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