Dr. Kathleen Brady of Philadelphia's AIDS Activities Coordinating Office (AACO) gave this presentation at the January 9, 2013 Comprehensive Planning Committee meeting.

1. The HIV Engagement in Care
Cascade
KATHLEEN A. BRADY, MD
MEDICAL DIRECTOR/MEDICAL
EPIDEMIOLOGIST
AIDS ACTIVITIES COORDINATING OFFICE
JANUARY 9, 2013

2. The Gardner Cascade

3. Engagement in Care

4. Gardner Stage of Engagement in HIV Care

5. Gardner Stage of Engagement in HIV Care
19%
undetectable

6. National and Local Engagement in Care
 Data
 National and local HIV Surveillance System
 Prevalence (total, diagnosed) – number of persons living with HIV
 Linkage to care
 Medical Monitoring Project (MMP)
 Retention in care
 Prescribed ART
 Viral suppression

7. Methods
 Prevalence
 HIV diagnosis data
 Data adjustments at the national level
 Back-calculation methods to estimate unaware
 Linkage to Care
 Data reported through December 2011
 Percentage of persons with >1 CD4 or viral load test result
within 3 months of HIV diagnosis

8. Medical Monitoring Project
 MMP is a national probability sample of HIV-infected
persons receiving care in the US in order to:
 describe HIV care and support services being received and the
quality of such services
 describe the prevalence and occurrence of co-morbidities related to
HIV disease
 determine prevalence of ongoing risk behaviors and access to and
use of prevention services among persons living with HIV
 identify met and unmet needs for HIV care and prevention services
in order to inform community and care planning groups, health care
providers and other stakeholders
 Philadelphia has participated in MMP since 2005. All
charts of sampled patients are abstracted for clinical
information and patients are offered a voluntary
interview.

9. MMP Population Size Estimates
 States, facilities, and patients sampled with known
probabilities
 Analysis weights include:
 Design weights
 Inverse of the probability of selection
 Extend inference from sample to reference population
 Non-response adjustment
 Extend inference from respondents to sample
 Sum of weights estimates number of HIV-infected
adults who received at least one medical visit
January-April 2009

10. MMP Definitions
 Retention in care: Number of HIV-infected adults
who received at least one medical care visit between
January and April 2009
 Prescription of antiretroviral therapy (ART):
Documentation in medical record abstraction of any
ART prescription in the past 12 months
 Viral suppression: Documentation in medical
record abstraction of most

12. Philadelphia Engagement in Care, 2009
25000 19188
20000 100% 15753
82% 11894
15000 62% 9944 8751
52% 46%
10000 5775
30%
5000
0

13. For every 100 people living with HIV:
US Philadelphia
Number Number
Are aware of their Are aware of their
82 82
infection infection
66 Are linked to HIV care 62 Are linked to HIV care
37 Stay in HIV care 52 Stay in HIV care
Get antiretroviral Get antiretroviral
33 46
therapy therapy
Have a very low amount Have a very low amount
25 30
of virus in their body of virus in their body
2009 Data

14. Who is Aware?

15. Philadelphia Engagement in Care, 2009
25000 19188
20000 100% 15753
82% 11894
15000 62% 9944 8751
52% 46%
10000 5775
30%
5000
0

18. HIV Prevalence in Philadelphia
(reported thru 6/30/2012)
 19,157 PLWHA (aware)  Rates (known) vary by
 11,583 AIDS cases race
 7,574 HIV cases  2.1% of blacks
 5,092 estimated to be  1.5% of Latinos
living with HIV and  0.7% of whites
unaware  Rates vary by sex
 1.59% Philadelphia  1.9% of males
residents estimated to be  0.7% of females
HIV+

19. HIV/AIDS Cases by Date of Diagnosis
AIDS HIV
1400 1308 1302
1178 1177 1200
1200 1001
Number of Cases
898 894 895 907 861 940 918 921 893
1000 821
712 756 729 712
800 652
600 452
400 221 239
176
200
0
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
10
11
19
19
19
19
19
19
19
20
20
20
20
20
20
20
20
20
20
20
20
Year
19

20. HIV/AIDS Cases by Sex and Date of
Diagnosis
AIDS Female AIDS Male HIV Female HIV Male
1600
1400
Number of Cases
1200
1000
800
600
400
200
0
91
93
95
97
99
01
03
05
07
09
11
19
19
19
19
19
20
20
20
20
20
20
Year
20

21. HIV Cases by Race/Ethnicity and Date of
Diagnosis
White AfrAm Hispanic
700
575 594
600 534
498
Number of Cases
479
500
400
300
171
200 142 127
210 106 110
100 133 146 127
95
0
2006 2007 2008 2009 2010 2011
Year
21

22. HIV diagnoses by risk group, 2007-2011
600
500
400
300
200
100
0
2007 2008 2009 2010 2011
MSM IDU HET

23. Demographics of new positives, MSM
New HIV diagnoses among New HIV diagnoses among
MSM by race, 2007-2011 MSM by age, 2007-2011
70% 60%
60% 50%
50% 40%
40%
30%
30%
20% 20%
10% 10%
0% 0%
Black Latino White 13 - 24 25 - 44 45+

24. Demographics of new positives, MSM youth
New HIV diagnoses among New HIV diagnoses among
MSM youth, 2007-2011 MSM youth, 2007-2011
Race Age
7.6%
12.6%
9.3%
75.4% 92.0%
Black White Latino 13-17 18-24

27. Demographics of new positives, IDU
New HIV diagnoses among New HIV diagnoses among
IDU, 2007-2011 IDU, 2007-2011
Race Age
10.2%
16.0%
44.1% 36.2%
38.0% 53.1%
Black White Latino 13-24 25-44 45+

28. Demographics of new positives, IDU
2007 - 2011
Sex
0
29.8%
Male
Female
70.1%

30. Demographics of new positives, Heterosexuals
New HIV diagnoses among New HIV diagnoses among
HET, 2007-2011 HET, 2007-2011
Race Age
8.8% 3.8%
15.0% 34.6%
50.6%
72.7%
Black White Latino 13-24 25-44 45+

31. Demographics of new positives, HET
2007 - 2011
Sex
0
Male
49.2%
Female
50.7%

35. Summary
 High HIV morbidity in Philadelphia
 Philadelphia epidemic predominantly affects
minority populations
 MSM and Heterosexual transmission
predominant modes of transmission
 Cases among MSM are increasing
 Growing numbers of persons living with HIV
and AIDS
 25% decline in newly diagnosed AIDS
35

36. Who is getting infected?

37. Philadelphia Engagement in Care, 2009
25000 19188
20000 100% 15753
82% 11894
15000 62% 9944 8751
52% 46%
10000 5775
30%
5000
0

38. Incidence Surveillance
 Collect and STARHS test the diagnostic blood
specimens from all newly diagnosed HIV infections
reported from public and private laboratories and
providers to HIV Surveillance Unit.
 Collect the HIV testing information needed for the
statistical estimates of incidence.
 Calculate population-based estimates of HIV
incidence.
 Use these estimates to identify emerging sub-
epidemics, monitor trends, target prevention
resources and interventions to areas and
populations most heavily affected, and evaluate
programs.

39. Incidence vs. Prevalence
1981 2006 2007
HIV Incidence = the number of individuals newly infected
with HIV within a given period of time (6 - 12
months).
1981 2006 2007
HIV Prevalence = the total number of HIV cases that exist at a
specific time within a specific population.

40. What is STARHS?
Serologic
Testing
Algorithm for
Recent
HIV
Seroconversion

41. Requirements for HIV Incidence
Surveillance
Remnant HIV+ Supplemental Data
Serum Includes:
•Race, sex, mode of
STARHS transmission
Testing •Testing history &
using BED reasons for testing
(Calculating weights)
Assay
•Any exclusionary
info (AIDS
diagnosis, prior
recent ART)
•Adjust for LFU, QNS
HIV Incidence Estimation

42. CDC STARHS Test Results
 (+) standard test and (+) STARHS test
= long-standing HIV infection
 (+) standard test and (-) STARHS test =
recent HIV infection

43. National Incidence Data, 2010
 Estimated 47,500 HIV infections in 2009 in adults
and adolescents (95% CI, 42,000 – 53,000)
 Estimated incidence 18.8 infections per 100,000 population
 44% among blacks, 21% Latinos
 63% among MSM, 25% heterosexual
 26% among 13-24 year olds
 Early signs of an encouraging decrease in new HIV
infections among black women
 21 percent decrease between 2008 and 2010
 Continuing increase in new infections among young
gay and bisexual men
 22 percent increase between 2008 and 2010

44. 2010 Local Estimate of
HIV Incidence
 Local estimate of 577 new HIV infections in 2010 in
adults and adolescents (95% CI, 385-769)
 2010 estimate is significantly lower than the
estimate from 2008 (926 infections) and 2009
(945 infections)
 Case rate of 45.1 infections per 100,000 population
(2.4 times that of the national rate)
 The estimated decline in incidence must be
interpreted with caution due to violations in the
estimation assumptions

45. HIV Incidence Trends by Demographic Groups
1000
800
Total
600 Age 13-24
400 Male
200 Black
MSM
0
2006 2007 2008 2009 2010

46. HIV Incidence Trends by Demographic Groups
1000
800 Total
600 Age 13-24
400 Male
200 Black
0 MSM
2006 2010

47. Estimated Incidence Rates - 2010
Population Population in Incidence Estimated 95% CI 95% CI
2010 (13 +) Estimate, Case Rate lower upper
ESTIMATED 20010 per bound bound
100,000
MSM 29,737 306 1,029.0 578.4 1,483.0
IDU 37,378 44 117.7 0.0 254.2
HET 294,682 226 76.7 30.1 60.1
*Includes persons >13 living in poverty
Data Source: PDPH/AACO HIV Incidence Surveillance Program

48. Incidence Summary
 Includes people unaware of their status.
 40% decrease between 2009 and 2010
 P<0.05
 Declines in all demographic groups
 Incidence higher than baseline 2006 data for MSM
and youth 13-24

49. Who is unaware?

50. Philadelphia Engagement in Care, 2009
25000 19188
20000 100% 15753
82% 11894
15000 62% 9944 8751
52% 46%
10000 5775
30%
5000
0

51. Concurrent HIV/AIDS, 2010

52. Concurrent HIV/AIDS, 2010

53. National HIV Behavioral Surveillance
 Risk Behaviors
 Assess prevalence of and trends in risk behaviors
 Sexual risk behaviors
 Drug-use risk behaviors
 HIV Testing Behaviors
 Assess prevalence of and trends in HIV testing behaviors (not
included until HET-1)

54. NHBS Objectives (cont.)
 Prevention
 Assess exposure to and use of prevention services
 Assess impact of prevention services on behavior
 Identify prevention service gaps and missed opportunities for
prevention

55. NHBS-MSM3
 Interviews conducted at venues where at least 50%
of men identified as MSM
 List of venues included in your attachments
 566 MSM interviewed in Philadelphia
 545 had sex with a man in the last 12 months
 26.2% white, 57.6% black, 11.4% Latino
 83.6% identified as gay, 14.6% bisexual, 1.9% as straight

56. NHBS-MSM Summary
 We are not currently meeting the PHS guidelines for
HIV testing
 76.8% of MSM ever tested
 Less than half (46.9%) of MSM had tested in the last year
 Lower prevalence of HIV in MSM seen in
Philadelphia

57. Philadelphia NHBS-MSM3, 2011
Demograp MSM3 MSM3
hic Group % HIV % New
% of MSM who had an Positive Positiv
HIV test in the last 12 Tested = es
519
months
78.5% Total 11.9% 29.0%
Race
76.4% 76.2% 76.1% Black 14.9% 31.8%
White 8.5% 16.7%
Latino 6.8% 50.0%
NHBS-MSM3 Age
ALL MSM Black MSM 18-24 8.2% 50.0%
Latino MSM White MSM 25-44 10.6% 35.1%
45+ 19.8% 21.1%

58. NHBS-IDU2
 539 IDU interviewed in Philadelphia
 75.3% male, 24.7% female, 88.1% over 30
 54.8% black, 42.8% white, 15% Latino
 87.8% reported ever testing for HIV with 2.8% reporting
being HIV+
 38.6% reported having an HIV test within the last year
 16.0% reported having an HIV test within the last 6
months
 57.7% ever tested for Hepatitis C
 52.1% told they had Hepatitis (95.0% Hep C)

59. IDU2 Testing Data
Demographic IDU2 IDU2
Group % HIV Positive % New
(Tested = 536) Positives
Total 8.9% 68.1%
Gender
Male 7.7% 70.0%
Female 12.9% 64.7%
Race
Black 14.3% 65.7%
White 2.6% 80.0%
Latino 8.6% 71.4%

60. IDU2 Testing Data
Demographic IDU2 IDU2
Group % HIV Positive % New
(Tested = 536) Positives
Age Group
18-24 0.0% 0.0%
25-44 3.8% 66.7%
45+ 13.5% 60.5%
Geographic Area
Kensington 4.2% 66.6%
NW 12.5% 100.0%
North 8.6% 76.9%
West 23.4% 55.5%

61. What is a High-Risk Heterosexual?
 Past definitions
 Multiple sexual partners
 Sexual partners’ risks
 New definitions evaluated in NHBS-HET1
 Geography (HIV is clustered in high-poverty
neighborhoods)
 Social networks (Some social and sexual networks have
high HIV despite equal individual risks, greater inter-
network mixing)

62. HIV Prevalence
NHBS-HET1 2006-2007
HIV Test Result N (%)
Negative 14,543 (98)
Positive 294 (2)
Total 14,837 (100)
2% HIV prevalence is 10 to 20 times greater
than that among all heterosexuals in the U.S.

63. HIV Prevalence, by Census Tract Poverty
NHBS-HET1 2006-2007
Percent HIV-positive
Chi-Square Trend, p< 0.0001
0 − 9% 10 − 19% 20 − 29% 30 − 39% ≥ 40%
Proportion of Census Tract Residents Living Below the Poverty Level

64. HIV Prevalence, by Income
NHBS-HET1 2006-2007
Percent HIV-positive
Chi-Square Trend, p< 0.0001
0 − 9,999 10 − 19,999 20 − 49,999 ≥ 50,000
Annual Household Income (in Dollars)

65. HIV Prevalence, by Income
NHBS-HET1 2006-2007
Percent HIV-positive
0 − 9,999 10 − 19,999 20 − 49,999 ≥ 50,000
Annual Household Income (in Dollars)

66. HIV Prevalence, by Income
NHBS-HET1 2006-2007
Percent HIV-positive
6X Greater
0 − 9,999 10 − 19,999 20 − 49,999 ≥ 50,000
Annual Household Income (in Dollars)

67. HIV Prevalence, Multivariable Model*
NHBS-HET1 2006-2007
Low socioeconomic status was
associated with higher HIV prevalence:
• Low income
• Limited education
• Unemployment
• Resident of city
• Sex with an opposite-gender partner in the past year
• English- or Spanish-speaking
*Controlling for
city, sex, race/ethnicity, age, education, employment, income, homeless
status, crack use, exchange sex, and STD diagnosis.

68. HIV Surveillance & Census Data
37 States with HIV Reporting 2007
Heterosexuals Living with HIV
Persons (in thousands)
African- Latino White
American

69. HIV Surveillance & Census Data
37 States with HIV Reporting 2007
Heterosexuals Living with HIV Adult & Adolescent Population
Persons (in thousands)
Persons (in millions)
African- Latino White African- Latino White
American American

70. Ratio of Heterosexuals Living
with HIV to the Population–
African-Americans:
> 20 times greater
Latinos:
6 times greater

71. HIV Prevalence, by Race/Ethnicity
NHBS-HET1 2006-2007
Percent HIV-positive
p= 0.14
African- Latino White
American

72. HIV Prevalence, by Race/Ethnicity
NHBS-HET1 2006-2007
All Census Tracts High Poverty Census Tracts
Percent HIV-positive
Percent HIV-positive
p= 0.73
p= 0.14
African- Latino White African- Latino White
American American

73. HIV Prevalence, by Race/Ethnicity
NHBS-HET1 2006-2007
All Census Tracts High Poverty Census Tracts
Percent HIV-positive
Percent HIV-positive
p= 0.73
p= 0.14
African- Latino White African- Latino White
American American

74. HIV Prevalence, by Race/Ethnicity
NHBS-HET1 2006-2007
All Census Tracts High Poverty Census Tracts
Percent HIV-positive
Percent HIV-positive
p= 0.73
p= 0.14
African- Latino White African- Latino White
American American

75. HIV Prevalence, by Risk Behavior
NHBS-HET1 2006-2007
Yes No
Percent HIV-positive
p< 0.0001 p< 0.0001 p< 0.0001
Crack Exchange STD
Use Sex Diagnosis

76. Summary
● HIV prevalence was very high
● Low socioeconomic status was
associated with higher HIV prevalence
● Racial and ethnic disparities in HIV
prevalence were substantially less than
those in the general population
● Crack use and exchange sex were not
associated with higher HIV prevalence

77. NHBS-HET2 Methods
 RDS method chosen for NHBS-HET2
 Eligibility Criteria
 Between the ages of 18-60
 Male or female
 Had vaginal or anal sex with a person of the opposite-sex in
the past 12 months
 Lives in the EMA
 Able to complete the interview in English or Spanish

78. NHBS-HET2 Data
 617 HET screened in Philadelphia
 552 HET interviewed
 510 met the HET definition
 42.5% male, 57.5% female
 25.3% 18-24
 84.3% black, 2.2% white, 12.4% Latino, 1.2% other
 94.9% had never injected drugs, 5.1% past IDU
 15.9% currently or previously homeless

79. NHBS-HET2 data
 Education
 34.5% less than high school education
 54.5% high school education
 10.0% with vocational/tech or some college
 1.0% college graduate
 Poverty
 10.6% above poverty guideline
 87.6% at or below poverty

80. HET2 Demographics
 HIV Testing
 76.3% reported ever testing for HIV with 2.8% reporting being
HIV+
 20.3% reported having an HIV test within the last 6 months
 28.4% reported having an HIV test within the last year

81. HET2 Testing Data
Tested # HIV Positive % New Positive
All Participants 4.4% (N=24) 79.2%
Low SES 4.5% (N=23)
Not Low SES 2.8% (N=1)
Male 5.9% (N=13)
Female 3.4% (N=10)
Black 5.1% (N=22)
Latino 1.6% (N=1)
White 0.0% (N=0)

82. HET2 Testing Data
Demographic HET2 HET2
Group % HIV Positive % New
(Tested = 552) Positives
All Participants 4.3% 79.2%
Gender
Male 5.4% 84.6%
Female 3.6% 72.7%
Race/Ethnicity
Black 5.0% 78.3%
Latino 1.4% 100.0%
White 0.0% 0.0%

83. HET2 Testing Data
Demographic HET2 HET2
Group % HIV Positive % New
(Tested = 552) Positives
Age
18-24 1.5% 50.0%
25-44 3.5% 75.0%
45+ 7.4% 85.7%
Low SES 3.4% 84.2%
Not Low SES 0.9% 60.0%

84. Linkage to care

85. Philadelphia Engagement in Care, 2009
25000 19188
20000 100% 15753
82% 11894
15000 62% 9944 8751
52% 46%
10000 5775
30%
5000
0

86. Linkage to Care 2009-2010
by Age, Race
85%
81%
80% 79%
76%
76%
75%
75% 74% 73%
72%
70%
68%
65%
60%
Total 13-24 25-34 35-44 45-54 55+ Black Hispanic White

87. Linkage to Care 2009-2010
by Sex, Mode
90%
81%
80% 75%
74% 73% 74%
72%
68% 69%
70%
60%
50%
43%
40%
30%
20%
10%
0%
Total Male Female MSM Male IDU Male HET Male Female IDU Female HET
MSM/IDU

88. Retention in care

89. Philadelphia Engagement in Care, 2009
25000 19188
20000 100% 15753
82% 11894
15000 62% 9944 8751
52% 46%
10000 5775
30%
5000
0

90. Definition: Met Need for Primary Care
 Met Need for Primary Care defined as measurement
of at least one CD4 count and/or one Viral Load
and/or receipt of antiretroviral therapy during a
specified time period

91. Framework
 Input
 Population sizes of those with HIV and AIDS within the service
area
 Care Patterns of those with HIV and AIDS
 Calculated Result
 Number of persons with HIV and AIDS with unmet need

92. Population Sizes
Population Sizes Value Data Source(s)
Row A. Number of persons living 11,569 Local HARS data
with AIDS (PLWA), for
the period of
12/31/2011
Row B. Number of persons living 7,523 Local HARS data
with HIV (PLWH)/non-
AIDS/aware, for the
period of 12/31/2011
Row C. Total number of 19,092 Local HARS data
HIV+/aware for the
period of 12/31/2011

93. Care Patterns Value Data Source(s)
Row D. Number of PLWA 9,948 Surveillance Data
who received the (Lab Data)
specified HIV CAREWare
primary medical
care during the 12-
month period of
2011
Row E. Number of 5,132 Surveillance Data
PLWH/non-AIDS (Lab Data)
who received the CAREWare
specified HIV
primary medical
care during the 12-
month period of
2011

94. Row F. Total number of 15,080
HIV+/aware who
received the
specified HIV primary
medical care during
the 12-month period
of 2011

95. Calculated Results Value Calculation
Row G. Number of PLWA who 1,621 =A–D
did not receive primary (14.0%)
medical services during
the 12-month period of
2011
Row H. Number of PLWH/non- 2,391 =B–E
AIDS who did not receive (31.8%)
primary medical services
during the 12-month
period of 2011
Row I. Total of HIV+/aware not 4,012 =G+H
receiving specified (21.0%)
primary medical care
services (quantified
estimate of unmet need

96. Unmet need by demographic groups, 2011
40.0% 40.0%
35.0% 35.0% 33.4%
31.8%
33.6%
30.0% 27.4% 30.0% 28.1%
25.0% 25.0%
20.0% 20.0%
15.5% 15.2%
15.0% 15.0%
15.2% 10.6%
10.0% 13.4% 10.0%
5.0% 5.0%
0.0% 0.0%
HIV AIDS HIV AIDS
Black White Hispanic Male Female

97. Unmet need by insurance status, 2011
50.0% 46.4%
45.0% 43.1%
40.0%
35.0% 33.7%
28.3% 29.6%
30.0% 26.6%
25.0% 22.4%
20.0%
15.0% 13.5%12.6%
10.0% 7.5%
5.0%
0.0%
HIV AIDS
Medicaid Private Other public Unknown None

98. Disparities

99. Philadelphia Engagement in Care, 2009
25000 19188
20000 100% 15753
82% 11894
15000 62% 9944 8751
52% 46%
10000 5775
30%
5000
0

101. Engagement in Care by Sex, 2009
Male Female
12000 6000
10000 5000
8000 4000
6000 3000
4000 2000
2000 1000
0 0

103. Engagement in Care by Race/Ethnicity, 2009
12000
10000
8000
6000
4000
2000
0
Diagnosed In Care On ART Suppressed
Black White Hispanic

105. Engagement in Care by Mode of
Transmission, 2009
6000
5000
4000
3000
2000
1000
0
Diagnosed In Care On ART Suppressed
MSM HET male HET female

107. Engagement in Care by Age Group, 2009
6000
5000
4000
3000
2000
1000
0
Diagnosed In Care On ART Suppressed
18-24 25-34 35-44 45-54 55+

108. Engagement in Care Summary
 On ART
 Higher for males than females
 Higher for men who have sex with men (MSM) than for
women who have sex with men (WSM)
 Viral suppression
 Higher for males than females
 Higher for MSM than WSM
 Higher for whites compared to blacks and Hispanics
 Higher for those >50 compared to 18-29 year olds
All P values <0.05

109. Starting Antiretroviral Therapy in 2012: A Compendium of Interactive Cases
clinicaloptions.com/hiv
What Will It Take to Substantially Reduce
HIV Transmission in an Entire Population?
Undiagnosed HIV
•1,200,000 Not linked to care
Not retained in care
•Number of Individuals
•1,000,000 ART not required
ART not utilized
•800,000 Viremic on ART
Undetectable
•600,000 HIV-1 RNA
•400,000 •66%
•200,000 •34% •28%
•19% •22% •21%
•0
•Current •DX •Engage •Treat •VL < 50 •Dx,
90% 90% 90% in 90% Engage, Tx,
and VL < 50
in 90%
•Answer: Treatment AND Prevention
•Gardner EM, et al. Clin Infect Dis. 2011;52:793-800.

110. The End
QUESTIONS?