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

Source: Ibrahim Dandakoye, Part A/MAI Grant and Quality Management Coordinator | Marion County Public Health Department Ryan White/HIV Services Program

Once upon a time, people infected by the Human Immunodeficiency Virus (HIV) had little hope to live beyond 6 months. Nowadays, with the discovery of the Antiretroviral Therapy (ART), HIV-infected individuals live a normal life, and life expectancy for People Living with HIV (PLWH) is almost the same as the general population, thus making HIV a chronic disease. With chronicity comes management; management requires measurement, and measurement leads to quality and improvement. The Marion County Public Health Department (MCPHD)’s Ryan White HIV services program is dedicated to ensure that all HIV patients living in the Transitional Grant Area (TGA) get the best quality of care defined by the Health Resources and Services Administration (HRSA). This goal is achievable by measuring services sub-recipients provide and program staff providing technical assistance in areas where improvement is needed.

Quality of Care

The HRSA’s HIV/AIDS Bureau (HAB) is committed to improving the quality of HIV care and treatment services for people living with HIV. Under the Ryan White HIV/AIDS Program, quality management is a series of activities that focus on enhancing the quality of HIV care provided and increasing access to services. These efforts focus on how health and social services meet established professional standards and user expectations.

The HIV/AIDS Bureau’s quality initiatives are designed to help Ryan White HIV/AIDS Program recipients implement quality management programs that target clinical, administrative, and support services.[1] Clinical Quality Management is the coordination of activities aimed at improving patient care, health outcomes, and patient satisfaction. Under the Ryan White HIV/AIDS Treatment Modernization Act of 2006 (Public Law 109-415), all Ryan White HIV/AIDS Program recipients are required to establish clinical quality management programs to:

• Assess the extent to which HIV health services are consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infections.
• Develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV services.

Clinical quality management activities should be continuous and fit within and support the framework of grant administration functions. Components of a clinical quality management program include: infrastructure, performance measurement, and quality improvement.

In an effort to align with these policies and procedures mentioned in the Policy Clarification Notice (PCN-15-02), the MCPHD Ryan White HIV Services Program is undertaking quality management monitoring starting fiscal year 2019-2020.

Quality Management Monitoring Site Visits

The Marion County Public Health Department (MCPHD) Ryan White Services Program will undertake QM monitoring site visits to all its sub-recipients. The goals of these visits are to measure the quality of services provided to clients, to offer technical assistance if needed and to provide support to sub-recipients in their day to day activities that they have misunderstandings in regard to QM. The site monitoring will also ensure that providers (sub-recipients) are compliant with Health Resources Services Administration (HRSA)/HIV AIDS Bureau (HAB) guidelines in quality HIV services. 

QM site visits are recommended by PCN 15-02[2] in order to: (1) assess the extent to which HIV health services provided to patients under the grant are consistent with the most recent Public Health Guidelines for the treatment of HIV disease and related opportunistic infections; (2) develop strategies for ensuring that such services are consistent with the guidelines for improvement in the access to and quality of HIV services; (3) collect data in a timely manner in CAREWare; (4) provide services as mentioned in PCN 16-02, and; (5) ensure QM plan(s) is implemented as mentioned in Indianapolis TGA QM plan. QM site visits are solely designed to assist Ryan White sub-awardees provide the best of care to PLWH, and therefore, PLWH are getting quality standard of care (Quality Assurance).

In sum, the goal of quality improvement is achievable with monitoring and technical assistance provided by the MCPHD, and quality of care for PLWH is feasible as “Ending the Epidemic” is looming on the horizon for the next decade or so. Quality improvement aiming at 95% of viral load suppression[3] among PLWH and increasing number of at risk populations getting to know their status[4] at 95% will help in Ending the Epidemic.

______________________________

[1] Quality of care: https://hab.hrsa.gov/clinical-quality-management/quality-care

[2] Policy Clarification Notice: https://hab.hrsa.gov/program-grants-management/policy-notices-and-program-letters

[3] https://www.cdc.gov/hiv/pdf/risk/art/cdc-hiv-art-viral-suppression.pdf

[4] Ending the Epidemic: https://www.hiv.gov/ending-hiv-epidemic

Source: Ibrahim Dandakoye Part A/MAI Grant and Quality Management Coordinator at the Marion County Public Health Department.
Published November 12, 2018

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 (PLWH) in central Indiana, including those out of care or historically underserved or uninsured. 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). This article sought to encourage HIV providers to offer Papanicolaou (Pap) tests for all adult (18 years and older) HIV infected female patients seeking care.

About Cervical Cancer

Cervical cancer caused by Human Papillomavirus (HPV) is the most common gynecological cancer in women infected by HIV. Knowledge regarding cervical cancer cause and pathogenesis is rapidly expanding[1]. Persistent infection with one of about 15 genotypes of carcinogenic HPV causes almost all cases. There are four major steps in cervical cancer development: infection of metaplastic epithelium at the cervical transformation zone, viral persistence, progression of persistently infected epithelium to cervical pre-cancer, and invasion through the basement membrane of the epithelium. Infection is extremely common in young women in their first decade of sexual activity. Persistent infections and pre-cancer are established, typically within 5–10 years, from less than 10% of new infections. Invasive cancer arises over many years or decades, in a minority of women with pre-cancer, with a peak or plateau in risk at about 35–55 years of age. Each genotype of HPV acts as an independent infection, with differing carcinogenic risks linked to evolutionary species.

Continue reading Pap Rates for Indianapolis TGA Parts A and C Recipients, and Tips/Resources for Improving Pap Screening Rates →

On Thursday, May 17, 2018, the Marion County Public Health Department Director, Dr. Virginia Caine, declared a public health epidemic due to a 1,000 percent increase between 2013 and 2017 in Hepatitis C cases. In response to the epidemic, Dr. Caine is proposing a safe syringe exchange program for Marion County at the next City-County Council meeting on Monday, May 21st.

Continue reading Public Health Epidemic Declared in Marion County due to Hepatitis C →

Source: AETC National Coordinating Resource Center
Published April 12, 2018

Six new HIV Meds Updates have been added online to the AETC National Coordinating Resource Center’s (AETC NCRC) ShareSpot. Summaries include key findings and treatment updates from CROI 2018:

• Bictegravir Approved for Initial ART, in Combination with TAF/FTC
• Bictegravir/TAF/FTC in Women
• Immediate ART Initiation Improves Time to Viral Suppression
• Darunavir/Cobicistat/FTC/TAF Single-Pill Combination in Treatment-Experienced Patients, EMERALD Study
• Ibalizumab Approved for Persons with Multidrug-Resistant HIV
• Naltrexone Improves Virologic Suppression

HIV Meds Updates are written by Susa Coffey, MD, medical editor of the AETC NCRC, and are posted as new treatment information becomes available.

Click here for other treatment updates, as well as more HIV/AIDS news.

Source: AAHIVM’s HIV Specialist Magazine
Published April 2018

Congratulations to Brooke Stevens, PharmD, BCPS, AAHIVP, from IU Health LifeCare, along with Blake Max, PharmD, AAHIVP, from the University of Illinois in Chicago, on their recent article titled “Test and Treat: A New Model for Better Patient Outcomes” that was published in the April 2018 edition of AAHIVM’s HIV Specialist Magazine:

Continue reading Test and Treat: A New Model for Better Patient Outcomes →

Source: Samir Gupta, MD, Indiana University School of Medicine
Published April 19, 2018

The Indiana Center for AIDS Research (CFAR) is working to increase collaborative research throughout the state of Indiana in all aspects of HIV/AIDS prevention and care. CFAR is currently conducting research in a variety of areas, including finding an HIV cure, improving quality of life for patients living with HIV, preventing new HIV infections, providing HIV care in resource-limited settings, and testing new HIV treatments.

To conduct successful research, CFAR needs community engagement from both people living with and without HIV. Currently, CFAR is seeking individuals to participate in their open studies. Community members interested in participating in open studies can click the link below or visit the IU School of Medicine’s Infectious Disease Clinical Research Program website by clicking here.

Click Here to Access the Current List of Studies 

 

For more information about CFAR and upcoming studies, visit the CFAR website by clicking here, or contact Samir Gupta, MD, at sgupta1@iu.edu or (317) 274-7926.