HIV/AIDS in Massachusetts Challenges and Opportunities to Enhance the Public Health Response May 14, 2013 Fenway Community Health Center H. Dawn Fukuda, Director Office of HIV/AIDS Bureau of Infectious Disease Massachusetts Department of Public Health
Massachusetts Epi at a Glance There are 18,459 individuals living with HIV in Massachusetts reported to the State Surveillance Program There were 657 new diagnoses in 2011 An estimated 26,000 28,000 people living with HIV in Massachusetts According to CDC, an estimated 18% do not know their HIV status (~4,800 individuals) Over half of PLWH in the State are people of color Fifty-five percent (55%) of newly diagnosed males are persons of color Eighty percent (80%) of newly diagnosed females are persons of color
Figure 2. Trends in HIV Infection and Death among People Reported with HIV/AIDS by Year: Massachusetts, 2000 2011 1,400 Number of Diagnoses and Deaths 1,200 1,000 800 600 400 Diagnosis of HIV Infection Death 200 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Data Source: MDPH HIV/AIDS Surveillance Program; Data as of 1/1/13
People Diagnosed with HIV Infection by Race/Ethnicity and Year of Diagnosis 1 : Massachusetts, 2002 2011 450 Number of Diagnoses 400 350 300 250 200 150 100 50 0 White NH Hispanic Black NH Asian/Pacific Islander 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year 1 Reflects year of diagnosis for HIV infection among all individuals reported with HIV infection, with or without an AIDS diagnosis. Data Source: MDPH HIV/AIDS Surveillance Program; NH = Non-Hispanic; Data as of 1/1/13
Why are we seeing reductions? Medicaid expansion in 2001 Targeted prevention activities Integrated HIV, STI, and viral hepatitis testing since 2005 Tailored programs for IDU, MSM HIV Drug Assistance Program (HDAP) 500% eligibility ceiling, never had a waitlist Ready access to care and treatment, TasP Routine HIV testing 2006 Clinical Advisory on Routine HIV Testing CDC Expanded Testing Initiative, starting in 2007 Change in state law authorizing verbal consent to test for HIV in 2012 Medical case management to support HIV care services not covered by health insurance Syringe deregulation in 2006 State health care reform in 2007, Health Safety Net Program
Prevention and Care Investments are Highly Cost-Effective Over 5,500 cases averted between 2000 and 2012 Estimated health care cost savings of $2.1 billion dollars Medicaid costs per HIV+ beneficiary down by 22% in a recent five-year period Inpatient hospital costs down 10% despite 6,000 new HIV+ beneficiaries during the same time frame Forty-six (46) Medical Case Management programs 95% - 99% of patients in care 91% - 96% eligible patients on ART Over 75% patients achieved HIV viral suppression
What challenges do we face? Incidence declines may be slowing More than 650 new infections every year Disparities By race/ethnicity By gender and race/ethnicity By world region of birth By exposure mode, notably MSM
People Living with HIV/AIDS on December 31, 2012 by Race/Ethnicity: Massachusetts Other 3% Hispanic/Latino 24% White 43% Black 30% N=18,459 Data Source: MDPH HIV/AIDS Surveillance Program, Data as of 1/1/13
Figure 2. People Diagnosed with HIV Infection Within the Years 2009 2011 by Gender and Race/Ethnicity: Massachusetts 100% White (non-hispanic) Black (non-hispanic) Hispanic/Latino Other Percent of Total HIV Diagnoses 80% 60% 40% 20% 0% 45% 52% 27% 25% 25% 20% 3% 3% Male Female Race/Ethnicity Data Source: MDPH HIV/AIDS Surveillance Program, Data as of 1/1/13
People Diagnosed with HIV Infection Within the Years 2009 2011 by Exposure Mode: Massachusetts MSM/IDU Injection Drug 3% Use 8% Other 1% Presumed Heterosexual Sex 11% Male-to-Male Sex 41% Heterosexual Sex 13% Undetermined 24% Data Source: MDPH HIV/AIDS Surveillance Program, Data as of 1/1/13
Males Diagnosed with HIV Infection Within the Years 2009 2011 by Exposure Mode: Massachusetts Heterosexual Sex 5% Injection Drug Use 7% MSM/IDU 4% Other <1% Male-to-Male Sex 56% Undetermined 28% N=1,447 Data Source: MDPH HIV/AIDS Surveillance Program, Data as of 1/1/13
Females Diagnosed with HIV Infection Within the Years 2009 2011 by Exposure Mode: Massachusetts Injection Drug Use 11% Other 2% Undetermined 14% Presumed Heterosexual Sex 40% Heterosexual Sex 33% N=532 Data Source: MDPH HIV/AIDS Surveillance Program, Data as of 1/1/13
People Diagnosed with HIV Infection Within the Years 2009 2011 by Exposure Mode and Race/Ethnicity: Mass. Percent 80% MSM IDU MSM/IDU HTSX Other Pres. HTSX Undetermined 70% 60% 50% 40% 30% 20% 10% 0% White NH, N=752 Black NH, N=665 Hispanic/Latino, N=488 Race/Ethnicity NH= Non-Hispanic, Data Source: MDPH HIV/AIDS Surveillance Program, Data as of 1/1/13
Males Diagnosed with HIV Infection Within the Years 2009 2011 by Exposure Mode and Race/Ethnicity: Mass. Percent 80% MSM IDU MSM/IDU HTSX Other Undetermined 70% 60% 50% 40% 30% 20% 10% 0% White NH, N=647 Black NH, N=386 Hispanic/Latino, N=357 Race/Ethnicity NH= Non-Hispanic, API=Asian/Pacific Islander Data Source: MDPH HIV/AIDS Surveillance Program, Data as of 1/1/13
Females Diagnosed with HIV Infection Within the Years 2009 2011 by Exposure Mode and Race/Ethnicity: Mass. Percent 80% IDU HTSX Other Presumed HTSX Undetermined 70% 60% 50% 40% 30% 20% 10% 0% White NH, N=105 Black NH, N=279 Hispanic/Latina, N=131 Race/Ethnicity NH= Non-Hispanic, Data Source: MDPH HIV/AIDS Surveillance Program, Data as of 1/1/13
What are the new opportunities? USPSTF Grade A Rating for HIV Testing Massachusetts 2012 change in HIV testing consent law to allow verbal informed consent 4 th Generation HIV testing (antigen/antibody)/acute HIV infection response Pre-exposure Prophylaxis (PrEP) Electronic Laboratory Reporting (ELR) of CD4-T-cell count and HIV viral load to generate MA care cascade Treatment as Prevention (TasP) Massachusetts State HIV/AIDS Strategy Meeting (March 13, 2013)
Care Cascade for the United States MMWR December 2, 2011/60(47): pp. 1618-1623
Experience of Medical Care Consumer Survey (N = 1,004) 100 90 80 70 60 50 40 30 20 10 0 In medical care Taking HIV medications Virally suppressed Health good to excellent Source: Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study Final Report, December 2011, JSI Research and Training, Inc.
Chart Review Medical Case Management Sites 93% in care 2010-2011 according to HRSA definition, 2 or more medical visits at least 3 months apart 98% on HAART enrolled in care at least 3 months with at least one visit during reporting period 76% virally suppressed Two+ medical visits more than 60 days apart 84% virally suppressed One+ medical visits, not deceased/incarcerated > 90 days/otherwise LTFU
Where do we go from here? Maximize testing opportunities Estimated 18% of PLWHA do not know their status Thirty-two percent (32%) of newly diagnosed persons in Massachusetts are concurrently diagnosed Reach vulnerable populations 24% of newly diagnosed individuals have Undetermined risk 36% of non-us born new diagnoses had already progressed to AIDS 41% of new HIV diagnoses are in MSM (over half of new diagnoses in males attributable to MSM) 80% of newly diagnosed females are persons of color Improve timely diagnosis and linkage to care Ensure access to treatment Increase rates of viral suppression Sustain essential prevention and care services
Thank you Contact information H. Dawn Fukuda, Director Office of HIV/AIDS Bureau of Infectious Disease Massachusetts Department of Public Health Tel. 617-624-5303 E-mail. Dawn.Fukuda@state.ma.us