Minnesota Treatment Cascade for People Living with HIV/AIDS - April 2015

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Table of Contents:

Introduction

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.

Data Source

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, 2013 and alive at year-end 2014 and reported to the MDH as of April 8th, 2015.

(1) HIV (non-AIDS) or AIDS at first report.

Data Limitations

Laboratory data are used as a proxy for a care visit to calculate each segment of the treatment cascade, which may underestimate the true value of engagement in care. The accuracy of the cascade depends on complete reporting of laboratory results.

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. CDC recommends for local adaptations of the treatment cascade 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 2014 who were diagnosed with HIV infection (regardless of residence at diagnosis) by the year end of 2013. 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

Retention in care is defined in Minnesota as one laboratory test within the year 2014 for patients alive and living in Minnesota at the end of 2014 who were diagnosed through year-end 2013. Because Minnesota’s definition of retention in care is different than the national and other local cascades, use caution when comparing the retention in care measure to the national estimate.

Viral Suppression

Viral suppression is defined as a viral load test result of < 200 copies/mL at the most recent test during 2014 for patients alive and living in Minnesota at the end of 2014 who were diagnosed through year-end 2013.

Linkage to Care

Linkage to care is calculated using a denominator that is different than the other measures on the cascade. Linkage to care is defined as those who are diagnosed in Minnesota during the year 2013 and had a CD4 or VL test performed within 90 days of initial diagnosis. Because the passage of the revised communicable disease reporting rule to mandate the report of all CD4 and VL tests for HIV positive patients only occurred in 2011, reports of laboratory tests performed before that time are incomplete. Therefore, estimates for linkage to care are not useful for cases diagnosed prior to 2011.

The continuum of HIV care in Minnesota (Overall)

In Minnesota, there are 7,628 people over the age of 13 who were diagnosed with HIV through 2013 and were living in Minnesota at the end of 2014. Of the 7,628 people living with HIV at the end of 2014, 5,514 (72%) had at least one CD4 or VL test performed in 2014 (retention in care). Additionally, of the 7,628 people living with HIV/AIDS, 4,826 (63%) had a VL test of <200 copies/mL at their most recent test in 2014 (viral suppression) (Table 1). In 2013, there were 299 persons over the age of 13 who were diagnosed in Minnesota. Of these 299,261 (87%) had a CD4 or VL test performed within 90 days of their initial diagnosis (linkage to care) (Table 2).

figure one

Table 1
Treatment Cascade

Characteristics

Number of persons diagnosed with HIV Infection through 12/31/2013 and living in Minnesota on 12/31/2014 (Overall population)

Number of persons who have >=1 lab tests between 1/1/2014 through 12/31/2014

Number of persons who had a VL test result of < 200 copies/ml at their last test result in the year 2014

Sex
Male 5850 4213 3743
Female 1778 1301 1083
Current Age
13-29 666 500 392
30-44 2432 1716 1426
45-59 3601 2611 2356
60+ 924 687 652
Race/Ethnicity
Hispanic 677 425 381
White 3835 2937 2667
African-American 1639 1105 898
African-born 1032 706 589
American Indian 116 93 78
Asian/Pacific Islander 138 102 92
Multiple Races 175 145 120
Mode of Exposure
MSM 3899 2882 2612
IDU 423 278 230
MSM/IDU 396 299 255
Hetero 1712 1257 1045
Other** 101 84 62
Unspecified 1091 714 621
Geography (Current Residence)
11- county Metropolitan Area*** 6532 4712 4141
Greater Minnesota 1068 790 673
Disease Status
HIV (non-AIDS) 3951 2613 2279
AIDS 3677 2901 2547
Total 7628 5514 4826

** Hemophilia, transplant, transfusion, mother with HIV or HIV risk
*** Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, Sherburne, Washington, Wright Counties

 

Table 2
Linkage to Care

Characteristics

Number of persons diagnosed with HIV Infection in 2013 in Minnesota (Overall population)

Number of persons who had >=1 lab tests within 90 days of diagnosis

Sex
Male 299 200
Female 68 61
Age at diagnosis
13-29 101 83
30-44 93 84
45-59 80 78
60+ 18 16
Race/Ethnicity
Hispanic 27 23
White 144 123
African-American 70 61
African-born 42 40
American Indian 6 6
Asian/Pacific Islander -- --
Multiple Races 7 7
Mode of Exposure
MSM 155 137
IDU 5 4
MSM/IDU 10 9
Hetero 77 66
Other** 0 0
Unspecified 52 45
Geography (Residence at diagnosis)
11- county Metropolitan Area*** 240 212
Greater Minnesota 58 48
Disease Status
HIV (non-AIDS) 196 165
AIDS 103 96
Total 299 261

** Hemophilia, transplant, transfusion, mother with HIV or HIV risk
*** Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, Sherburne, Washington, Wright Counties

 

Highlights of the continuum of HIV care among select populations:

Sex at Birth

Substantial differences in the continuum of HIV care are not seen between males and females. However women are linked to care at a slightly higher than rate than men (90% versus 87%), but men have a higher rate of viral suppression than women (64% versus 61%).

figure 2

Race/Ethnicity

Trends in the cascade of HIV care in Minnesota differ by racial/ethnic group. White people have the highest rate of viral suppression (70%) while African-American, Hispanic and African-born persons have lower rates at 55%, 56% and 57%, respectively. Linkage to care cannot be displayed for all racial/ethnic groups because some groups had less than 5 persons in 2013.

figure 3

Risk Group

Differences in retention of care and viral suppression exist between risk groups. People who inject drugs (IDU) have the lowest rate of viral suppression (54%) while men who have sex with men (MSM) have the highest viral suppression rate (67%). Linkage to care cannot be displayed for all risk groups because some groups had less than 5 persons with that risk in 2013.

figure 4

Current Age

Young people living with HIV/AIDS (aged 13-29) have lower rates of linkage to care and retention in care compared to other age groups and they also have the lowest rate of viral suppression (59%). The rate of viral suppression increases in each of the age groups with people living with HIV/AIDS age 60 and older with highest rate of suppression at 71%.

figure 5

Geography

The HIV treatment cascade differs for people who live in the 11-county metropolitan area compared to those who live in Greater Minnesota. While linkage to care is higher in the metro area (88% versus 83% in the Greater Minnesota), there is no difference in viral suppression by geography.

figure 6

HIV Disease Status

People who have had an AIDS diagnosis have higher rates of engagement in care at every step of the treatment cascade than people living with HIV (non-AIDS). There could be several explanations for this difference. One possible explanation for this is AIDS patients could be more closely monitored by their physician. Another potential explanation is there could be underreporting of laboratory results for patients without an AIDS diagnosis as this was how CD4 and VL tests were reported prior to the rule change in 2011.

figure 7

Loss to follow-up

An analysis of those who were not virally suppressed was conducted to determine if people had simply not had a VL test done during 2013 or if the VL result was >200 copies/mL (Table 3). Of the 2,802 people who were not virally suppressed, 566 (20%) had a VL of >200 copies/mL, while 2,236 (80%) had no VL test performed at all.

figure 8

Table 3
Not Virally Suppressed
High Viral Load vs. No Viral Load Reported
Characteristics VL >200 No VL in 2014
Sex
Male 374 1733
Female 192 503
Current Age
13-29 93 181
30-44 257 749
45-59 189 1056
60+ 27 245
Race/Ethnicity
Hispanic 35 261
White 214 954
African-American 177 564
African-born 96 347
American Indian 11 27
Asian/Pacific Islander 10 36
Multiple races 23 32
Mode of Exposure
MSM 208 1079
IDU 42 152
MSM/IDU 37 104
Hetero 185 482
Other 21 18
Unspecified 73 401
Geography (Current Residence)
11- county Metropolitan Area* 469 1922
Greater Minnesota 97 298
Disease Status
HIV (non-AIDS) 260 1412
AIDS 306 824
Total 566 2236

* Persons with multiple, and unknown races
** Hemophilia, transplant, transfusion, mother with HIV or HIV risk
*** Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, Sherburne, Washington, Wright Counties


Future Work

Because CD4 and VL reporting did not become mandatory until 2011, it is not currently possible to calculate a treatment cascade among people with new diagnoses. In the future, as more years of data are complete, MDH will calculate a cascade for new diagnoses. This will allow for the comparison of the treatment cascade for those newly diagnosed to those who were diagnosed in the past as well as monitor changes in the trends over time.

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Updated Tuesday, August 11, 2015 at 12:27PM