This figure shows the number and proportion of adult and adolescent males by stage at diagnosis by earliest CD4 count 12 months after diagnosis, by transmission category, Georgia, 2011
Although the high proportion of Stage Unknown limits comparison with other groups, the known proportions indicate that at least 23% MSM, 46% IDU, 25% MSM/IDU and 46% HET transmission category had stage 3 (AIDS) disease at or within 12 months of diagnosis.
Multiple imputation is used to estimate number of persons in each transmission category. Estimates are rounded to the nearest whole number and when totaled may not equal 2214
Adults and adolescent males >= age 13, diagnosed 1/1/ /31/2011, Georgia = 2214
CD4<200 = Stage 3 disease (AIDS) Stage Unknown = no CD4 within 12 months of diagnosis
Multiple imputation 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

7. Resources
For further information on late HIV diagnosis, the Care Continuum, surveillance reports, fact sheets and other slides sets visit:
The remainder of this presentation will focus on the Care Continuum among people with late HIV diagnoses in Georgia in 2011
For further information on late HIV diagnosis, the Care Continuum, surveillance reports, fact sheets and other slides sets visit:
The remainder of this presentation will focus on the Care Continuum among people with late HIV diagnoses in Georgia in 2011

8. Persons with HIV Engaged in Selected Stages of the Continuum of Care, United States82 66
Percent 37 33 25
The Centers for Disease Control and Prevention (CDC) estimated the HIV Care Continuum, sometimes called the HIV Care Cascade, for the US population. This slide, presented by Dr. Irene Hall at the XIX International AIDS Conference in 2012, is based on estimates from multiple subsets of the US population living with HIV. For example, linkage to care was extrapolated from the proportion of people linked to care within 3 months of diagnosis in 2009 from a regional study. Retained in care and viral suppression for the nation were based on estimates from local data, and the proportion prescribed antiretroviral therapy (ART) was based on Medical Monitoring Project (MMP) data. Despite these limitations, monitoring the continuum of care on the national, as well as the local level, can help to determine weak links in efforts to control HIV.
Because Georgia law mandates reporting of all HIV-related laboratory tests from laboratory facilities licensed in Georgia to the Georgia Department of Public Health (DPH), Georgia is able to create multiple care continuums for the state as a whole and stratified by demographic variables using reported laboratory test data. With complete reporting of all CD4 and viral load test results, surveillance data can now provide information on care and treatment outcomes.
This slide set presents HIV Care Continuum data for persons with HIV in diagnosed in Georgia
Hall et al. XIX International AIDS Conference, 2012
ART, antiretroviral therapy

9. Care Continuum Methodology, Late HIV Diagnoses 2011, Georgia
Adults and adolescents are those aged >= 13 years
Diagnosed between 01/01/ /31/11
Alive at least 15 months after diagnosis
Residence at diagnosis and current address within Georgia
Excludes 52 persons deceased within 15 months of diagnosis
Late diagnosis = first CD4 within 12 months of diagnosis <200
Linked to care = CD4 or VL within 3 months of diagnosis, excluding day of diagnosis
Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis
Retained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosis
Viral suppression (VS) = VL<200 copies/ml in most recent viral load
All percentages are percent of total number of persons with late diagnosis of HIV in 2011
The Georgia Care Continuum for persons diagnosed with HIV in 2011 uses the following methodology:
Persons included are adults and adolescents age 13 years and older at the time of diagnosis, and who were diagnosed between 01/01/11 and 12/31/11; alive at least 15 months after HIV diagnosis, residence at diagnosis and current address in Georgia
Excludes 52 persons deceased within 15 months of diagnosis
Late diagnosis is defined as first CD4 within 12 months of diagnosis <200 cells/ml
Linked to care is defined as having had a CD4 or viral load (VL) measurement within 3 months of diagnosis , excluding the CD4 or VL drawn on day of diagnosis
Engaged in care is defined as having had at least 1 CD4 or VL measurements 4-15 months after HIV diagnosis
Retained in care is defined as having had at least 2 CD4 or VL measurements at least 3 months apart 4-15 months after HIV diagnosis
Estimated percentage who were prescribed ART was derived from the Medical Monitoring Project (MMP) Georgia sample data
Viral suppression (VS) is defined as a VL<200 copies in most recent viral load
Each bar in the cascade is independent of those preceding it; all percentages are of the total number of persons diagnosed with HIV in category

10. HIV Care Continuum Methodology, Late Diagnosis, Georgia, 2011
Months 0-3 after diagnosis
Months 4-15 after diagnosis
Confirmatory Diagnosis Date
CD4 or Viral Load
CD4 or Viral Load
CD4 or Viral Load
For clarity, let’s look at an example.
On this timeline, the red dot represents the date of the confirmatory diagnostic test. The person in this example receives a CD4 or VL at 2 months <click> represented by this yellow mark, another CD4 or VL at 8 months <click> and a third at 12 months <click>. The first CD4 count at 2 months was <200. The last VL was <200 copies <click> Is this person linked, engaged, retained in care and virally suppressed?
This person is <click>:
Linked YES
Engaged YES
Retained YES
Virally suppressed YES
First CD4 <200 cell/ml
Last viral load <200 copies/ml
This person is:
Linked YES
Engaged YES
Retained YES
Virally suppressed YES

11. Adults and adolescents with late HIV diagnosis*, 2011, Georgia
This figure depicts the HIV Care Continuum for the 795 adults and adolescents with late HIV diagnosis in 2011 with residence at diagnosis in Georgia and living as of 03/31/2013, compared to that of all persons diagnosed
Among those with late diagnosis, 82% were linked to care within 3 months of diagnosis, 83% were minimally engaged in care with at least 1 CD4 or viral load (VL) 4-15 months after diagnosis, 66% retained in care with at least 2 CD4 or VL measures 4-15 months after diagnosis, 41% prescribed ART and 59% were virally suppressed. In contrast, among all persons with and without later diagnosis, 62% were linked, 66% engaged, 46% retained and 45% virally suppressed
Persons with late diagnosis are more likely than those is an earlier stage of disease to be symptomatic, seek care and be treated with ART. Nevertheless, viral suppression is achieved in only 59%
Note that all proportions are percent of total number of persons diagnosed with HIV in the category. Each bar is independent of the one preceding it. Hence it is possible for Engaged in Care to be greater than Linked to Care as seen here.
N = 795
N = 2885
Adults and adolescents >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11
*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/ml
Linked to care = CD4 or VL within 3 months of diagnosis
Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis
Retained in care >= 2 CD4 or VL at least 3 months apart months after diagnosis
Viral suppression (VS) = VL<200 copies/ml in most recent viral load = 1307
Note: all percentages are proportion of total number of persons diagnosed with HIV in category

12. Adults and adolescents with late HIV diagnosis*, by sex, Georgia, 2011
This figure shows the number and proportion of adults and adolescents with late HIV diagnosis in Georgia in 2011 and living as of 03/31/13
who are linked, engaged, retained and virally suppressed by sex.
Little difference is seen in the Late HIV Diagnosis Care Continuum by sex
Among 594 males with late diagnosis, 81% were linked to care within 3 months, 83% engaged, 66% retained and 59% virally suppressed
Among 169 females with late diagnosis, 86% were linked, 84% engaged, 66% retained and 60% virally suppressed
Adults and adolescents >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11
*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/ml
Excludes 32 persons for whom sex was not reported
Linked to care = CD4 or VL within 3 months of diagnosis
Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis
Retained in care >= 2 CD4 or VL at least 3 months apart months after diagnosis
Viral suppression (VS) = VL<200 copies/ml in most recent viral load

13. Adults and adolescents with late HIV diagnosis
Adults and adolescents with late HIV diagnosis*, by race/ethnicity, Georgia, 2011
This figure depicts the HIV Care Continuum for adults and adolescents with late HIV diagnosis in Georgia in 2011 by race/ethnicity.
Among 504 Blacks with late diagnosis 03/31/2013, 82% were linked to care within 3 months of diagnosis, 83% engaged, 64% retained and 54% virally suppressed.
Among 55 Hispanic/Latinos with late HIV diagnosis, 93% were linked, 90% engaged, 65% retained and 71% virally suppressed.
Among 99 Whites with late HIV diagnosis, 88% were linked, 87% engaged, 70% retained and 69% virally suppressed
Because American Indian/Alaska Native, Asian, and Native Hawaiian/Other Pacific Islanders combined equal <2% of new diagnoses in Georgia, these groups are included in Other/Unknown category shown to the far right on this slide. Race was not reported for the great majority of persons included in this category.
Among 137persons in the Other/Unknown Race category, 76% were linked, 79% engaged, 66% retained and 65% virally suppressed.
Complete reporting including race, sex, and transmission category is critical to HIV surveillance and identification of health care disparities
In contrast, for all persons diagnosed with HIV 2011,
Among 504 Blacks 62% were linked, 65% engaged, 44% retained and 38% virally suppressed.
Among 144 Hispanic/Latinos, 72% were linked, 70% engaged, 53% retained and 56% virally suppressed.
Among 271 Whites, 71% were linked, 73% engaged, 54% retained and 54% virally suppressed
Among 854 persons in the Other/Unknown Race category, 57% were linked to care within 3 months, 64% engaged, 55% retained and 54% virally suppressed.
Adults and adolescents >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11
*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/ml
Linked to care = CD4 or VL within 3 months of diagnosis
Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis
Retained in care >= 2 CD4 or VL at least 3 months apart months after diagnosis
Viral suppression (VS) = VL<200 copies/ml in most recent viral load
American Indian/Alaska Native, Asian, and Native Hawaiian/Other Pacific Islanders combined equal <2% of new diagnoses and are included in Other/Unknown

14. Adult and adolescent males with late HIV diagnosis
Adult and adolescent males with late HIV diagnosis*, by race/ethnicity, Georgia, 2011
This figure depicts the HIV Care Continuum for adult and adolescent males diagnosed with HIV infection in Georgia in 2011 by race/ethnicity.
Among 365 Black males with late HIV diagnosis in 2011 in Georgia 80% were linked to care within 3 months of diagnosis, 83% were engaged, 64% were retained and 54% were virally suppressed.
Among 47 Hispanic/Latino males, 91% were linked, 85% engaged, 73% retained and 71% virally suppressed.
Among 80 White males, 91% were linked, 72% engaged, 52% retained and 55% virally suppressed
Because American Indian/Alaska Native, Asian, and Native Hawaiian/Other Pacific Islanders combined equal <2% of new diagnoses in Georgia, these groups are included in Other/Unknown category shown to the far right on this slide. Race was not reported for the great majority of persons included in this category.
Among 102 males in the Other/Unknown Race category, 74% were linked to care within 3 months, 80% engaged, 68% retained and 65% virally suppressed.
Complete reporting including race, sex, and transmission category is critical to HIV surveillance and identification of health care disparities
In contrast for all persons diagnosed in 2011,
Among 1215 Black males were 59% linked, 63% engaged, 42% retained and 35% virally suppressed
Among 112 Hispanic/Latino males, 72% were linked, 74% engaged, 56% retained and 56% virally suppressed.
Among 216 White males, 73% were linked, 72% engaged, 52% retained and 55% virally suppressed
Among 671 males in the Other/Unknown Race category, 59% were linked to care within 3 months, 66% engaged, 47% retained and 57% virally suppressed.
Adult and adolescent males >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11
*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/ml
Linked to care = CD4 or VL within 3 months of diagnosis
Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis
Retained in care >= 2 CD4 or VL at least 3 months apart months after diagnosis
Viral suppression (VS) = VL<200 copies/ml in most recent viral load
American Indian/Alaska Native, Asian, and Native Hawaiian/Other Pacific Islanders combined equal <2% of new diagnoses and are included in Other/Unknown

15. Adult and adolescent females with late HIV diagnosis
Adult and adolescent females with late HIV diagnosis*, by race/ethnicity, Georgia, 2011
This figure depicts the HIV Care Continuum for adults and adolescents diagnosed with HIV infection living in Georgia in 2011 by race/ethnicity.
Please note the small N for some categories (e.g., 8 Hispanic/Latino females with late diagnosis) and use caution in interpretation
Among 137 Black females with late HIV diagnosis, 88% were linked to care within 3 months of diagnosis, 82% engaged, 70% retained and 57% virally suppressed.
Among 8 Hispanic/Latino females, 100% were linked, 100% engaged, 75% retained and 88% virally suppressed.
Among 19 White females, 74% were linked, 95% engaged, 58% retained and 58% virally suppressed
Because American Indian/Alaska Native, Asian, and Native Hawaiian/Other Pacific Islanders combined equal <2% of new diagnoses in Georgia, these groups are included in Other/Unknown category shown to the far right on this slide. Race was not reported for the great majority of persons included in this category.
Among 32 females in the Other/Unknown Race category, 84% were linked to care within 3 months, 78% engaged, 63% retained and 69% virally suppressed.
Complete reporting including race, sex, and transmission category is critical to HIV surveillance and identification of health care disparities
In contrast for all persons diagnosed in 2011,
Among 390 Black females 72% were linked , 71% engaged, 51% retained and 50% virally suppressed
Among 32 Hispanic/Latino females, 69% were linked, 56% engaged, 41% retained and 53% virally suppressed
Among 55 White females, 64% were linked, 76% engaged, 45% retained and 47% virally suppressed
Among 178 females in the Other/Unknown Race category, 53% were linked to care within 3 months, 57% engaged, 35% retained and 44% virally suppressed
Adult and adolescent females >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11
*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/ml
Linked to care = CD4 or VL within 3 months of diagnosis
Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis
Retained in care >= 2 CD4 or VL at least 3 months apart months after diagnosis
Viral suppression (VS) = VL<200 copies/ml in most recent viral load
American Indian/Alaska Native, Asian, and Native Hawaiian/Other Pacific Islanders combined equal <2% of new diagnoses and are included in Other/Unknown

16. Adults and adolescents with late HIV diagnosis*, by age, Georgia, 2011
This figure shows the number and proportion of adults and adolescents with late HIV diagnosis in 2011 in Georgia and living as of 03/31/2013, linked, engaged, and retained in care and virally suppressed by age at diagnosis (years).
Although persons aged years at time of late HIV diagnosis were 81% linked and 88% engaged in care, viral suppression was achieved in only 52%
Viral suppression generally increases with increasing age from 52% among those aged years to 65% among those aged years and 55% among those aged 55 years and older
Among all those diagnosed with HIV in 2012:
Viral suppression generally increases with increasing age in a similar pattern to those with late diagnosis from 34% among those aged years to 54% among those aged years and 52% among those aged 55 years and older
Adults and adolescents >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11
*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/ml
Linked to care = CD4 or VL within 3 months of diagnosis
Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis
Retained in care >= 2 CD4 or VL at least 3 months apart months after diagnosis
Viral suppression (VS) = VL<200 copies/ml most recent viral load
Note: all percentages are percent of total number of persons diagnosed with HIV in category

17. 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
Because transmission category is not reported for a large proportion of HIV cases in Georgia, multiple imputation was used to re-distribute transmission category where it was missing. This statistical technique is the same as that used by CDC in re-distribution of transmission category in the national dataset
MSM is defined as male to male sexual contact
IDU is defined as injection drug use
The MSM/IDU transmission category includes those persons who reported both male sexual contact and injection drug use
HET is defined as heterosexual contact with a person known to have, or to be at high risk for, HIV infection
Other includes the transmission categories of hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

18. Multiple Imputation
Multiple imputation (MI) methods are used to assign transmission categories to those persons whose diagnoses are reported without a risk factor
MI is a statistical approach in which missing transmission categories are replaced with plausible values
CDC uses MI for the national HIV dataset*
Georgia uses the same methodology as CDC
Missing data is an ongoing problem in routinely collected data or large-scale epidemiologic studies.
Because a substantial proportion of persons with diagnosed HIV infection are reported to the Georgia Department of Public Health without an identified risk factor, multiple imputation methods are used to assign transmission categories to those persons whose diagnoses are reported without a risk factor
Multiple imputation is a statistical approach in which missing transmission categories for each person are replaced with plausible values that represent the uncertainty regarding the actual, but missing, values.
This is the same statistical strategy that the CDC uses to assign transmission categories to those reported without a risk factor in the national dataset
Whether these transmission category adjustments using MI introduce any bias in overestimation or underestimation of percentages of HIV infection attributed to specific categories is unknown.
*Harrison KM, Kajese T, Hall HI, Song R. Risk factor redistribution of the national HIV/AIDS surveillance data: an alternative approach. Public Health Rep 2008;123:618–27.

19. Adult and adolescent males with late HIV diagnosis
Adult and adolescent males with late HIV diagnosis*, by transmission category**, Georgia, 2011
This figure shows the number and proportion of adult and adolescent males with late HIV diagnosis who are linked, engaged, retained and virally suppressed by transmission category, living in Georgia, 2011
Please note the small N for some categories (e.g., 11 males in the MSM/IDU transmission category) and use caution in interpretation
Although 82% of MSM were linked and 85% engaged in care, viral suppression was lowest for MSM at 53%
Although the “Other” transmission category has the lowest proportion linked (70%) and highest proportion of viral suppression (64%), this is difficult to interpret as no transmission category information was reported on most of the cases in this group.
Complete reporting of risk information on case report forms would improve our understanding and interpretation of the care continuum.
Multiple imputation is used to estimate the number of persons in each transmission category. Estimates are rounded to the nearest whole number.
These findings are qualitatively similar to those for all new diagnoses 2011 by transmission category:
Viral suppression is lowest among MSM and MSM/IDU (both 39%), higher among HET (48%) and highest among Other (58%).
Adult and adolescent males >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11
*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/ml
Linked to care = CD4 or VL within 3 months of diagnosis
Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis
Retained in care >= 2 CD4 or VL at least 3 months apart months after diagnosis
Viral suppression (VS) = VL<200 copies/ml in most recent viral load
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

20. Adults and adolescent females with late HIV diagnosis
Adults and adolescent females with late HIV diagnosis*, by transmission category**, Georgia, 2011
N= 30
N= 139
N= 27
This figure shows the number and proportion of adult and adolescent females with late HIV diagnosis in Georgia in 2011 and living as of 03/31/13
who are linked, engaged, retained and virally suppressed by transmission category
Please note the small N in some categories (e.g., IDU N=30) and use caution in interpretation
Linkage was high at 87% for women in the IDU and HET transmission categories but then the groups diverge
Among female IDU, 90% were engaged, 70% retained and 70% viral suppression
Among female HET, 84% were engaged, 67% retained and 57% viral suppression
Note that the “Other” category includes women missing risk information re-distributed to this category. Among these, 61% achieved viral suppression. Reporting risk information is critical in HIV reporting so that we can better understand the epidemiology and needs of this population
Multiple imputation is used to estimate number of persons in each transmission category. Estimates are rounded to the nearest whole number
In contrast, among all women diagnosed in 2011,
54% of women in the IDU transmission category and 50% in the heterosexual transmission category are virally suppressed
Adult and adolescent females >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11
*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/ml
Linked to care = CD4 or VL within 3 months of diagnosis
Engaged in care >= 1 CD4 or VL 4-15 months after diagnosis
Retained in care >= 2 CD4 or VL at least 3 months apart months after diagnosis
Viral suppression (VS) = VL<200 copies/ml in most recent viral load
Multiple imputation was used to re-distribute transmission category where missing
**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

21. Adults and adolescents, total diagnosed and late diagnosis
Adults and adolescents, total diagnosed and late diagnosis*, Georgia, 2011
The 2 bar graphs on the left side of this figure depict the Care Continuum for all persons diagnosed with HIV in Georgia 2011 and for those in the IDU transmission category, Georgia, 2011
The 2 bar graphs on the right side of this figure depict the Care Continuum for all persons with late diagnosis in Georgia 2011 and for late diagnosis IDU
The Care Continuum for late diagnosis IDU more closely resembles that of all late diagnosis than it does that of all IDU.
IDU transmission category is less predictive of care continuum outcomes than late diagnosis status
Perhaps counter-intuitively, late diagnosis is a predictor of viral suppression.
Persons with late diagnosis have AIDS by definition and are more likely to be symptomatic, may have initially presented to medical care with an opportunistic infection, and are more likely to be virally suppressed because of ART administration, regardless of HIV transmission category
Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia
* Late diagnosis = Stage 3 (AIDS)at or within 12 months of initial HIV diagnosis
Multiple imputation is used to estimate number of persons in each transmission category.
IDU = Injection drug use

22. Conclusions
Late diagnosis is a predictor or viral suppression (VS) among persons diagnosed with HIV in 2011 in Georgia (VS 45% overall vs. 59% late diagnosis)
Among those with late diagnosis 2011, VS by race was lowest for Blacks (54%) than Hispanic/Latinos (71%) or Whites (69%)
Among those with late diagnosis 2011, VS by age was lowest for age years (52%) and highest for age years (65%)
In conclusion,
Late diagnosis is a predictor or viral suppression (VS) among persons diagnosed with HIV in 2011 in Georgia (VS 45% overall vs. 59% late diagnosis)
Among those with late diagnosis 2011, VS by race was lowest for Blacks (54%) than Hispanic/Latinos (71%) or Whites (69%)
Among those with late diagnosis 2011, VS by age was lowest for age years (52%) and highest for age years (65%)

23. Limitations Incomplete reporting
Missing data for race/ethnicity, sex, and complete address at diagnosis
Lack of transmission category information
Estimation using multiple imputation to redistribute risk when missing
Missing laboratory reports
Small N is some sub-groups limits meaningful analysis
There are multiple limitations in examining the HIV Care Continuum in Georgia
Incomplete reporting on case report forms on race, sex, complete address at diagnosis and risk behavior (which is used in defining transmission category) limit stratification and comparison among groups
Georgia HIV Surveillance is limited by a high proportion of missing risk behavior information on case report forms. Rather than presenting the data as No Reported Risk for these cases, Georgia utilizes multiple imputation, a statistical technique used by the Centers for Disease Control and Prevention (CDC) to re-distribute missing information and estimate transmission category.
Health care providers and organizations serving people living with HIV are encouraged to complete case report forms with risk category information
Although electronic laboratory reporting to the Georgia Department of Public Health has greatly improved in recent years, certain laboratory facilities (such as the Veterans Administration laboratories) are not required by law to report HIV-related laboratory results (although they do report new HIV cases), thus limiting Georgia CD4 and viral load ascertainment

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