Marion County Public Health Department, Epidemiology Request DR2370
Prepared by: Tammie L. Nelson

Continuum of Care – Delayed linkage and poor engagement in care among people living with HIV (PLWH) has been associated with increased transmission, drug resistance, quicker progression to AIDS, increased morbidity (i.e., hospitalizations, opportunistic infections) and increased mortality.[1],[2],[3] For this reason, it is vital to monitor and improve engagement in each step of the HIV continuum of care. Figure 1 illustrates the engagement among PLWH at EOY 2013 in the Indianapolis-Carmel Metropolitan Statistical Area (MSA)[4] as compared to all PLWH in the U.S. at EOY 2011 (includes the MSA).[5],[6]National data reflect engagement in care prior to implementation of initiatives that may be reflected in the more recent MSA data.

The Marion County Public Health Department’s Ryan White HIV Services Program (RWSP) employs a continuum of care based on common indicators[7] published by the Health Resources and Service Administration’s HIV/AIDS Bureau (HAB). This method encourages similarity in jurisdictional reporting. Locally they are used to provide RWSP staff, Planning Council, providers and consumers with information to measure program efficacy.

Figure 2 and Table 1 are based on HAB common indicators and reflect engagement in care among PLWH in the MSA vs. the rest of the U.S. (MSA excluded from U.S. data). As in Figure 1, the U.S. data in Figure 2 is not a direct comparison to MSA data and should not be construed as such. Definitions used to construct Figure 2 can be viewed at [Definitions Table]. 

Additional performance measures[8] serve as indicators of health and engagement in care among PLWH in the MSA. Some are discussed below, while others will be highlighted in future MATEC Indiana newsletters.

Late Diagnoses – Of 236 MSA residents diagnosed with HIV during CY 2013, 25.0% (N=59) received AIDS diagnoses within 90 days of initial HIV diagnosis. Among those diagnosed late, 86.4% (N=51) received concurrent HIV and AIDS diagnoses.

Gap in Medical Visits – Among PLWH in the MSA, 17.9% (N=579) experienced a gap in HIV medical care visits during 2013. This gap occurs when an individual has at least one medical visit in the first six months, but not during the last six months, of the measurement year.

Undetectable Viral Load – Among PLWH in the MSA who attended at least one HIV medical visit during 2013 (N=3,859), 54.7% (N=2,110) had undetectable viral loads (<50 copies/mL). These residents are included in the suppressed viral load calculation for Figure 2.

Unmet Need – Among 5,384 PLWH in the MSA on March 31, 2014, 26.3% (N=1,417) received no HIV primary medical care during the preceding 12-months (Table 2). [5],[9],[10],By AIDS status, 31.5% of residents living with HIV non-AIDS were out of care; whereas, 21.6% of residents living with AIDS were out of care.

Sources:

[1] Branson, B. M., Handsfield, H. H., Lampe, M. A., Janssen, R. S., Taylor, A. W., Lyss, S. B., and Clark, J. E. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR, 2006;55(RR14): 1-17.

[2] Gardner, E. M., McLees, M. P., Steiner, J. F., del Rio, C., and Burman, W. J. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52(6): 793-800.

[3] Centers for Disease Control and Prevention. (2011). Vital signs: HIV prevention through care and treatment – United States. MMWR, 2011;60(47):1621.

[4] The Indianapolis-Carmel MSA is congruent with the RWSP transitional grant area and includes: Boone, Brown, Hamilton, Hancock, Hendricks, Johnson, Marion, Morgan, Putnam, and Shelby Counties.

[5] Centers for Disease Control and Prevention. (2014). Enhanced HIV/AIDS Reporting System (eHARS).

[6] U.S. Department of Health & Human Services. (2013). HIV/AIDS care continuum.

[7] U.S. Department of Health & Human Services. (2013). Common indicators for HHS-funded HIV programs and services.

[8] U.S. Department of Health & Human Services. (2013). HIV/AIDS Bureau performance measures.

[9] Indiana Office of Medicaid Policy and Planning. (2014). Indiana health coverage program HIV/AIDS enrollment. Available from Indianapolis: Indiana State Department of Health.

[10] Total HIV-positive, aware, not receiving HIV primary medical care services (quantified estimate of unmet need).