1. Mean HIV viral load among resident cases and undiagnosed in Oregon Jeff Capizzi, Epidemiologist Sean Schafer, HIV/STD/TB Medical Epidemiologist Lea Bush, Program Analyst HIV/STD/TB Program, Public Health Division 971-673-0182 Jeff.Capizzi@state.or.us HIV Data and Analysis: http://public.health.oregon.gov/DiseaseConditions/CommunicableDisease /DiseaseSurveillanceData/HIVData/Pages/Index.aspx http://public.health.oregon.gov/DiseaseConditions/CommunicableDisease /DiseaseSurveillanceData/HIVData/Pages/Index.aspx

2. Presenter disclosure Jeffrey Capizzi The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose

3. Objectives of this presentation Review methods and findings of a population viral load analysis in Oregon – Describe trends in Oregon diagnoses and viral loads – Estimate prevalence of people infected with HIV in Oregon (diagnosed and undiagnosed residents) – Describe undiagnosed residents with high viral loads – Describe diagnosed residents with high viral loads Hypothesize reasons why the community viral load in Oregon may differ from other regions

4. Background Decreases in HIV viral load associated with decreased transmission Community Viral Load (CVL), a measure of transmission potential among those diagnosed (in/out of care) Population Viral Load (PVL), a measure of both CVL and viral loads among those undiagnosed Metrics include: – Mean Viral Load (MVL) – Proportion with suppressed viral load (≤200 copies/mL ) – Proportion with high viral load (≥10,000 copies/mL )

5. Data used in the analysis Oregon HIV/AIDS Reporting System (eHARS) Residence updated from CD4/viral load test results and Oregon’s AIDS Drug Assistance Program data system A comparison with Medical Monitoring Project random sample of HIV patients, suggested viral load reporting completeness at 96% and case reporting 98%

6. Methods Based on: Guidance on Community Viral Load: Measures, Definitions, and Methods for Calculation, CDC, August 2011 MVL for undiagnosed residents – The number of people undiagnosed in Oregon was based on national estimates of the percent unaware of their HIV infection – The number estimated undiagnosed was then assigned the observed mean first viral load of Oregon diagnoses, 8/9/06– 8/8/11 MVL for diagnosed residents – Last viral load in previous 12 months – If missing, the last viral load in 18 months was used (n=374/5,582) – Cases without a viral load in 18 months, were assigned the mean first viral load among Oregon diagnoses (n=263/5,582)

7. Methods Variables – Sex – Age – Race/ethnicity – Urban/Rural – Transmission category – HIV/AIDS status Group differences – Geometric mean (z-score) – Percent clinically suppressed – Percent with high viral load

8. Diagnosis rate dropped from 8.5 to 6.2 cases/100,000 residents, 2003–2011 Among all cases with viral loads reported in Oregon, 2007–10: – MVL decreased from 245 to 97 copies/mL – Clinical suppression increased from 67% to 80% – High VL decreased from, 19% to 9% HIV(notAIDS) reporting began Oct. 2001 All CD4 / viral loads reportable Aug. 2006

9. Viral load among undiagnosed residents National estimates of the percentage unaware of infection were used to estimate the number of Oregon residents undiagnosed (Torian et al, MMWR June 3, 2011); (5,582 resident cases/(1 - 0.201) = 6,986 total infected, of which 1,404 were undiagnosed) A MVL of 33,884 copies/mL per person was observed among 1,137 new diagnoses in Oregon, 8/9/2006– 8/8/2011 1,404 undiagnosed residents had a MVL of 33,884 copies/mL 73% had a MVL of ≥10,000 copies/mL

10. Residents not yet diagnosed in Oregon with higher MVL Those who will be first diagnosed with AIDS vs. HIV(notAIDS) (74,131 vs. 16,982 copies/mL) Males vs. females (38,018 vs. 15,848 copies/mL) Males with unknown risk vs. MSM (75,857 vs. 36,307 copies/mL) Male IDU had a MVL = 12,022 copies/mL No statistical differences by age, race or region

11. CVL among resident living cases 5,582 diagnosed residents had a MVL of 92 copies/mL 80% had clinically suppressed viral load (≤200 copies/mL) 10% had a MVL of ≥10,000 copies/mL

12. Living resident cases with higher MVL HIV(notAIDS) status vs. AIDS (120 vs. 60 copies/mL) 20-24 vs. 45-49 year olds (645 vs. 75 copies/mL) African Americans vs. whites (169 vs. 85 copies/mL) Male IDU & MSM/IDU vs. MSM (117 & 131 vs. 85 copies/mL) Female IDU vs. heterosexual contact (204 vs. 93 copies/mL) No statistical differences by sex or region

13. Population Viral Load Population viral Load = (5,582 cases * 92 copies/mL) + (1,404 undiagnosed* 33,884 copies/mL) = 513,544 + 47,573,136 = 48,086,680 copies/mL MVL among Oregon population = (48,086,680 copies/mL)/6,986 persons) = 6,883 copies/mL per person

14. Residents with high viral load High viral loads (≥10,000 copies/mL) 73% of undiagnosed 10% of diagnosed 65% of high viral loads among undiagnosed

15. Conclusions 65% of high viral loads among the undiagnosed Higher MVLs in Oregon undiagnosed residents were among – Those who will be first diagnosed with AIDS – Males – Males with unknown risk Higher MVLs in Oregon diagnosed residents were among – HIV(notAIDS) cases – Younger people – IDUs – African Americans

16. Why might Oregon’s viral load be lower than other jurisdictions? The Oregon diagnosis rate is about half the national average of around 16 diagnoses/100,000 residents Oregon’s ADAP covers insurance premiums so that almost all cases have access to ART Long-term state-supported syringe exchange program Living cases are mostly older MSM (64% MSM-only; mean age of all cases = 47 years) Oregon’s low population density isolates sexual and IDU networks relative to other regions Tiered case management system outside the Portland Metro Area uses Assoc. of Nurses in AIDS Care certified nurses to work with private medical providers and high acuity patients