HIV Care Continuum New Diagnoses, 2011,

DeKalb County, Georgia

Diagnose

d

Linke

d to ca

re

Retained in

care

Prescribed ART

Viral S

uppression

0102030405060708090

100

Persons with HIV Engaged in Selected Stages of the Continuum of Care, United States

Perc

ent

82

66

37 3325

Hall et al. XIX International AIDS Conference, 2012ART, antiretroviral therapy

Care Continuum Methodology, New HIV Diagnoses 2011, DeKalb County • Adults and adolescents are those aged >= 13 years• Diagnosed between 01/01/11 -12/31/11,• Alive at least 15 months after diagnosis• Residence at diagnosis DeKalb County, current residence

in Georgia• Excludes 6 persons deceased within 15 months of

diagnosis• 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• Estimated percentage prescribed ART derived from

Medical Monitoring Project (MMP) Georgia sample • Viral suppression (VS) = VL<200 copies/ml in most recent

viral load (VL)• All percentages are percent of total number of persons

diagnosed with HIV

HIV Care Continuum Methodology

HIV Confirmatory

Diagnosis Date

Months 0-3 after diagnosis

Months 4-15 after diagnosis

CD4 or Viral Load

CD4 or Viral Load

CD4 or Viral Load

This person is:• Linked YES• Engaged YES • Retained YES• Virally suppressed YES

Last viral load <200 copies/ml

HIV Care Continuum Methodology

HIV Confirmatory

Diagnosis Date

Months 0-3 after diagnosis

Months 4-15 after diagnosis

CD4 or Viral Load

This person is• Linked YES• Engaged YES• Retained NO• Virally suppressed YES

• “Engaged in care” is minimal engagement that indicates the person “touched” the medical system at least once during that 12 month period

Last viral load undetectableCD4 or Viral Load

HIV Care Continuum Methodology

HIV Confirmatory

Diagnosis Date

Months 0-3 after diagnosis

Months 4-15 after diagnosis

CD4 or Viral Load

This person is• Linked NO• Engaged YES• Retained YES• Virally suppressed NO

• If no viral load done, it is assumed to be not suppressed

CD4 done but no viral load done

Adults and adolescents diagnosed with HIV infection, DeKalb County, 2011

Diagnosed only0

102030405060708090

100100

6166

4641 42

DiagnosedLinked to careEngaged in careRetained in carePrescribed ARTViral sup-pression

Perc

en

t

Adults and adolescents >= age 13, diagnosed 01/01/11-12/31/11, DeKalb County = 525Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosisRetained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosisPrescribed ART derived from MMP sample Viral suppression (VS) = VL<200 copies/ml in most recent viral load = 220Note: all percentages are percent of total number of persons diagnosed with HIV in category

Adults and adolescents diagnosed with HIV infection, by race/ethnicity, DeKalb County

2011

Black Hispanic/Latino White Other/unknown0

102030405060708090

100

5968

61 626561 63

70

47 4843 44

35

4554 52

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

en

t

N=300 N=31 N=46 N=148

Adults and adolescents >= age 13, diagnosed 01/01/11 - 12/31/11, DeKalb County= 525Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosisRetained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosisViral 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

Adults and adolescents diagnosed with HIV infection, by age, DeKalb

County, 2011

13-24 25-34 35-44 45-54 55+0

20

40

60

80

100

50

62 6068

74

62 66 62

74 70

3947

40

5749

30

43 4351 53

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

en

t

Adults and adolescents >= age 13, diagnosed 01/01/11 - 12/31011, current address DeKalb County =525Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosisRetained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosisViral suppression (VS) = VL<200 copies/ml in most recent viral load Note: all percentages are percent of total number of persons diagnosed with HIV in category

N=128 N=160 N=99 N=95 N=43

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 diagnosed with HIV infection, by transmission category*, DeKalb

County, 2011

MSM IDU MSM/IDU HET Other0

20

40

60

80

100

58

7060 64 60

6573 71

6070

47

61

41 44 4638

4540 40

54

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

en

t

N=277 N=10N=10 N=14 N=112

Adult and adolescent males >= age 13, diagnosed 01/01/11 - 12/31/11, DeKalb County = 423Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosisRetained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosisViral 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 useMSM/IDU = Male to male sexual contact and injection drug useHET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infectionOther = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

Adults and adolescent females diagnosed with HIV infection, by transmission category*, DeKalb

County, 2011

IDU HET Other0

102030405060708090

100

7164

7472

6165

45 45

35

48

3843

Diagnosed Linked to care Engaged in care Retained in care Viral suppression

Perc

en

t

Adults and adolescent females >= age 13, diagnosed 01/01/11 - 12/31/11, DeKalb County = 101Note: small N in all categories; use caution in interpretationLinked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosisRetained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosisViral 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 useHET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infectionOther = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

N=13 N=65 N=23

Adult and adolescent Black MSM* diagnosed with HIV infection, by age (years), DeKalb

County 2011

Age at diagnosis (years)

N** LinkedN (%)

Engaged N (%)

Retained N (%)

Viral suppressio

nN (%)

13-24 79 36 46% 48 61% 30 38% 17 22%

25-34 75 45 60% 51 68% 40 53% 29 39%

35-44 28 16 57% 17 61% 12 43% 11 39%

45-54 14 11 79% 12 86% 10 71% 8 57%

55+ 8 5 63% 4 50% 2 25% 2 25%

Adults and adolescent males >= age 13, diagnosed 01/01/11 -12/31/11, DeKalb County = 203Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosisRetained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosisViral suppression (VS) = VL<200 copies/ml in most recent viral load Multiple imputation was used to redistribute transmission category when missing*MSM = men who have sex with men**N = number of persons in that categoryNote: all percentages are percent of total number of persons diagnosed with HIV in category

Adult and adolescent Black MSM diagnosed with HIV infection, by age, DeKalb County,

2011

13-24 25-34 35-44 45-54 55+0

20

40

60

80

100

46

60 57

79

636168

61

86

50

38

5343

71

2522

39 39

57

25

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

en

t

N= 79 N= 75 N= 28 N= 14 N= 8

Adult and adolescent males >= age 13, diagnosed 01/01/11 - 12/31011, DeKalb County= 203Linked to care = CD4 or VL within 3 months of diagnosis Engaged in care >= 1 CD4 or VL 4-15 months after diagnosisRetained in care >= 2 CD4 or VL at least 3 months apart 4-15 months after diagnosisViral suppression (VS) = VL<200 copies/ml in most recent viral load Note: all percentages are percent of total number of persons diagnosed with HIV in category

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)

Stage of HIV disease at diagnosis

• Stage at diagnosis is defined by the first CD4 done within 3 months of diagnosis

Stage 1 = CD4 >=500Stage 2 = CD4 200-499Stage 3 = CD4 <200 or OI

• Stage at diagnosis is unknown if no CD4 done within 3 months of diagnosis

Stage of disease by earliest CD4 count within 3 months of HIV diagnosis, adults and adolescents,

DeKalb County, 2011

Stage 1 CD4

>=500

Stage 2 CD4 200-

499

Stage 3 CD4 <200

Stage unknown

0

0.1

0.2

0.3

0.4

0.5

14%

21% 22%

43%

Perc

en

t

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, DeKalb County = 525CD4<200 = Stage 3 disease (AIDS)Stage unknown = no CD4 within 3 months of diagnosis

N=76 N=110 N=114 N=225

Stage of disease by earliest CD4 count within 12 months of HIV diagnosis, adults and adolescents,

DeKalb County 2011

Stage 1 CD4

>=500

Stage 2 CD4 200-

499

Stage 3 CD4 <200

Stage unknown

0

0.1

0.2

0.3

0.4

0.5

18%

26% 25%

32%

Perc

en

t

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, DeKalb County = 525CD4<200 = Stage 3 disease (AIDS)Stage unknown = no CD4 within 12 months of diagnosis

N=92 N=135 N=130 N=168

Number and proportion of adults and adolescents by stage at diagnosis by earliest CD4 count within 3 and 12 months after diagnosis, by race/ethnicity,

DeKalb County, 2011

Race/ Ethnicit

y

N**Stage 1

CD4>500Stage 2

CD4 200-499Stage 3

CD4 <200Stage

Unknown CD4 Missing

3 mos.N (%)

12 mos.

N (%)

3 mos.N (%)

12 mos.

N (%)

3 mos.N (%)

12 mos.N (%)

3 mos.N (%)

12 mos.

N (%)

Black, 300 43 (14) 54 (18) 57 (19) 72 (24) 77 (26) 89 (30) 123 (41)

85 (28)

Hispanic/ Latino

31 2 (6) 3 (10) 7 (23) 8 (26) 10 (32) 10 (32) 12 (39) 10 (32)

White 46 8 (17) 10 (22) 11 (24) 16 (35) 5 (11) 5 (11) 22 (48) 15 (33)

Other*/ Unknown

148 23 (16) 25 (17) 35 (24) 39 (26) 22 (16) 26 (18) 68 (46) 58 (39)

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, DeKalb County = 525CD4<200 = Stage 3 disease (AIDS)Stage Unknown = no CD4 within 3 or 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, 2011 and are grouped with other/unknown race/ethnicity** N = total number in this category

Stage of disease by CD4 count within 12 months of HIV diagnosis, adults and

adolescents, by race/ethnicity, DeKalb County 2011

Black Hispanic/Latino White Other*/Unknown

05

1015202530354045

18

10

2217

24 26

35

2630 32

11

18

2832 33

39

Stage 1 CD4 >500 Stage 2 CD4 200-499Stage 3 CD4 <200 Stage Unknown

Perc

en

t

Adults >= age 13, diagnosed 1/1/2011 - 12/31/2011, DeKalb County= 525CD4<200 = Stage 3 disease (AIDS)Stage Unknown = no CD4 within 3 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

N=300 N=31 N=46 N=148

Number and proportion of adults and adolescents by stage at diagnosis using

earliest CD4 count within 3 and 12 months after diagnosis, by sex, DeKalb County, 2011

Sex N*Stage 1

CD4>500Stage 2

CD4 200-499Stage 3

CD4 <200Stage

Unknown CD4 Missing

3 mos.N (%)

12 mos.

N (%)

3 mos.N (%)

12 mos.N (%)

3 mos.N (%)

12 mos.

N (%)

3 mos.N (%)

12 mos.

N (%)

Male 423 66 (16) 81 (19) 86 (20) 104 (25)

84 (20) 99 (23) 187 (44) 139 (33)

Female

101 10 (10) 11 (11) 24 (24) 31 (31) 30 (30) 31 (31) 37 (37) 28 (28)

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, DeKalb County = 524Excludes 1 case for which sex was not reportedCD4<200 = Stage 3 disease (AIDS)Stage Unknown = no CD4 within 3 or 12 months of diagnosis*N = total number in this categoryExcludes 12 cases for which sex was not reported

Stage of disease by CD4 count within 12 months of HIV diagnosis, adults and

adolescents, by sex, DeKalb County, 2011

Male Female0

10

20

30

40

50

60

1911

2531

233133

28

Stage 1 CD4 >500 Stage 2 CD4 200-499Stage 3 CD4 <200 Stage Unknown

Perc

en

t

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, DeKalb County = 524Excludes 1 case for which sex was not reportedCD4<200 = Stage 3 disease (AIDS)Stage Unknown = no CD4 within 3 months of diagnosis

N=423 N=101

Number and proportion of adults and adolescents by stage at diagnosis by earliest CD4 count within 3

and 12 months after diagnosis, by transmission category*, DeKalb County, 2011

Trans-mission categor

y

N**Stage 1

CD4>500Stage 2

CD4 200-499Stage 3

CD4 <200Stage

Unknown CD4 Missing

3 mos.N (%)

12 mos.N (%)

3 mos.N (%)

12 mos.

N (%)

3 mos.N (%)

12 mos.N (%)

3 mos.N (%)

12 mos.N (%)

MSM 277 38 (14) 50 (18) 57 (21) 72 (26) 59 (21) 71 (26) 124 (45)

85 (31)

IDU 22 3 (14) 3 (14) 4 (18) 5 (23) 10 (45) 10 (45) 6 (27) 5 (23)

MSM/IDU 10 3 (30) 3 (30) 1 (10) 1 (10) 2 (20) 2 (20) 4 (40) 4 (40)

HET 79 10 (13) 11 (14) 16 (20) 22 (28) 25 (32) 27 (34) 28 (35) 19 (24)

Other 136 23 (17) 25 (18) 32 (24) 35 (26)

18 (13) 20 (15) 63 (46) 56 (41)

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, DeKalb County = 525CD4<200 = Stage 3 disease (AIDS) Stage Unknown = no CD4 within 3 or 12 months of diagnosisMultiple imputation was used to re-distribute transmission category where missing*MSM = Male to male sexual contact IDU = Injection drug useMSM/IDU = Male to male sexual contact and injection drug useHET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infectionOther = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified**N = total number in this category

Stage of disease by earliest CD4 count within 12 months of HIV diagnosis, adults and adolescents, by transmission category*,

DeKalb County, 2011

MSM IDU MSM/IDU HET Other 0

10

20

30

40

50

1814

30

1418

2623

10

28 2626

45

20

34

15

31

23

40

24

41

CD4 >500 CD4 200-499 CD4 <200 Stage Unknown

Perc

en

t

N=79 N=136

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, DeKalb County = 525CD4<200 = Stage 3 disease (AIDS) Stage Unknown = no CD4 within 3 months of diagnosisMultiple imputation was used to re-distribute transmission category where missing*MSM = Male to male sexual contact IDU = Injection drug useMSM/IDU = Male to male sexual contact and injection drug useHET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infectionOther = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

N=277 N=22 N=10

Limitations

• Incomplete reporting • Missing data for race/ethnicity, sex, and address

at diagnosis• Lack of transmission category information• 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• CD4 within 3 and 12 months of diagnosis yields

high unknown stage in DeKalb County and in Georgia overall

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• Understanding barriers to ART adherence• Prioritizing further research

Viral suppression on most recent viral load, by stage of disease by earliest CD4 within 3

months of HIV diagnosis, adults and adolescents, DeKalb County, 2011

Stage 1 CD4

>=500

Stage 2 CD4 200-

499

Stage 3 CD4 <200

Stage unknown

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

45%

55%61%

25%

Perc

en

t

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, DeKalb County = 525CD4<200 = Stage 3 disease (AIDS)Stage unknown = no CD4 within 3 months of diagnosis

N=76 N=110 N=114 N=225

For information on HIV prevention visithttp://dph.georgia.gov/hiv-prevention-program

For more information on HIV surveillance in Georgia, visithttp://dph.georgia.gov/georgias-hivaids-epidemiology-surveillance-section