Source: Samir Parmar, MPH, HIV & Opioid Epidemiologist at Marion County Public Health Department

Published May 14, 2019

Introduction

The Marion County Public Health Department’s Ryan White HIV Services Program (RWSP) manages Part A, Minority AIDS Initiative (MAI), and Part C funding to address the needs of people living with HIV/AIDS (PLWH) in central Indiana, including those out of care or historically underserved or uninsured. The RSWP has received Part C funding since 1991, and Part A/MAI funding since 2007. The program helps out-of-care clients gain access to points of entry; provides a comprehensive HIV continuum of care; and complies with the National HIV/AIDS Strategy (NHAS).[1] The program works in the Ryan White Part A transitional grant area (TGA). TGA counties include Boone, Brown, Hamilton, Hancock, Hendricks, Johnson, Marion, Morgan, Putnam, and Shelby County.  Rates were calculated per 100,000 TGA residents at risk. The primary goal of this summary is to provide knowledge to providers on current disparities in HIV diagnoses and HIV outcomes in Central Indiana. The hope is that providers will be able to use this information to better focus on those most in need and in turn improve health outcomes.

Incidence

The estimated total population for the TGA in 2018 was 1.92 million people; 49% of those people resided within Indianapolis city limits. In 2018, there were 243 new HIV diagnoses at a rate of 12.7 (95% CI: 11.1-14.4). In comparison, the nationwide rate was 11.8 in 2017 and the rate for Indiana was 7.8 in 2017. [2] As an additional comparison to a nearby TGA, the Nashville (Tennessee) TGA a diagnosis rate of 9.6 in 2016. [3] It is important to note that the rate for 2017 in the Indy TGA was 15.0 (95% CI: 13.3-16.8).

Demographics and Exposures of New Cases

In looking at demographics and exposures of HIV diagnoses in 2018 (n=243), several groups appeared highly impacted. Males made up the majority of new diagnoses, as 75% were male (n=182) and 24% were female (n=58). Considering race/ethnicity, Blacks and Hispanics continue to be most at risk for new HIV infections. 54% were Black (n=132) at a rate of 44 (95% CI: 36.8-52.1), 28% were White (n=68) at a rate of 5 (95% CI: 3.8-6.3), and 14% were Hispanic (n=34) at a rate of 25 (95% CI: 17.6-35.5). Blacks had a diagnosis rate 9 times and Hispanics had a diagnosis rate 5 times that of Whites. Considering age groups, young adults 20-34 years old continue to be most at risk for HIV with rates at least double that of other age groups. 40% of HIV diagnoses were among 25-34 year olds (n=96) at a rate of 35 (95% CI: 28-42.2) and 19% were among 20-24 year olds (n=46) at a rate of 37.7 (95% CI: 27.6-50.3). Examining nativity status revealed 70% were native born (N=169) at a rate of 9 (95% CI: 8.1-11) and 17% were foreign born at a rate of 34 (95% CI: 24.5-46). Foreign born residents experienced a rate about 4 times that of native-born residents.

In looking at exposures, men who have sex with men continue to bear the greatest burden of HIV. 44% had male-to-male sexual contact (MSM, n=108) at an estimated rate of 216 (95% CI: 177-261), 34% had heterosexual contact (n=82) at a rate of 4 (95% CI: 3.5-5.4), and 7.4% had injection drug use (IDU, n=18). MSM had an estimated rate 49 times that of heterosexuals.

Prevalence

When looking at prevalence of HIV in the TGA, we found many similar disparities. We estimated 6,149 people were diagnosed and living with HIV/AIDS in the TGA by end of 2018. Additionally, 13% of PLWH were estimated to be undiagnosed/unaware (n=919). The majority of individuals with HIV were living in Marion County at 85% (n=5,258).  By gender, the majority of PLWH are male, as 78% (n=4,828) were male.  HIV prevalence continues to be higher among racial/ethnic minorities than among Whites in the TGA. By race/ethnicity, 46% (n=2,808) were Black, 40% (n=2,448) were White. Adults over 45 years old account for over 55% of the TGA’s PLWH. By current age, 28% were 45-54 (n=1,717) and 21% were 55-64 (n=1,292). By exposure group, MSM individuals continue to make up the majority of the individuals living with HIV. 56% were MSM (n=3,444), 22% were heterosexual (n=1,340), and 10% were IDU (n=612). An estimated 34% of HIV-positive MSM were unaware of their status. [4]

HIV Care Continuum

In updating the HIV Care Continuum of the TGA, we see similar Care Continuum outcomes as years prior.  Linkage to care, retention in care, ART Rx estimate, and viral load suppression were considered for Continuum of Care measures. Linkage to care defined as people who have a CD4/viral load test within 90 days of diagnosis was at 81% (n=197), while linkage to care within 30 days was at 58%. Retention in care defined by 2 or more CD4/viral load test at least 3 months apart was at 51.4% (N=3,185). ART Rx defined as individuals who received an ART prescription was estimated at 54% to 73%. Viral load suppression (<200 RNA copies/mL) based on last viral load result was at 61.7% (n=3,824). Note that 25% (n=1,581) did not have a CD4/viral load test in 2018 and these individuals were presumed to not be virally suppressed. Linkage to care within 30 days and retention in care is still below 60%, and viral load suppression is still below 65% for the TGA.

When comparing to historical outcomes, the TGA has made important progress. In looking at the outcomes over time, the TGA has improved on linkage to care within 90 days which was 78% in 2014 to 81% in 2018; however we have fallen on linkage to care within 30 days which was nearly 61% in 2014 to 58% in 2018. Retention in care has increased from 43.9% in 2014 to 51.4% in 2018. Viral suppression has increased to 61.7% from 54% in 2014; however viral load suppression has fluctuated around 61% since 2016.

Males, Blacks, and adolescents/young adults appear to be most likely to have an unsuppressed viral load. By gender, 61.3% of males and 63.1% of females have a suppressed viral load. By race/ethnicity, Whites have 66.5%, Blacks have 57.3%, Hispanics have 60.2%, and Asian/Pacific Islanders have 78% viral load suppression. By age group, the three age groups with the lowest viral load suppression include 15-19 year olds at 55.3%, 20-24 at 47.5% and 25-34 year olds at 55.5%. 

Discussion and Major Takeaways

As the undetectable equals untransmittable (U=U) campaign points out, getting and keeping an undetectable viral load is one of the best things that PLWH can do to stay healthy. Risk of HIV transmission for people with undetectable viral load is very low by sex (oral, anal or vaginal) and for pregnancy. [5] As recent results from the PARTNER study have concluded, HIV transmission through condomless sex among gay couples when HIV viral load is suppressed is effectively zero and support the message of the U=U campaign. [6] Close monitoring and individualized care is essential to improving retention in care, ART adherence, and viral suppression. [7]

Efforts to improve HIV care outcomes should consider epidemiological disparities among the key populations highlighted across race/ethnicity, sex/gender, age group, and exposure categories. These key populations include Black and Hispanic individuals, males, adolescents and young adults, and MSM individuals. Current trends shows that were are will have challenges in meeting recent White House Ending the HIV: A Plan for America national goals of 75% reduction of new HIV infections in 5 years and 90% reduction in 10 years and 90% nationwide viral load suppression.  [8]The proposed strategic initiative to getting there has 4 pillars: diagnosing all individuals with HIV as early as possible, treating HIV rapidly and effectively to get viral load suppression, preventing at risk individuals from acquiring HIV infection including via PrEP, and rapidly detecting and responding to emerging HIV clusters to reduce new transmissions. [9] Coordination of resources and services and effective organizational partnerships will be extremely important in the success of these goals. [9] These goals and recommendations should be considered by readers from HIV care providers in Central Indiana. Additional information is provided in the epi profile and the full viral load report posted on the Indy TGA Ryan White website resources section (http://www.ryanwhiteindytga.org/Resources).

Sources

[1] White House Office of National AIDS Policy. (2015). National HIV/AIDS strategy for the United States: Updated to 2020. https://www.aids.gov/federal-resources/national-hiv-aids-strategy/nhas-update.pdf

[2] Centers for Disease Control and Prevention. (2018). HIV surveillance report, 2017; Vol. 29. Retrieved from https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2017-vol-29.pdf

[3] Nashville Regional Planning Council. (2018). Ryan White Part A Nashville Transitional Grant Area 2018 Needs Assessment.  Retrieved from https://www.nashrpc.com/s/2018-Needs-Assessment-Final2.pdf

[4] Centers for Disease Control and Prevention. (2016). HIV Testing in the United States: Fact sheet. Retrieved from https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/hiv-testing-us-508.pdf

 [5] CDC. (2018). HIV treatment Can Prevent Sexual Transmission. https://www.cdc.gov/hiv/pdf/risk/art/cdc-hiv-tasp-101.pdf

[6] Rodger, A. J., Cambiano, V., Bruun, T., Vernazza, P., Collins, S., Degen, O., … & Raben, D. (2019). Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. The Lancet. Retrieved from https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30418-0/fulltext

[7] Thompson, M. A., Mugavero, M. J., Amico, K. R., Cargill, V. A., Chang, L. W., Gross, R.,  … & Beckwith, C. G. (2012). Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel. Annals of internal medicine, 156(11), 817-833. Retrieved from https://annals.org/aim/fullarticle/1170890/guidelines-improving-entry-retention-care-antiretroviral-adherence-persons-hiv-evidence

[8] U.S. Department of Health & Human Services. (2019). Ending the HIV Epidemic: A Plan for America. Retrieved from https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview

[9] Fauci, A. S., Redfield, R. R., Sigounas, G., Weahkee, M. D., & Giroir, B. P. (2019). Ending the HIV epidemic: a plan for the United States. Jama, 321(9), 844-845. Retrieved from https://jamanetwork.com/journals/jama/article-abstract/2724455