HIV Care Continuum New Diagnoses, Georgia, 2011

Diagnosed

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, Georgia

• 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 and current address within Georgia• Excludes 52 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

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,

Georgia, 2011

Series10

102030405060708090

100 100

62 66

46 41 45

DiagnosedLinked to careEngaged in careRetained in carePrescribed ARTViral sup-pression

Perc

ent

Adults and adolescents >= age 13, diagnosed 01/01/11 -12/31/11, Georgia = 2885Linked 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 = 1307Note: all percentages are proportion of total number of persons diagnosed with HIV in category

Adults and adolescents diagnosed with HIV infection, by sex, Georgia,

2011

Males Females0

20

40

60

80

100

61 6665 67

46 4544 48

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

Perc

ent

Adults and adolescents>= age 13, diagnosed 01/01/11 - 12/31/11, Georgia =2869Excludes 16 persons for whom sex was not reported Linked 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

N=2,214 N=655

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

Georgia, 2011

Black Hispanic/Latino White Other/unknown0

102030405060708090

100

6272 71

5765 70 73

64

4453 54

4538

56 54 54

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

ent

N=1616 N=144 N=271 N=854

Adults and adolescents >= age 13, diagnosed 01/01/11 - 12/31/11, Georgia = 2885Linked 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

Adult and adolescent males diagnosed with HIV infection, by race/ethnicity,

Georgia, 2011

Black Hispanic/Latino White Other/unknown0

102030405060708090

100

5972 73

596374 72

66

42

56 52 4735

56 55 57

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

ent

N=1215 N=112 N=216 N=671

Adult and adolescent males >= age 13, diagnosed 01/01/11 - 12/31/11, Georgia = 2214Linked 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

Adult and adolescent females diagnosed with HIV infection, by race/ethnicity,

Georgia, 2011

Black Hispanic/Latino White Other/unknown0

102030405060708090

100

72 69 6453

71

56

76

5751

41 4535

50 5347 44

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

ent

N=390 N=32 N=55 N=178

Adult and adolescent females >= age 13, diagnosed 01/01/11 - 12/31/11, Georgia = 655 Linked 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, Georgia, 2011

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

20406080

100

57 59 65 68 6762 66 67 69 64

3946 47 52 47

3443

50 54 52

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

ent

Adults and adolescents >= age 13, diagnosed 01/01/11 - 12/31011, Atlanta = 2885Linked 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 most recent viral load Note: all percentages are percent of total number of persons diagnosed with HIV in category

N=655 N=786 N=649 N=537 N=258

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*,

Georgia, 2011

MSM IDU MSM/IDU HET Other0

20406080

100

61 67 6775

5865 60 67 71 65

46 44 42 45 4839 40 39

4858

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

ent

N=1386 N=36N=68 N=101 N=623

Adult and adolescent males >= age 13, diagnosed 01/01/11 - 12/31/11, Georgia = 2214Linked 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*,

Georgia, 2011

IDU HET Other0

102030405060708090

100

75 71

50

74 71

5552 50

32

54 5042

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

Perc

ent

Adults and adolescent females >= age 13, diagnosed 01/01/11 - 12/31/11, Georgia = 655Linked 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=81 N=411 N=163

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

Georgia, 2011

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

20

40

60

80

100

52 5764

706461 63

69 66

4937

44 4653

3826

35 3847

36

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

ent

N= 388 N= 348 N= 162 N= 107 N= 45

Adult and adolescent males >= age 13, diagnosed 01/01/11 - 12/31011, Georgia = 1050Linked 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, Georgia, 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%22% 19%

44%

Perc

ent

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, Georgia = 2885CD4<200 = Stage 3 disease (AIDS)Stage unknown = no CD4 within 3 months of diagnosis

N=418 N=649 N=561 N=1257

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

adolescents, Georgia, 2011

Stage 1 CD4

>=500

Stage 2 CD4 200-

499

Stage 3 CD4 <200

Stage unknown

00.10.20.30.40.5

17%27%

22%

35%

Perc

ent

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, Georgia = 2885CD4<200 = Stage 3 disease (AIDS)Stage unknown = no CD4 within 12 months of diagnosis

N=484 N=632N=766 N=1003

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, Georgia, 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 1616 202 (13)

244 (15)

359 (22)

444 (27)

351 (22)

404 (25)

704 (44)

524 (32)

Hispanic/ Latino

144 15 (10) 18 (13) 39 (27) 43 (30) 48 (33) 50 (35) 42 (29) 33 (23)

White 271 50 (18) 54 (20) 66 (24) 78 (29) 68 (25) 76 (28) 87 (32) 63 (23)

Other*/ Unknown

854 151 (18)

168 (20)

185 (22)

201 (24)

94 (11) 102 (12)

424 (50)

383 (45)

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, Georgia = 2885CD4<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, Georgia 2011

Black Hispanic/Latino White Other*/Unknown

0

10

20

30

40

50

15 1320 20

27 30 292425

3528

12

3223 23

45

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

Perc

ent

Adults >= age 13, diagnosed 1/1/2011 - 12/31/2011, Georgia = 2885CD4<200 = Stage 3 disease (AIDS)Stage Unknown = no CD4 within 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, 2010 and are grouped with Unknown race/ethnicity

N=1616 N=144 N=271 N=854

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

earliest CD4 count within 3 and 12 months after diagnosis, by sex, Georgia, 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 2214 335 (15) 385

(17)497 (22)

579 (26)

404 (18)

464 (21)

978 (44) 786 (36)

Female

655 81 (12) 97 (15) 151 (23)

186 (28)

152 (23)

163 (25)

271 (41) 209 (32)

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, Georgia = 2869CD4<200 = Stage 3 disease (AIDS)Stage Unknown = no CD4 within 3 or 12 months of diagnosis*N = total number in this categoryExcludes 16 cases for which sex was not reported

Stage of disease by CD4 count within 12 months of HIV diagnosis, adults and adolescents, by sex, Georgia, 2011

Male Female0

102030405060

17 1526 28

21 2536 32

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

Perc

ent

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, Georgia = 2869Excludes 16 cases for which sex was not reportedCD4<200 = Stage 3 disease (AIDS)Stage Unknown = no CD4 within 12 months of diagnosis

N=2214 N=655

Number and proportion of adult and adolescent males by stage at diagnosis by earliest CD4 count within 3

and 12 months after diagnosis, by transmission category*, Georgia, 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 1386

184 (13)

222 (16) 319 (23)

388 (28)

267 (19)

318 (23)

616 (44)

458 (33)

IDU 68 6 (9) 7 (10) 12 (18) 15 (22) 30 (44) 31 (46) 20 (29) 16 (24)

MSM/IDU 36 7 (19) 7 (19) 7 (19) 8 (22) 8 (22) 9 (25) 14 (39) 12 (33)

HET 101 10 (10) 12 (12) 20 (20) 22 (22) 44 (44) 46 (46) 27 (27) 22 (22)

Other 623 128 (21)

137 (22) 138 (22)

147 (24)

56 (9) 60 (10) 301 (48)

279 (45)

Adult and adolescents males >= age 13, diagnosed 1/1/2011 - 12/31/2011, Georgia = 2214 CD4<200 = Stage 3 disease (AIDS) Stage Unknown = no CD4 within 3 or 12 months of diagnosisMultiple imputation 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, adult and

adolescent males, by transmission category*, Georgia, 2011

MSM IDU MSM/IDU HET Other 010

2030

4050

1610

1912

2228

22 22 22 2423

46

25

46

10

3324

33

22

45

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

Perc

ent

N=101 N=623

Adults and adolescent males >= age 13, diagnosed 1/1/2011 - 12/31/2011, Georgia = 2214CD4<200 = Stage 3 disease (AIDS) Stage Unknown = no CD4 within 12 months of diagnosisMultiple imputation 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=1386 N=68 N=36

Number and proportion of adult and adolescent females by stage at diagnosis using earliest CD4 count within 3 and 12 months after diagnosis, by

transmission category*, Georgia, 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 (%)IDU 81 10 (12) 13 (16) 18 (22) 21 (26) 25 (31) 27 (33) 28 (35) 20 (25)

HET 411 52 (13) 61 (15) 102 (25)

128 (31)

107 (26)

116 (28)

150 (36) 106 (26)

Other 163 19 (12) 23 (14) 31 (19) 37 (23) 20 (12) 20 (12) 93 (57) 83 (51)Adult and adolescent females >= age 13, diagnosed 1/1/2011 - 12/31/2011, Georgia = 655CD4<200 = Stage 3 disease (AIDS)Stage Unknown = no CD4 within 3 or 12 months of diagnosisMultiple imputation 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 = total number in this category

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

adolescent females, by transmission category*, Georgia, 2011

IDU HET Other0

102030405060

16 15 1426 31

2333 28

1225 26

51

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

Perc

ent

Adult and adolescent females >= age 13, diagnosed 1/1/2011 - 12/31/2011, Georgia = 655CD4<200 = Stage 3 disease (AIDS)Stage Unknown = no CD4 within 12 months of diagnosisMultiple imputation 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=81 N=163N=411

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

address at diagnosis• Lack of transmission category information• Estimation using multiple imputation to

redistribute risk when missing• 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 Georgia

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 at or within 3 months of HIV diagnosis, adults and adolescents, Georgia,

2011

Stage 1 CD4

>=500

Stage 2 CD4 200-

499

Stage 3 CD4 <200

Stage unknown

00.10.20.30.40.50.60.7

50% 55%62%

32%

Perc

ent

Adults and adolescents >= age 13, diagnosed 1/1/2011 - 12/31/2011, Georgia = 2885CD4<200 = Stage 3 disease (AIDS)Stage unknown = no CD4 within 3 months of diagnosis

N=418 N=649 N=561 N=1257

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