Tiffany LaDanaWest, MPH, MSPHBureau Chief, Strategic Information BureauDistrict of Columbia, Department of Health

Uses of Strategic Information to Assess Health Equity

Health Inequities in US Gender, Race and Socioeconomic Factors that drive health inequities

in US

Heavily Influence by Environment Disease Syndemics Access to Prevention, Care and Treatment Services

Influence Individual Behavior Risk Behaviors in social and sexual networks Health Seeking Behavior Utilization of Prevention, Care and Treatment Services

Triangulate Syndemic, Behavioral, Service to assess Health Inequities to target policies and programs populations at greatest need

Greater Focus on Health Outcomes where inequities exist

Cumulative and Annual Diagnosed Number of AIDS Cases, By Race/Ethnicity and Year, United States, 1989-2008

Cumulative_v_Dx_with_trails_wmv.wmv

Cumulative and Annual Diagnosed Number of AIDS Cases, By Transmission Category and Year, United States, 1989-2008

MOT_no_total_wmv.wmv

Annually Diagnosed AIDS Cases, by Sex and Year, United States, 1989-2008

Percent Below the Federal Poverty Line, By Race/Ethnicity and Year, United States, 1989-2008

HIV Infection Among Heterosexuals in Urban Areas, by Socio-Economic Indicators, 2006-2007, N=14,837

National HIV Behavioral Surveillance (NHBS) Heterosexuals at High Risk for HIVAreas of High Rates of HIV/AIDS and Poverty

Approximately 2.0% HIV Prevalence 2.1% Women and 1.9% Men 4.2% 40-50 year olds, 2.2% 30-39 year olds, 0.6%, 18-29 year

olds 3.1% Northeast, 2.7% South, Midwest, South, Territories

<1%

*CDC. Characteristics Associated with HIV Infection Among Heterosexuals in Urban Areas with High AIDS Prevalence --- 24 Cities, United States, 2006--2007. MMWR 2011;60:1045-1049.

HIV Infection Among Heterosexuals in Urban Areas, by Socio-Economic Indicators, 2006-2007, N=14,837-Structural/Environmental

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

HIV

Pre

vale

nce

*CDC. Characteristics Associated with HIV Infection Among Heterosexuals in Urban Areas with High AIDS Prevalence --- 24 Cities, United States, 2006--2007. MMWR 2011;60:1045-1049.

HIV Infection Among Heterosexuals in Urban Areas, by HIV Risk Factor, 2006-2007, N=14,837-Behavioral

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

Used crack cocaine Did not Exchanged sex for money or drugs

Did not Received an STD diagnosis

Had not

HIV

Pre

vale

nce

*CDC. Characteristics Associated with HIV Infection Among Heterosexuals in Urban Areas with High AIDS Prevalence --- 24 Cities, United States, 2006--2007. MMWR 2011;60:1045-1049.

Estimated Number of New HIV Infections among Men who have Sex with Men, By Age

Estimated Number of New HIV Infections among Men who have Sex with Men (MSM), 2009,By Race/Ethnicity and Age

* Estimates of New HIV Infections in the United States, 2006–2009, The Center for Disease Control and Prevention Fact Sheet, August 2011

Estimated Number of New HIV Infections among Men who have Sex with Men, By Race

Estimated Number of New HIV Infections among Men who have Sex with Men (MSM), Ages 13-29, 2006-2009, By Race/Ethnicity and Age

* Estimates of New HIV Infections in the United States, 2006–2009, The Center for Disease Control and Prevention Fact Sheet, August 2011

Washington DC

14

• 16,721 reported living with HIV/AIDS in the District at the end of 2009• 5,505 new HIV cases reported between 2005 and 2009• 3.2% of the District’s population diagnosed with HIV/AIDS• one-third to one-half of people (locally) may be unaware of their HIV status. (Source: DC NHBS data)

Prevalence of HIV/AIDS in the District of Columbia, 2009

DC Resident Living with HIV/AIDS as of 2009, by Gender and Race/Ethnicity

Black Hispanic White Other Total

Male 8,325 756 2,620 350 12,051

Female 4,256 156 141 117 4,670

Total 12,581 912 2,761 467 16,721

DC% 75.2% 5.5% 16.5% 2.8% 100.0%

US% (2008) 49.3% 20.0% 27.8% 2.9% 100.0%

Overview: HIV/AIDS in District of Columbia

HIV Prevalence among High Risk Population, District of Columbia

7.1%

4.7%

3.4%

2.9% 2.8%

2.1%1.8%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

Black Males

All Blacks Hispanic Males

White Males

Black Females

All Hispanics

All Whites

25.0%

7.7%

13.0%

3.9%

6.3%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Black MSM White MSM IDU Male Heterosexuals

Female Hterosexuals

HIV Prevalence among Study PopulationsHIV Prevalence by Sex and Race/Ethnicity

Syndemics and Service Delivery High rates of STDs among

youth High rates of Syphilis,

chronic Hepatitis B and HIV among MSM and High rates of co-infection

High rates of chronic Hepatitis C among IDU and Heterosexuals

Sub-optimal health outcomes

Approximately 91% Health Care Coverage

Generous prevention, care and treatment programs

No ADAP Waiting List Extensive ADAP formulary Generous coverage on local

public health insurance programs

Poor Healthcare Utlization

Mean Community Viral Load among Whites and Blacks Living with HIV/AIDS in DC, 2008

18,283

39,173

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

White Black

Mea

n C

omm

unit

y V

iral

Loa

d (c

opie

s/m

L)

N=762 N=3,395

Linkage to Care among Newly Diagnosed Cases in DC, by Race/Ethnicity, 2005-2009

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

< 3 months 3-6 months 6-12 months > 1 year

Prop

orti

on e

nter

ing

care

White

Black

*Entry into care was determine by the date of the first CD4 count or percentage test or viral load test reported to the DCDOH.

Retention in Care and Not in Care among Newly Diagnosed Cases in DC, by Race/Ethnicity 2005-2009

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

White Black

Retained in care

No care

Not in care: absence of any HIV-related laboratory tests indicative of receipt of HIV primary care within the study period•Continuously in care (retained in care): presence of at least 2 HIV-related laboratory tests within 12 months of the initial linkage laboratory test date, each 10 to 14 weeks apart (modified HRSA definition)

National HIV Behavioral Surveillance Project (NHBS) Men who have Sex with Men, 2008

Unprotected Receptive Anal Intercourse, By Race, N=422

Unprotected Insertive Anal Intercourse, By Race, N=422

56.7%

25.3%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

White MSM Black MSM

51.0%

29.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

White MSM Black MSM

7.9%

26.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

White MSM Black MSM

National HIV Behavioral Surveillance Project (NHBS) Men who Have Sex with Men, 2008

HIV Prevalence among Study Participants, by Race, N=422

Mean Community Viral Load among White and Black MSM with HIV/AIDS in DC, 2008

N=645 N=901

19,732

31,404

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

White MSM Black MSM

Mea

n C

omm

unit

y V

iral

Loa

d (c

opie

s/m

L)

Linkage to Care among Newly Diagnosed White and Black MSM in DC, 2005-2009

Linkage to care was determine by the date of the first CD4 count or percentage test or viral load test reported to the DCDOH.

Pearson’s Chi-square p value, p=0.0006

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

< 3 months 3-6 months 6-12 months > 1 year

White MSM

Black MSM

Retention in HIV Care among Newly Diagnosed White and Black MSM in DC, 2005-2009

Pearson’s Chi-square p-value, p=0.0020

Continuous care is defined as having evidence (e.g. HIV-related lab test) of at least 2 visits to an HIV medical provider 10-14 weeks apart. Sporadic care is defined as having only one visit to a provider or 2 visits but more than 14 weeks apart.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Retained in Care Sporadic Care No Care

Prop

orti

on o

f MSM

Cas

es

White MSM

Black MSM

Social Determinants of Health

Social Determinants of Health (2)

Social Determinants of Health (3)

Targeted Messaging

Targeted Services Finding Action

General Populations • High burden of disease (HIV, STD, HepC)

• Opt out routine screening in emergency departments

• Routine GC/CT screening in women and girls of childbearing age

• Health Behavior and Risk Reduction• Municipal Condom Distribution:

online, venues, schools• Increased HIV/STD partner services

MSM • Co morbidities: HIV/Syphilis• High Rates HIV• High rates of high risk behaviors

• Engage w/providers who serve MSM• Encourage routine HIV and syphilis

screening• Bi-Annual HIV and STD testing• Messages developed to reduce stigma• Increase HIV/STD partner services• Hepatitis A/B Screening/Vaccination

Heterosexuals • High rates HIV, STDs• High rates of high risk behaviors• Low risk perception

• (General Population Strategies)• Social Marketing/harm Reduction• Integrated Partner Services (PCRS)

29

Condom Distribution Locations

Geographic Distribution of Substance Abuse Needle Exchange Programs Overlay - Heroin Arrests in the District of Columbia, 2008

Heroin Arrests

Substance Abuse Needle Exchange Programs

Preview

Dir

Preview

DC GOVTLeadership,

Coordination, $$$NGOs, CBOs:

program, pops

Fed Gov: $$$, TA, Guidelines

DC Planning Councils:Priorities, $

direction/advice

Medical Establishment: services, pops

FBOs: leaders, stigma, support, services

Involvement in the HIV response

Academia: TA, Research, Services

Media: info, ads

Families, Social Networks, Individuals:change

•Priorities•Experiences & Approaches•Reality & Implementation•Best Practices•Gaps in Service, Effect and

Intention•Cost-efficiency, ResourcesEVENTUAL IMPACT

Private/Businessinsurance, social resp

prevention

Conclusions: Health Inequalities are associated with both environmental and

social and sexual networks Role of Public Health System is to ensure targeted, evidence

scalable strategies that influence positive health outcomes Targeted, Integrated Messages and Service Delivery Monitoring Evaluation of Health Outcomes to influence Change

Special Thank You ONAP-LA Mario Perez

George Washington University School of Public Health Alan Greenberg, Amanda Castel, Manya Magnus, Irene Kuo

Emory University CFAR Patrick Sullivan, Jeb Jones

HAHSTA-DC Angelique Griffin, Jen Opoku, Sarah Willis, Rowena Samala

CDC Irene Hall, Amy Lansky

Dad, Mom, Tony-For Believing in Me