Minnesota Treatment Cascade for People Living with HIV/AIDS - January 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, 2012 and alive at year-end 2013 and reported to the MDH as of December 22, 2014.

(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. The accuracy of the cascade depends on complete reporting of laboratory results. One lab in the state has not been 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. 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 2013 who were diagnosed with HIV infection (regardless of residence at diagnosis) by the year end of 2012. 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 2013 for patients alive and living in Minnesota at the end of 2013 who were diagnosed through year-end 2012. Because of Minnesota’s adaptation of retention in care, 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 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 2012 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. To compensate for the lack of data prior to 2011, the CDC recommends only using data from one year to calculate the proportion of people diagnosed in that year who were linked to care. In this iteration of Minnesota’s HIV treatment cascade, linkage to care was calculated as the number of people who were diagnosed in Minnesota in 2012 who had at least one CD4 or VL test within 90 days of their diagnosis.

The continuum of HIV care in Minnesota (Overall)

In Minnesota, there are 7,389 people over the age of 13 who were diagnosed with HIV through 2012 and were living in Minnesota at the end of 2013. Of the 7,389 people living with HIV at the end of 2013, 5,305 (72%) had at least one CD4 or VL test performed in 2013 (retention in care). Additionally, of the 7,389 people living with HIV/AIDS, 4,565 (62%) had a VL test of <200 copies/mL at their most recent test in 2013 (viral suppression) (Table 1). In 2012, there were 311 persons over the age of 13 who were diagnosed in Minnesota. Of these 311, 281 (90%) 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 12/31/2012 and living in Minnesota on 12/31/2013 (Overall population)

Number of persons who have >=1 lab tests between 1/1/2013 through 12/31/2013

Number of persons who had a VL test result of<200 copies/ml at their last test result in the year 2013

Sex
Male 5673 4018 3517
Female 1716 1287 1048
Current Age
13-29 602 457 346
30-44 3270 1673 1371
45-59 3509 3537 2256
60+ 893 637 591
Race/Ethnicity
Hispanic 368 399 355
White 3759 2814 2530
African-American 1594 1090 862
African-born 984 685 564
American Indian 112 88 67
Asian/Pacific Islander 134 93 79
Multiple Races 158 135 107
Mode of Exposure
MSM 3783 2779 2477
IDU 414 271 222
MSM/IDU 384 262 225
Hetero 1653 1233 1003
Other** 101 82 61
Unspecified 1054 678 577
Geography (Current Residence)
11- county Metropolitan Area*** 6207 4424 3835
Greater Minnesota 830 552 442
Disease Status
HIV (non-AIDS) 3772 2486 2137
AIDS 3617 2819 2428
Total 7389 5305 4565

* American Indian, Asian/Pacific Islander, persons with multiple or unknown races
** 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 2012 in Minnesota (Overall population)

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

Sex
Male 250 228
Female 61 53
Age at diagnosis
13-29 83 76
30-44 128 115
45-59 84 74
60+ 12 12
Race/Ethnicity
Hispanic 41 38
White 135 126
African-American 75 64
African-born 40 36
American Indian 10 8
Asian/Pacific Islander 5 5
Multiple Races 5 4
Mode of Exposure
MSM 166 154
IDU 12 12
MSM/IDU 10 9
Hetero 57 49
Other** 0 0
Unspecified 66 57
Geography (Residence at diagnosis)
11- county Metropolitan Area*** 241 217
Greater Minnesota 55 50
Disease Status
HIV (non-AIDS) 215 189
AIDS 96 92
Total 311 281

* American Indian, Asian/Pacific Islander, persons with multiple or unknown races
** 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 men are linked to care at a slightly higher than rate than women (91% versus 87%), but women are retained in care at a higher rate than men (75% versus 71%).

figure 2

Race/Ethnicity

Trends in the cascade of HIV care in Minnesota differ by racial/ethnic group. While Hispanic people have one of the highest rates of linkage to care in 2012 (93%), they have the lowest rates of retention in care (63%). White people have the highest rate of viral suppression (67%) while African-Americans have the lowest, at 54%. Linkage to care cannot be displayed for all racial/ethnic groups because some groups had less than 5 persons in 2012.

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 (65%). Linkage to care cannot be displayed for all risk groups because some groups had less than 5 persons with that risk in 2012.

figure 4

Current Age

Young people living with HIV/AIDS (aged 13-29) have similar rates of linkage to care and retention in care compared to other age groups, however they have the lowest rate of viral suppression (57%). 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 66%.

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 similar between the two groups, people living in Greater Minnesota are virally suppressed at a lower rate (53%) compared to people living in the metro area (62%).

figure 6

(2) Includes Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, Sherburne, Washington and Wright Counties.

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 2,824 people who were not virally suppressed, 637 (23%) had a VL of >200 copies/mL, while 2,187 (77%) had no VL test performed at all. This high percentage of people who are missing a VL test warrants further investigation to determine if there is underreporting of laboratory tests in Minnesota.

figure 8

Table 3
Those not Virally Suppressed
High Viral Load vs. No Viral Load Reported
Characteristics VL >200 No VL in 2012
Sex
Male 419 1737
Female 218 450
Current Age
13-29 168 156
30-44 324 738
45-59 252 1012
60+ 38 267
Race/Ethnicity
Hispanic 40 243
White 224 1005
African-American 209 523
African-born 107 313
American Indian 19 26
Asian/Pacific Islander 13 42
Multiple races 25 26
Mode of Exposure
MSM 246 1060
IDU 45 147
MSM/IDU 29 130
Hetero 209 441
Other 19 21
Unspecified 89 388
Geography (Current Residence)
11- county Metropolitan Area* 504 1868
Greater Minnesota 97 291
Disease Status
HIV (non-AIDS) 286 1349
AIDS 351 838
Total 637 2187

* American Indian, Asian/Pacific Islander, 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, January 13, 2015 at 08:40AM