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