HIV Care Continuum New Diagnoses, 2011,

Fulton 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 StatesPe

rcen

t

82

66

37 3325

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

Care Continuum Methodology, New HIV Diagnoses 2011, Fulton 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 of diagnosis Fulton County, current address Georgia• Excludes 10 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 the

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

load• 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, Fulton County, 2011

Diagnosed only0

102030405060708090

100100

5864

4440

44

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, Fulton County = 726Linked 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 = 319Note: all percentages are percent of total number of persons diagnosed with HIV in category

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

2011

Black Hispanic/Latino White Other/unknown0

102030405060708090

100

52

7162

6658

79 7671

35

61 6055

33

57 5460

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

en

t

N=422 N=28 N=50 N=226

Adults and adolescents >= age 13, diagnosed 01/01/11 - 12/31/11, Fulton County = 726Linked 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, Fulton

County, 2011

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

20

40

60

80

100

4855

6861 6258

6471

64 64

33

4550 49 45

3540

5449

43

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, Fulton County = 726Linked 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 proportion of total number of persons diagnosed with HIV in category

N=161 N=220 N=164 N=123 N=58

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*, Fulton

County, 2011

MSM IDU MSM/IDU HET Other0

20

40

60

80

100

52 50

67 68 6661 56 56 59

73

38 39 4432

59

3428 33 36

63

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

en

t

N=372 N=9N=18 N=22 N=188

Adult and adolescent males >= age 13, diagnosed 01/01/11 - 12/31/11, Fulton County = 608Linked 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*, Fulton

County, 2011

IDU HET Other0

20

40

60

80

100

63 65

50

64 67

55

4047

32

47 5041

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, Fulton County = 109Note: 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=15 N=72 N=22

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

County, 2011

Age at diagnosis (years)

N** LinkedN (%)

Engaged N (%)

Retained N (%)

Viral suppressio

nN (%)

13-24 106 45 42% 60 57% 32 30% 30 28%

25-34 110 52 47% 64 58% 39 33% 31 28%

35-44 42 27 64% 28 67% 14 33% 15 36%

45-54 32 18 56% 16 50% 13 41% 10 31%

55+ 10 4 40% 3 30% 1 10% 1 10%

Adults and adolescent males >= age 13, diagnosed 01/01/11 -12/31/11, Fulton County = 300Linked 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 proportion of total number of persons diagnosed with HIV in category

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

Fulton County, 2011

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

20

40

60

80

100

4247

6456

40

57 5867

50

3030 33 3341

10

28 2836

31

10

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, Fulton County = 300Linked 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 proportion 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,

Fulton 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

15%21%

15%

49%

Perc

en

t

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, Fulton County = 726CD4<200 = Stage 3 disease (AIDS)Stage unknown = no CD4 within 3 months of diagnosis

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

adolescents, Fulton 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

16%

27%

17%

40%

Perc

en

t

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, Fulton County = 726CD4<200 = Stage 3 disease (AIDS)Stage unknown = no CD4 within 12 months of diagnosis

N=119 N=127N=193 N=287

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, Fulton 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, 422 35 (8) 45 (11) 82 (19) 109 (26)

70 (17) 89 (21) 235 (56)

179 (42)

Hispanic/ Latino

28 4 (14) 4 (14) 6 (21) 7 (25%)

9 (32) 9 (32) 9 (32) 8 (29)

White 50 9 (18) 9 (18) 12 (24) 17 (34) 9 (18) 11 (22) 20 (40) 13 (26)

Other*/ Unknown

226 58 (26) 61 (27) 55 (24) 60 (27) 18 (8) 18 (8) 95 (42) 87 (38)

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, Fulton County = 726CD4<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, Fulton County 2011

Black Hispanic/Latino White Other*/Unknown

05

1015202530354045

1114

18

2726 25

34

27

21

32

22

8

42

2926

38

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, Fulton County = 726CD4<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=422 N=28 N=50 N=226

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

earliest CD4 count within 3 and 12 months after diagnosis, by sex, Fulton 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 608 86 (14) 96 (16) 130 (21)

163 (27)

83 (14) 101 (17)

309 (51) 248 (39)

Female

109 19 (17) 22 (20) 24 (22) 29 (27) 20 (18) 23 (21) 46 (42) 35 (32)

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, Fulton County = 717CD4<200 = Stage 3 disease (AIDS)Stage Unknown = no CD4 within 3 or 12 months of diagnosis*N = total number in this categoryExcludes 9 cases for which sex was not reported

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

adolescents, by sex, Fulton County, 2011

Male Female0

10

20

30

40

50

60

1620

27 27

1721

41

32

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, Fulton County = 717Excludes 9 cases for which sex was not reportedCD4<200 = Stage 3 disease (AIDS)Stage Unknown = no CD4 within 3 months of diagnosis

N=608 N=109

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*, Fulton 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 372 34 (9) 41 (11) 76 (20) 102 (27)

53 (14) 70 (19) 208 (56)

159 (43)

IDU 33 3 (9) 4 (12) 6 (18) 8 (24) 9 (27) 10 (30) 15 (45) 11(33)

MSM/IDU 9 1 (11) 1 (11) 1 (11) 2 (22) 2 (22) 2 (22) 4 (44) 4 (44)

HET 94 11 (12) 14 (15) 20 (21) 25 (27) 25 (27) 28 (30) 38 (40) 27 (29)

Other 219 57 (26) 60 (27) 51 (23) 56 (26) 17 (8) 17 (8) 94 (43) 86 (39)Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, Fulton County = 726CD4<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*,

Fulton County, 2011

MSM IDU MSM/IDU HET Other 0

10

20

30

40

50

11 12 1115

272724 22

27 26

19

30

22

30

8

43

33

44

29

41

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

Perc

en

t

N=94 N=219

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, Fulton County = 726CD4<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=372 N=33 N=9

Limitations

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

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 Fulton County and 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, Fulton 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

0.758%

51%

63%

30%

Perc

en

t

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, Fulton County = 726CD4<200 = Stage 3 disease (AIDS)Stage unknown = no CD4 within 3 months of diagnosis

N=119 N=193 N=127 N=287

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