Minnesota Treatment Cascade for People Living with HIV/AIDS - April 2015
Table of Contents:
- Data Source
- Data Limitations
- Definitions of measures used in Minnesota’s Treatment Cascade
- The continuum of HIV care in Minnesota (Overall)
- Highlights of the continuum of HIV care among select populations:
- Future Work
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, 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.
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 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).
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%).
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.
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.
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%.
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.
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.
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.
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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