Minnesota Treatment Cascade for People Living with HIV/AIDS - September 2013
As part of the National HIV/AIDS Strategy for the United States, the Minnesota Department of Health (MDH) has calculated an HIV treatment cascade using HIV surveillance data. These calculations help us better understand the HIV epidemic and the disparities that exist in the delivery of care among HIV positive people in Minnesota.
In Minnesota, laboratory-confirmed infections of human immunodeficiency virus (HIV) are monitored by MDH through an active and passive surveillance system. State rules (Minnesota Rule 4605.7040) require both physicians and laboratories to report all cases of HIV infection (HIV or AIDS) directly to the MDH (passive surveillance). Additionally, regular contact is maintained with several clinical sites to ensure completeness of reporting (active surveillance). In June 2011, an amendment to the communicable disease reporting rule was passed, requiring the report of all CD4 and viral load (VL) test results.
Data in this report include cases diagnosed with HIV infection (1) as of December 31, 2011 and alive at year-end 2012 and reported to the MDH as of April 1, 2013.
(1) HIV (non-AIDS) or AIDS at first report.
Laboratory data are used as a proxy for a care visit to calculate each segment of the treatment cascade. The accuracy of the cascade depends on complete reporting of laboratory results. The transition from voluntary reporting of CD4 and VL results to mandated reporting has occurred at different rates among the various reporting laboratory facilities. We have been made aware of at least one lab in the state that has had difficulty consistently reporting all CD4 and VL results which could potentially bias the results. We also know that patients who have laboratories drawn as part of research studies are not reported to MDH. One clinic estimates that approximately 90 of their patients are participating in a research study.
Definitions of measures used in Minnesota’s Treatment Cascade
People Living with HIV/AIDS (Diagnosed Prevalence)
CDC estimates that between 18 and 20 percent of HIV infected individuals are not diagnosed and includes this estimate of unaware individuals in the national treatment cascade. For local adaptations of the treatment cascade, CDC recommends to use the diagnosed prevalence as the estimate for people living with HIV/AIDS within their jurisdiction. This does not include an estimate of the proportion of people living with undiagnosed HIV infection. Therefore Minnesota’s treatment cascade is not a direct comparison to other cascades that include an estimate of positive persons with unknown status.
To calculate the diagnosed prevalence used in this cascade, surveillance data were used to estimate the number of people over the age of 13 living in Minnesota at the end of 2012 who were diagnosed with HIV infection (regardless of residence at diagnosis) by the year end of 2011. This estimate serves as the underlying population for retention in care and viral suppression measures, hence is seen on the graph as 100% as people living with HIV/AIDS in Minnesota.
Retention in care
The CDC defines retention in care for local adaptations of the treatment cascade for jurisdictions without medical monitoring funding as two laboratory results at least three months apart. This is not displayed on Minnesota’s treatment cascade because initial analyses showed that 30% of people who were virally suppressed at the end of 2012, did not meet this definition of retention in care. After discussing with our prevention and care partners, it was noted that patients who are doing well on treatment may have only one laboratory ordered each year to monitor progression of disease. Therefore, on Minnesota’s treatment cascade, retention in care is defined as one laboratory test within the year 2012 for patients alive and living in Minnesota at the end of 2012 who were diagnosed through year-end 2011. Because of Minnesota’s adaptation of retention in care, use caution when comparing the retention in care measure to the national estimate.
Viral suppression is defined as a viral load test result of ≤200 copies/mL at the most recent test during 2012.
Linkage to Care
Linkage to care is defined as those who were diagnosed in Minnesota during the year 2011 and had a CD4 or VL test performed within 90 days of initial diagnosis. Calculation of the linkage to care measure use a denominator that is different due to guidance from CDC that instructs local jurisdictions to make this calculation based on one year of diagnoses. Therefore results for this measure are displayed in a different color in the graphics.
The continuum of HIV care in Minnesota (Overall)
In Minnesota, there are 7,147 people over the age of 13 who were diagnosed with HIV through 2011 and were living in Minnesota at the end of 2012. Of the 7,147 people living with HIV at the end of 2012, 5,233 (73%) had at least one CD4 or viral load test performed in 2012 (retention in care). Additionally, of the 7,147 people living with HIV/AIDS, 4,394 (61%) had a viral load test of ≤200 copies/mL at their most recent test in 2012 (viral suppression) (Table 1). In 2011, there were 291 persons over the age of 13 who were diagnosed in Minnesota. Of these 291, 229 (79%) had a CD4 or viral load test performed within 90 days of their initial diagnosis (linkage to care) (Table 2).
Highlights of the continuum of HIV care among select populations
Sex at Birth
While women are linked to care at a higher than rate than men (90 percent versus 75 percent), women are virally suppressed at a lower rate than men (58 percent versus 62 percent). Retention in care does not vary greatly by gender.
Trends in the cascade of HIV care in Minnesota differ by racial/ethnic group. Among the uniquely defined racial/ethnic populations, Hispanic people exhibit the highest rate of linkage to care (87%), while having the lowest rates of retention in care (64%). White people have the highest rate of viral suppression (68%) while African-Americans have the lowest, at 52 percent.
Differences in retention of care and viral suppression exist between groups by mode of exposure. People for whom risk was unable to be ascertained have the lowest rate of viral suppression (54%) while men who have sex with men (MSM) have the highest viral suppression rate (65%). Linkage to care cannot be displayed for all risk groups because some groups had less than 5 persons with that risk in 2011, and are therefore suppressed.
Young people living with HIV/AIDS (aged 13-29) have much lower rates of linkage to care and viral suppression (70 and 51 percent respectively) than older people living with HIV/AIDS. Of note, the rate of viral suppression increases in each of the age groups.
The HIV treatment cascade is similar for both people living in the 11 counties (2) that comprise the Minneapolis-St. Paul metropolitan statistical area and greater Minnesota. However, people living in the metropolitan area had a substantially higher linkage to care rate (81%) compared to greater Minnesota (65%).
(2) Includes Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, Sherburne, Washington and Wright Counties.
HIV Disease Status
People living with an AIDS diagnosis have 13 to 14% higher rates of engagement in care at each step of the treatment cascade than people living with HIV (non-AIDS).
Examination of Persons Not Virally Suppressed
An analysis of those who were not virally suppressed was conducted to determine if people had not had a viral load test done during 2012 or if the viral load result was >200 copies/mL (Table 3). Of the 2,753 of people who were not virally suppressed, 782 (28%) had a viral load of >200 copies/mL, while 1,971 (72%) had no viral load test performed at all.
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