Kathleen Brady - HIV in Philadelphia (Annual Epidemiological Presentation)

HIV in Philadelphia

Kathleen A. Brady, MDMedical Director/Medical Epidemiologist

AIDS Activities Coordinating OfficePhiladelphia Department of Public Health

From Bench to Bus StopJanuary 26, 2016

THE HIV CARE CONTINUUM

HIV Care Continuum

Adapted from Eldred et al AIDS Patient Care STDs 2007;21(Suppl1):S1-S2Cheever LW Clin Infect Dis 2007;44:1500-2

Not in HIV Care Engaged in HIV Care

Unaware of HIV infection

Aware of HIV infection (not in care)

Receiving some medical care but

not HIV care

Entered HIV care but lost to

follow-up

Cyclical or intermittent user

of HIV care

Fully engaged in HIV care

Prevalence-Based Continuum Denominator:

National HIV Surveillance System Persons aged ≥13 years with diagnosed or undiagnosed HIV

infection in the United States Estimates derived using back-calculation Persons with HIV infection at the end of the specified

year (2009, 2010, 2011, 2012) Numerators:

National HIV Surveillance System Persons with diagnosed HIV infection in the United States;

calculated as a part of overall prevalence estimate for specified year

Medical Monitoring Project Persons aged ≥18 years with diagnosed HIV infection in the

United States and Puerto Rico Received HIV medical care - Care visit during January to

April of data collection year (2009, 2010, 2011, 2012) Prescribed antiretroviral therapy - Documentation of

antiretroviral prescription in the medical record Viral Suppression – Most recent viral load test result in

the preceding year was undetectable or <200 copies/mL

Persons Living with Diagnosed or Undiagnosed HIV Infection

HIV Care Continuum Outcomes, 2012 — United States and Puerto Rico

National HIV Surveillance System,: Estimated number of persons aged ≥13 years living with diagnosed or undiagnosed HIV infection (prevalence) in the United States at the end of 2012. The estimated number of persons with diagnosed HIV infection was calculated as part of the overall prevalence estimate.Medical Monitoring Project: Estimated number of persons aged ≥18 years who received HIV medical care during January to April of 2012, were prescribed ART, or whose most recent VL in the previous year was undetectable or <200 copies/mL—United States and Puerto Rico.

Diagnosis-Based Continuum Denominator:

National HIV Surveillance System Persons aged ≥18 years with diagnosed HIV

infection in the United States and Puerto Rico Persons with diagnosed HIV infection by the end of the

year preceding the specified year (2008, 2009, 2010, 2011) and alive at the end of the specified year (2009, 2010, 2011, 2012)

Numerators: Medical Monitoring Project

Persons aged ≥18 years with diagnosed HIV infection in the United States and Puerto Rico Received HIV medical care - Care visit during January

to April of data collection year Prescribed antiretroviral therapy - Documentation of

antiretroviral prescription in the medical record Viral Suppression – Most recent viral load test result in

preceding year was undetectable or <200 copies/mL

Persons Living with Diagnosed HIV Infection HIV Care Continuum Outcomes, 2012

United States and Puerto Rico

National HIV Surveillance System: Estimated number of persons aged ≥18 years diagnosed with HIV infection by year-end 2011 and alive at year-end 2012—United States and Puerto Rico.Medical Monitoring Project: Estimated number of persons aged ≥18 years who received medical care January to April of 2012, were prescribed antiretroviral therapy, or whose most recent VL was undetectable or <200 copies/mL—United States and Puerto Rico.

2010 2011 2012 2013 20140

10

20

30

40

50

60

70

80

90

100

Philadelphia HIV Linkage by YearPe

rcen

tage

(%)

*Significant increase in linkage within 30 days between 2010 and 2014 (p=0.02)Source: PDPH, AIDS Activities Coordinating Office, 2015

2011 2012 2013 20140

10

20

30

40

50

60

70

80

90

100

Philadelphia Care Continuum MeasuresPe

rcen

tage

(%)

*Significant increase between 2011 and 2014 (p<0.0001)Source: PDPH, AIDS Activities Coordinating Office, 2015

US (2012 Data) Philadelphia (2014 Data

Number

100 Diagnosed

80 Are linked to HIV care

54 Stay in HIV care

50 Get antiretroviral therapy

42Have a very low amount of virus in their body

Number

100 Diagnosed

82 Are linked to HIV care

52 Stay in HIV care

N/A Get antiretroviral therapy

53Have a very low amount of virus in their body

For every 100 people living with HIV:

Source: PDPH, AIDS Activities Coordinating Office, 2015

NEW HIV DIAGNOSES

Rates of Diagnoses of HIV Infection Among Adults and Adolescents, by Area of Residence, 2013

United States and 6 Dependent Areas N= 47,957 Total rate = 18.0

Newly Diagnosed HIV (Non-AIDS) for 2012-2014, Philadelphia EMA

EMATotal

N=2,120

EMA

%

PhilaN=1,433

%

PA N=391

%

NJ N=224

%Race/EthnicityWhite, non-Hispanic 409 19.3 13.0 38.9 23.6Black, non-Hispanic 1,335 63.0 70.1 45.3 52.0Hispanic 307 14.5 14.1 10.0 22.3Asian/Pacific Islander 30 1.4 1.6 1.8 0.0American Indian/Alaskan Native

9 0.4 0.6 0.3 0.0

Multi-Race 24 1.1 0.6 3.8 0.0Unknown 6 0.3 0.0 0.0 2.0GenderMale 1,641 76.2 78.3 79.0 70.9


EMATotal

N=2,120

EMA

%

PhilaN=1,433

%

PA N=391

%

NJ N=224

%Age<13 years 12 0.6 0.1 1.3 1.713 - 19 years 126 5.9 6.8 4.9 3.420-24 years 442 20.8 22.7 17.9 15.525-29 years 365 17.2 18.1 15.6 15.230-39 years 435 20.5 19.7 20.5 24.740-49 years 370 17.5 16.7 17.9 20.650+ years 370 17.5 15.9 22.0 18.9


EMATotal

N=2,120

EMA

%

PhilaN=1,433

%

PA N=391

%

NJ N=224

%Mode of TransmissionMen who have sex with men (MSM)

1048 49.4 52.1 49.9 35.8

Injection drug users (IDU)

140 6.6 6.8 5.1 7.8

MSM/IDU 24 1.1 1.2 1.3 0.7Heterosexuals 786 37.1 37.5 33.5 39.9Other/hemophilia/blood transfusion

0 0.0 0.0 0.0 0.0

Perinatal exposures 15 0.7 0.3 1.3 1.7Risk not reported or identified

107 5.0 2.1 9.0 14.2

Newly Diagnosed HIV Cases, Deaths, and Living HIV Cases by YearPhiladelphia, 2008-2014

2008 2009 2010 2011 2012 2013 20140

200

400

600

800

1000

1200

1400

1600

1800

2000

15000

15500

16000

16500

17000

17500

18000

18500

19000

19500

20000

928 897739 680 729 679 624

524 511 546 473 432 393

165*

18640

1923719525

19157

1983219564 19494

Newly Diagnosed Deaths Living HIV Cases

*Data incomplete due to reporting delays


Newly Diagnosed HIV 2014

• 624 Newly Diagnosed cases

• 78.8% male at birth• 67.6% black, 14.5%

Hispanic, 14.4% white• 23.2% among 13-24

year olds

51.1%

5.4%

40.7%

0.4% 0.3% 1.9%

Mode of Transmission

MSM IDU HETMSM/IDU Pediatric NIR


19

HIV/AIDS Cases by Date of Diagnosis

10861020

939862

763 779672

745 800 744 694 695 659521

424333 297 257 257

186 159

530 546 565 578442 423 472 493 465

1266

0200

400600

8001000

12001400

Year

Num

ber

of C

ases

AIDS HIV

Newly Diagnosed HIV Disease by Sex at Birth (regardless of AIDS status)

0

100

200

300

400

500

600

2010 2011 2012 2013 2014

Year

Num

ber

of C

ases

HIV Female HIV Male

Newly Diagnosed HIV Disease by Race/Ethnicity (regardless of HIV status)

105 9773 90

479 501 503

422

87110

80 910

100

200

300

400

500

600

2010 2011 2012 2013 2014

Year

Num

ber

of C

ases

White AfrAm Hispanic

22

Newly Diagnosed HIV Disease by Mode of Transmission (regardless of AIDS status)

281297

5169

35 34

274

11 12

319352

254

324324

299

050

100150200250300350400

2010 2011 2012 2013 2014

Year

Num

ber

of C

ases

MSM IDU HetSx NIR

Newly Diagnosed HIV Disease by Age at Diagnosis(regardless of HIV status)

39 32

219

265251

211

138

126111

127 133120

136

3243

134146149152

159

112

0

50

100

150

200

250

300

2010 2011 2012 2013 2014

Year

Num

ber

of C

ases

13-19 20-29 30-39 40-49 50+

Newly Diagnosed HIV Cases, Deaths, and Living HIV Cases by YearPhiladelphia, 2008-2014

2008 2009 2010 2011 2012 2013 20140

200

400

600

800

1000

1200

1400

1600

1800

2000

15000

15500

16000

16500

17000

17500

18000

18500

19000

19500

20000

928 897739 680 729 679 624

524 511 546 473 432 393

165*

18640

1923719525

19157

1983219564 19494

Newly Diagnosed Deaths Living HIV Cases

*Data incomplete due to reporting delays


Rates of Adults and Adolescents Living with Diagnosed HIV Infection, by Area of Residence, Year-end 2012

United States and 6 Dependent Areas N= 931,449 Total rate = 352.3

Proportion of Philadelphia Residents Diagnosed and Living with HIV by Race/Ethnicity and Sex, 2014

Black Males Hispanic Males

Black Females

White Males Hispanic Females

White Females

-1.0%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

2.9%

2.2%

1.1% 1.1%0.8%

0.2%

Overall Prevalence 1.3%

Epidemic Level 1.0%


PLWHA 2014

• 27,121 PLWHA (current EMA residents)

• 71.7% male at birth• 57.9% black, 14.9%

Hispanic, 23.2% white• 48.0% among 50+ year

olds

35.6%

20.9%

35.4%

3.0% 1.5% 3.6%

Mode of Transmission

MSM IDU HETMSM/IDU Pediatric NIR


2013 Local Estimate of HIV Incidence

• Local estimate of 508 new HIV infections in 2013 in adults and adolescents (95% CI, 333-683)


HIV Incidence Trends by Demographic Groups

0

200

400

600

800

1000

1200

2006 2007 2008 2009 2011 2012 2013

TotalAge 13-24MaleBlackMSM


Estimated Incidence Rates - 2013

Population Population in 2010 (13 +)ESTIMATED

Incidence Estimate, 2013

EstimatedCase Rate per 100,000

95% CI lower bound

95% CI upper bound

MSM 29,737 324 1,089.6 632.2 1,550.3IDU 37,378 18 48.2 0 136.4HET 294,682* 166 56.3 25.5 86.9

*Includes persons >13 living in poverty

Data Source: PDPH/AACO HIV Incidence Surveillance Program, 2015

Unaware Estimates by Select Demographic Groups, Philadelphia, 2013

Demographic Group % Unaware (95% CI)SexFemale 7.5% (0.9 %-14.1%)Male 11.5% (6.7%-15.4%)

Race/EthnicityBlack 12.5% (8.4%-17.0%)Hispanic 9.6% (1.4%-17.5%)White/Other 4.7% (0.1%-11.1%)

Mode of TransmissionHeterosexual 13.5% (9.0%-19.1%)IDU (including MSM/IDU) 5.1% (2.9%-7.3%) MSM 13.2% (8.2%-19.2%)

Total 10.4% (13.7% – 7.5%)Source: PDPH, AIDS Activities Coordinating Office, 2015

Non-Concurrent and Concurrent HIV/AIDS Among Incident HIV Diagnosis 2014 (EMA) Non-Concurrent Concurrent

HIV/AIDS TotalN Row % N Row % N Col %

Total 739 72.9% 227 24.8% 917 100%SexMale 579 81.4% 169 23.8% 711 77.5%Female 160 77.7% 58 28.2% 206 22.5%Race/EthnicityBlack 440 78.7% 140 25.0% 559 61.0%Hispanic 159 85.5% 46 24.7% 186 20.3%White 116 81.7% 33 23.2% 142 15.5%Other 24 80.0% 8 26.7% 30 3.3%

Non-Concurrent and Concurrent HIV/AIDS Among Incident HIV Diagnosis 2014 (EMA) Non-Concurrent Concurrent

HIV/AIDS TotalN Row % N Row % N Col %

Age Group at HIV Diagnosis<13 0 0.0% 0 0.0% 0 0.0%13-19 41 95.3% * 7.0% 43 4.7%20-24 141 93.4% 11 7.3% 151 16.5%25-29 130 90.3% 22 15.3% 144 15.7%30-39 152 77.6% 54 27.6% 196 21.4%40-49 127 73.0% 64 36.8% 174 19.0%50+ 148 70.8% 73 34.9% 209 22.8%

Non-Concurrent and Concurrent HIV/AIDS Among Incident HIV Diagnosis 2014 (EMA)

Non-Concurrent Concurrent HIV/AIDS Total

N Row % N Row % N Col %Transmission RiskMSM 386 86.4% 81 18.1% 447 48.7%IDU 45 86.5% 10 19.2% 52 5.7%MSM/IDU 9 100.0% * 22.2% 9 1.0%Heterosexual 270 73.0% 119 32.2% 370 40.3%No identified risk 24 61.5% 15 38.5% 39 4.3%Pediatric 0 0.0% 0 0.0% 0 0.0%Geographic AreaPhiladelphia 480 76.9% 144 23.1% 624 68.1%PA Counties 110 69.2% 49 30.8% 159 17.3%NJ Counties 100 74.6% 34 25.4% 134 14.6%

SPECIAL POPULATIONS

HIV CARE CONTINUUM BY RESIDENCE IN GEOGRAPHIC HOTSPOTS

Kathleen A. Brady, MD37

Diagnosed Linked to Care Retained in Care Virally Suppressed0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

100.0%

64.6%

33.0%26.3%

100.0%

54.3%

24.0%

9.1%

Not a Hotspot Hotspot

p < .05

p < .05 p

< .05

N=1,704


Percent Retained, Using ART and Virally Suppressed


Overall Transgender0

10

20

30

40

50

60

70

80

90

100

2014 Care Continuum Measures: TransgenderPe

rcen

tage

(%)


Philadelphia HIV Care Continuum 2014

Diagnosed Engaged in Care Prescribed ART Virally Suppressed0%

10%20%30%40%50%60%70%80%90%

100%90%

47%

68%

48%

87%

44%

63%47%

87%

44%

66%

48%

ALL PLWHA MSM of Color Black MSMHispanic MSM Other MSM of Color White MSM


NHBS-IDU4

National HIV Behavioral Surveillance• Conducted 2004-Present• Establish and maintain a

surveillance system among groups at high risk for HIV infection

• 3 rounds completed to-date• Rounds consist of 3 cycles

– MSM– IDU– HET

• 6 city / 14 state health departments


NHBS IDU4 Cycle• Sample collection began July 2015

• Eligibility Requirements– Present a valid NHBS-IDU coupon– Have not previously participated in the current NHBS-IDU cycle– Live in the participating MSA (Philadelphia, Montgomery, Delaware, Chester, Bucks

Counties)– 18 years old or older– Have injected drugs in the last 12 months

• N=645– Goal: 500 interviews


Screening Process with an NHBS Interviewer

EligibleInterview $25:

Risk Behavior Survey

Offered to be Recruiter: Given Coupons to give to give to people they

know to bring them into the study$10 per Recruit

Optional:HIV Testing - INSTI $25

HCV Testing -ORAQUICK

Ineligible

Nothing Further

Brief Overview of NHBS Process


Sample Characteristics• Gender

– Male 74%– Female 25%– Transgender 1%

• Race– White 66%– Black 11%– Hispanic 11%– Multiracial 12%– Asian <1%– American Indian/Alaskan

Native <1%– Native Hawaiian/Other

Pacific Islander <1%

Age 18-24 8% 25-29 16% 30-34 23% 35-39 19% 40+ 34%

Region Kensington 42% Northeast Phila 19% North Phila 13% Center City 7% Outside Phila 5% South Phila 5% Other 9%


IDU3 IDU40

100

200

300

400

500

600

16%

24%

Youth Sample Comparision IDU3 to IDU4

Parti

cpan

ts


HIV Preliminary Results

• IDU4 HIV Results – 32 Positive Participants (5%)

• 19 Self-Reported as HIV positive

• IDU3 HIV Results (2012)– 28 Positive Participants (5%)


HCV Results and Testing History

HCV Results– 522 (81%) Reactive

• 169 Newly Dxed HCV Infections

– 109 (17%) Non-reactive– 2% Other

• Coinfection Rates– 27 of the 32 HIV reactive

individuals also reactive on the HCV test

– 4% of total sample

553(86%) had previously been tested for HCV 28% Public Health/Community

Health Center/Provider 19% Correctional Facility 15% Drug Treatment Program 15% Needle or Syringe Exchange

Program 5% Mobile/Street Outreach 3% CTR site 3% Family Planning /OB 2% Don’t Know/Refused


Limitations

• Do not perform the confirmatory HCV test – Unable to follow up to capture these results– Unable to calculate linkage rates on a person level

• Survey sample may not be representative of overall IDU population in Philadelphia– Youth Population– Female Population– Hispanic Population


Questions

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Kathleen Brady - HIV in Philadelphia (Annual Epidemiological Presentation)