HIV/AIDS in Massachusetts

Challenges and Opportunities toEnhance the Public Health Response

May 14, 2013Fenway Community Health Center

H. Dawn Fukuda, DirectorOffice of HIV/AIDS

Bureau of Infectious DiseaseMassachusetts 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

0

200

400

600

800

1,000

1,200

1,400

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Year

Num

ber o

f Dia

gnos

es a

nd D

eath

s Diagnosis of HIV Infection

Death

Data Source: MDPH HIV/AIDS Surveillance Program; Data as of 1/1/13

People Diagnosed with HIV Infection by Race/Ethnicity and Year of Diagnosis1: Massachusetts, 2002–2011

0

50

100

150

200

250

300

350

400

450

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Year

Num

ber o

f Dia

gnos

es

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

White NH

Asian/Pacific Islander

Hispanic

Black NH

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

White43%

Hispanic/Latino24%

Other3%

Black30%

Data Source: MDPH HIV/AIDS Surveillance Program, Data as of 1/1/13

N=18,459

Figure 2. People Diagnosed with HIV Infection Within the Years 2009–2011 by Gender and Race/Ethnicity: Massachusetts

45%

20%27%

52%

25% 25%

3% 3%0%

20%

40%

60%

80%

100%

Male FemaleRace/Ethnicity

Perc

ent o

f Tot

al H

IV D

iagn

oses

White (non-Hispanic) Black (non-Hispanic) Hispanic/Latino Other

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

Undetermined24%

Presumed Heterosexual

Sex11%

Injection Drug Use8%

MSM/IDU3%

Other1%

Heterosexual Sex13%

Male-to-Male Sex41%

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

Male-to-Male Sex 56%

Undetermined 28%

Injection Drug Use 7%

Heterosexual Sex 5%

Other <1%

MSM/IDU 4%

Data Source: MDPH HIV/AIDS Surveillance Program, Data as of 1/1/13

N=1,447

Females Diagnosed with HIV Infection Within the Years 2009–2011 by Exposure Mode: Massachusetts

Other 2%

Injection Drug Use 11%

Undetermined 14%

Heterosexual Sex 33%

Presumed Heterosexual

Sex 40%

Data Source: MDPH HIV/AIDS Surveillance Program, Data as of 1/1/13

N=532

People Diagnosed with HIV Infection Within the Years 2009–2011 by Exposure Mode and Race/Ethnicity: Mass.

0%

10%

20%

30%

40%

50%

60%

70%

80%

White NH, N=752 Black NH, N=665 Hispanic/Latino, N=488Race/Ethnicity

Percent

MSM IDU MSM/IDU HTSX Other Pres. HTSX Undetermined

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.

0%

10%

20%

30%

40%

50%

60%

70%

80%

White NH, N=647 Black NH, N=386 Hispanic/Latino, N=357Race/Ethnicity

Percent

MSM IDU MSM/IDU HTSX Other Undetermined

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.

0%

10%

20%

30%

40%

50%

60%

70%

80%

White NH, N=105 Black NH, N=279 Hispanic/Latina, N=131Race/Ethnicity

Percent

IDU HTSX Other Presumed HTSX Undetermined

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 4th 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)

MMWR December 2, 2011/60(47): pp. 1618-1623

Care Cascade for the United States

Experience of Medical CareConsumer Survey (N = 1,004)

0102030405060708090

100

In medicalcare

Taking HIVmedications

Virallysuppressed

Health goodto excellent

Source: Massachusetts and Southern New Hampshire HIV/AIDS Consumer Study Final Report, December 2011, JSI Research and Training, Inc.

Chart ReviewMedical Case Management Sites

2010-2011 93% in care

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, DirectorOffice of HIV/AIDSBureau of Infectious DiseaseMassachusetts Department of Public HealthTel. 617-624-5303E-mail. Dawn.Fukuda@state.ma.us