Late HIV Diagnoses, Georgia, 2011-2012

Background• Late HIV diagnosis is defined as first CD4 within 12 months

of diagnosis <200 cells/ml• Late HIV diagnosis is associated with shorter

lifespan compared to those with earlier diagnosis.

•  It is estimated that persons with late HIV diagnosis have been living 8-10 years with HIV, but have been undiagnosed and untreated.

•  Persons with late HIV diagnosis have twice the lifetime risk of transmitting HIV to others compared to those diagnosed early.1

1 Farnham, P.G., et al, J Acquir Immune Defic Syndr, Vo. 64, No. 2, Oct 1,2013.

Costs of Late Diagnosis • Lifetime direct medical costs and productivity losses for new

HIV infections were estimated in 2002 as almost $1 million per person.2

• The costs are likely much higher today largely because of increased medical expenses.

•  The biggest cost, however, is in terms of new infections transmitted.

•  Each person with late HIV diagnosis has an average lifetime risk of transmitted HIV to 1.4 others.1

• Depending on risk behaviors, number of partners, concurrent STDs, lifetime transmission risk can be even higher.

• Further, persons unaware of their HIV diagnosis have a higher annual rate of sexual transmission on HIV (9% vs. 0.4% per person per year).1

2 Hutchinson, A.B., et al. J Acquir Immune Defic Syndr, Vol 43, No. 4, December 1, 2006.

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

Stage of disease by earliest 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

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 0

1020

3040

50

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

For further information on late HIV diagnosis, the Care Continuum, surveillance reports, fact sheets and other slides sets visit:http://dph.georgia.gov/data-fact-sheet-summaries

The remainder of this presentation will focus on the Care Continuum among people with late HIV diagnoses in Georgia in 2011

Resources

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, Late 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• Late diagnosis = first CD4 within 12 months of diagnosis <200 • 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• Viral suppression (VS) = VL<200 copies/ml in most recent viral

load• All percentages are percent of total number of persons with

late diagnosis of HIV in 2011

HIV Care Continuum Methodology, Late Diagnosis, Georgia, 2011

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

First CD4 <200 cell/mlLast viral load <200 copies/ml

Adults and adolescents with late HIV diagnosis*, 2011,

Georgia

Persons with late HIV di-agnosis

All persons diagnosed 20110

20

40

60

80

100 100 100

82

62

83

6666

4659

45

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

Perc

ent

Adults and adolescents >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/mlLinked 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 = 1307Note: all percentages are proportion of total number of persons diagnosed with HIV in category

N = 795 N = 2885

Adults and adolescents with late HIV diagnosis*, by sex, Georgia,

2011

Males Females0

20

40

60

80

10081 8683 84

66 6659 60

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

Perc

ent

Adults and adolescents >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11 *Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/mlExcludes 32 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= 594 N= 169

Adults and adolescents with late HIV diagnosis*, by race/ethnicity, Georgia,

2011

Black Hispanic/Latino White Other/unknown0

102030405060708090

10082

93 8876

8390 87

79

65 65 70 6654

71 69 65

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

ent

N=504 N= 55 N=99 N= 137

Adults and adolescents >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/mlLinked 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 with late HIV diagnosis*, by race/ethnicity,

Georgia, 2011

Black Hispanic/Latino White Other/unknown0

102030405060708090

10080

91 91

7483

89 85 80

64 6473 68

54

68 7165

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

ent

N= 365 N= 47 N= 80 N= 102

Adult and adolescent males >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/mlLinked 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 with late HIV diagnosis*, by race/ethnicity, Georgia,

2011

Black Hispanic/Latino White Other/unknown0

102030405060708090

10088

100

748482

100 95

7870 75

58 6357

88

5869

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

ent

N= 137 N= 8 N= 19 N= 32

Adult and adolescent females >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/mlLinked 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 with late HIV diagnosis*, by age, Georgia,

2011

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

20

40

60

80

10081 80 78

86 9088 85 83 837267 64 62

7260

52 57 60 6555

Diagnosed Linked to care Engaged in care Retained in care

Perc

ent

Adults and adolescents >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/mlLinked 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= 101 N= 209 N= 210 N=192 N= 83

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

Multiple Imputation• Multiple imputation (MI) methods are used to

assign transmission categories to those persons whose diagnoses are reported without a risk factor

• MI is a statistical approach in which missing transmission categories are replaced with plausible values

• CDC uses MI for the national HIV dataset*• Georgia uses the same methodology as CDC

*Harrison KM, Kajese T, Hall HI, Song R. Risk factor redistribution of the national HIV/AIDS surveillance data: an alternative approach. Public Health Rep 2008;123:618–27.

Adult and adolescent males with late HIV diagnosis*, by transmission category**,

Georgia, 2011

MSM IDU MSM/IDU HET Other0

20406080

10082 86 91 87

7085

7588

77 7967

5766

5770

53 59 58 59 64

Diagnosed Linked to care Engaged in careRetained in care Viral suppression

Perc

ent

N= 406 N= 11N= 37 N= 55 N= 84

Adult and adolescent males >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/mlLinked 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 with late HIV diagnosis*, by transmission category**,

Georgia, 2011

IDU HET Other0

102030405060708090

10087 87

8190

847470 67

56

70

57 61

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

Perc

ent

Adult and adolescent females >= age 13, Georgia residence at diagnosis 01/01/11-12/31/11*Late diagnosis = earliest CD4 within 12 months of diagnosis <200 cells/mlLinked 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= 30 N= 139 N= 27

Adults and adolescents, total diagnosed and late diagnosis*,

Georgia, 2011

Total 2011 IDU Late diagnosis total

Late diagnosis IDU

020406080

100

6272

82 87

66 6883 82

46 4866 64

45 4759 60

Diagnosed Linked Engaged Retained Viral suppression

Perc

ent

N= 2,885 N= 795 N= 149 N= 67

Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia* Late diagnosis = Stage 3 (AIDS)at or within 12 months of initial HIV diagnosis Multiple imputation is used to estimate number of persons in each transmission category. IDU = Injection drug use

Conclusions• Late diagnosis is a predictor or viral

suppression (VS) among persons diagnosed with HIV in 2011 in Georgia (VS 45% overall vs. 59% late diagnosis)

• Among those with late diagnosis 2011, VS by race was lowest for Blacks (54%) than Hispanic/Latinos (71%) or Whites (69%)

• Among those with late diagnosis 2011, VS by age was lowest for age 13-24 years (52%) and highest for age 45-54 years (65%)

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• Missing laboratory reports• Small N is some sub-groups limits meaningful

analysis

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FOR MORE INFORMATION VISITHTTP://DPH.GEORGIA.GOV/HIV-CARE-CONTINUUM