San Francisco Medical Monitoring Project (MMP) Maree Kay Parisi Applied Research, Community Health Epidemiology and Surveillance

San Francisco Medical Monitoring Project (MMP) Maree Kay Parisi Applied Research, Community Health Epidemiology and Surveillance

Medical Monitoring Project Overview National prospective Local data and findings Future of MMP

Medical Monitoring Project (MMP) Background Supplemental surveillance system Created in response to 2004 Institute of Medicine report Need for population-based, nationally representative data on HIV-infected persons in care

Methods: MMP Design Complex sample cross-sectional survey 17 states or territories sampled from 50 US states, Washington DC and Puerto Rico Contain 73% of all adults diagnosed with HIV in the US Outpatient HIV care facilities within sampled states or territories HIV-infected adults receiving medical care during January-April within sampled facilities

MMP Participating Project Areas, 2009-2014 WA WA OR OR NY San Francisco Los Angeles County CA Chicago IL MI IN PA VA NC New York City Philadelphia NJ DE TX MS GA Houston FL PR

Methods: Data Collection Interview: Self-reported demographics, experiences and behaviors Medical record abstraction (MRA): Documented clinical care Linkage to the National HIV Surveillance System (NHSS) Minimum data set (MDS) Facility characteristics HIV provider survey

CDC COLLABORATIONS Collaborations EXTERNAL COLLABORATIONS Division of HIV/AIDS Prevention HIV Incidence and Case Surveillance Branch Prevention Communication Branch Prevention Research Branch Prevention Evaluation Branch Epidemiology Branch Division of STD Prevention Division of TB Elimination Office of Smoking and Health HIV Medicine Association (HIVMA) American Academy of HIV Medicine (AAHIVM) AIDS Education Training Centers (AETCs) Association of Nurses in AIDS Care (ANAC) Health Resources and Services Administration (HRSA) Institute of Medicine (IOM) Committee on Monitoring HIV Care White House Office of National AIDS Policy (ONAP) Kaiser Family Foundation (KFF) Emory University School of Public Health London School of Hygiene and Tropical Medicine

Overview of San Francisco MMP 1464 total participants in San Francisco from 2007-2013 Year n 2007 147 2008 182 2009 212 2010 220 2011 219 2012 249 2013 235 Facility type of participants 2007-2013 Public clinic 15% (n=219) VA 3% (n=44) Public hospital 21% (n=313) Private/ HMO 61% (n=888)

MMP patient characteristics 2009-2010 Weighted %* Male 93% Female 4% Transgender 3% 25-34 years 6% 35-44 years 22% 45-54 years 40% 55+ years 31% Any MSM (MSM only+msmw) 84% MSW only 7% Any WSM (WSM only+wsmw) 4% White 57% African American 11% Hispanic 19% Other 13% Have continuous health coverage 92% At or below poverty level 11% Homeless 15% HIV diagnosis <5 years 13% HIV diagnosis 5-9 years 14% HIV diagnosis 10 years 73% *data were weighted to adjust for probability of selection and facility and patient nonresponse

ART, viral suppression and prevention counseling 2009-2010 Prescription of ART (%) Viral suppression among those on ART (%) Prevention counseling by a health care provider (%) Weighted %* Weighted %* Weighted %* 25-34 86% 68% 48% 35-44 83% 81% 44% 45-54 90% 85% 37% >=55 94% 90% 13% Male 90% 85% 30% Female 96% 72% 50% Black or African American 84% 76% 42% Hispanic or Latino** 83% 85% 41% White 93% 86% 25% Other 89% 86% 37% Men who have sex with men 90% 87% 29% Men who have sex with women only 89% 69% 44% Women who have sex with men 96% 72% 50% Total 90% 85% 32% *data were weighted to adjust for probability of selection and facility and patient nonresponse

Met and Unmet Needs for Services, 2009-2010 (N = 418) Dental Services Public benefits incl SSI/SSDI Mental Health Services AIDS Drug Assistance Program (ADAP) HIV Case Management Services Meals or food services Transportation Assistance Services HIV peer group support HIV prevention education Shelter services Adherence services Drug or alcohol counseling/treatment Home health services Domestic violence services Services with the largest unmet need 1. Dental services 2. HIV peer group support 3. Mental health 4. Transportation services 5. HIV Case Management Interpreter services Childcare Services 0 2000 4000 6000 8000 10000 12000 Met need Unmet Need

Is age associated with unmet need for supportive services among HIV-infected patients receiving HIV care? 761 MMP participants in SF: 3% were ages 18-29, 13% were 30-39 years, 39% 40-49 years and 46% were 50 years old 86% had at least one supportive service need and 45% had at least one unmet service need in the past 12 months Age was not associated with need for any supportive service Patients from public facilities and uninsured reported higher need for any supportive service.

90% 80% 79% Sexual Behavior, 2009-2010 (N = 418) 83% 70% 67% 60% 50% 44% 50% 40% 39% 30% 20% 20% 22% 18% 10% 11% 11% 4% 0% Total MSM MSW WSM Any sex Unprotected sex Unprotected sex with HIV negative or unknown status partner

Percentage of Persons with HIV Engaged in Selected Stages of the Continuum of Care United States 100 90 80 70 60 50 40 30 20 10 0 82 37 Diagnosed Retained in care Prescribed ART Viral suppression 33 25 Hall et al. JAMA Int Med. 2013; DOI:10.1001/jamainternmed.2013.6841

Linkage, Retention, ART Use and Viral Suppression Successful HIV treatment involves: Timely linkage to medical care Ongoing engagement in care Access and adherence to effective HIV treatment

80% 28% get to viral suppression CDC. Vital signs: HIV prevention through care and treatment United States. MMWR 2011; 60:1617-23.

Number of persons 18000 100% (n=17,665) Stages of HIV Care, San Francisco 16000 14000 12000 10000 8000 80% 80% (n=14,132) 68% (n=12,012) 57% (n=10,034) 50% (n=8,930) 46% (n=8,216) 85% 6000 4000 71% 89% 92% 2000 0 HIV-infected HIV Diagnosed Linked to care In care On ART Suppressed

Percent of estinated total HIV-infected Percentage of estimated number of HIV-infected persons* in stages of the continuum of HIV care in four large United States cities through December 2009 compared to national estimates; Chicago, Philadelphia, Los Angeles and San Francisco. 100% 90% US (Total infected=1,178,350) Chicago (Total infected=23,799) 80% Los Angeles County (Total infected=47,658) 70% 60% 50% 62% 54% 62% 58% 68% 53% 57% Philadelphia (Total infected=19,691) San Francisco (Total infected=17,665) 50% 47% 46% 40% 30% 20% 41% 31% 39% 36% 26% 34% 28% 22% 41% 27% 10% 0% Linked to Care In Care On ART** Suppressed viral load*** *Includes people diagnosed with and unaware of their HIV infection **Percent of people in care on antiretroviral therapy from Medical Monitoring Project *** Most recent HIV viral load test indicating <=200 copies/ml among those on ART from Medical Monitoring Project

Future of MMP Case Surveillance Based Sampling (CSBS) Sample is based on diagnosis date and last known residence Potential to sample people who are out of care

Acknowledgements SF MMP Team Susan Scheer, PhD, MPH Principal Investigator Anthony Buckman, MS Anne Hirosawa, MPH Alison Hughes, MPH Patrick Norton, PhD, MA Kristiana Dhillon Maree Kay Parisi Project Coordinator Patrick Norton, PhD, MA Rolando Ramirez Nashanta Stanley Maya Yoshida-Cervantes Zachary Matheson All MMP participants and participating facilities Andrew Lopez, SF MMP Community Advisory Board Dr. Toby Dyner, SF MMP Provider Advisory Board