Council of State and Territorial Epidemiologists Annual Conference June 4, 2012 Omaha, Nebraska

1. Factors Associated with HIV Viral Load Suppression among HIV-positive Adults in Care in Washington State in 2009 Council of State and Territorial Epidemiologists Annual Conference June 4, 2012 Omaha, Nebraska Tom Jaenicke, MPH, MBA, MES Washington State Department of Health Tom.Jaenicke@doh.wa.gov

2. Outline for today • Overview of the Medical Monitoring Project (MMP) • Results from 2009 data collection cycle • Descriptive statistics • Focus on factors associated with HIV viral suppression • Conclusions

3. Medical Monitoring Project (MMP) • MMP is a stratified complex sample survey with three stages: state, facility and individual patients • Provides much clinical and behavioral data • Health outcomes • How patients interact with the care system • Barriers to care • Behaviors that affect health outcomes • Behaviors that affect transmission • Is a primary source for providing HIV viral load data for measuring National HIV/AIDS Strategy progress

4. MMP Data Collection • Annual cycle • ‘Population Definition Period’ – January through April of the calendar year • ‘Surveillance Period’ – 12 months before the interview (or attempt to contact if no interview) • Two primary methods of collecting data • Lengthy and in-depth interview with patient • Medical record abstraction (MRA)

5. MMP Topic Areas • Demographics • Access to care • HIV treatment and adherence • Sexual behavior • Drug and alcohol use • Prevention activities • Mental health • Health conditions and preventive therapy • Gynecological and reproductive history

6. Challenges • Significant logistical challenges associated with sampling, data collection and transfer • CDC provides direction to 16 states, six large cities and one U.S. territory, some of which consider it surveillance, others research • Facilities and providers are involved with contacting patients and providing access to medical records

7. MMP weighted data • Centers for Disease Control and Prevention (CDC) responsible for weighting data • Peer-reviewed article in near future • For 2009 data, 9 strata, 64 clusters • Separate weights for separate datasets • Medical record • Nine weights, frequency of each ranges from 1 to 113 • Interview • Five weights, frequency of each ranges from 2 to 89 • Weighted data provide population estimates

8. Washington MMP participants compared to persons reported to Washington core surveillance

9. WA MMP participants similar to persons reported to core surveillance

10. WA MMP participants similar to persons reported to core surveillance (cont.)

11. WA MMP participants similar to persons reported to core surveillance (cont.)

12. Antiretroviral (ARV) Use

13. ARV use

14. ARV use during past 12 months (from medical record)Odds Ratio = 12.4 (3.3 – 45.8)

15. Currently on ARVs (from interview) Odds Ratio = 25.4 (6.7 - 96.4)

16. Ever taken ARVs (from interview)Odds Ratio = 15.2 (3.8 - 61.0)

17. Drug holiday during past year (from interview)Odds Ratio = 3.7 (1.5 - 9.3)

18. Drug and Alcohol Abuse

19. Drug and alcohol abuse

20. Substance abuse, other than alcohol(from medical record) No substance abuse vs. 3 or more substances,Odds Ratio = 6.4 (2.2 – 18.1)

21. Alcohol abuse(from medical record)Odds Ratio = 2.8 (1.4 – 5.6)

22. Illicit drug use(from interview)Odds Ratio = 2.4 (1.4 – 4.3)

23. Income

24. Income

25. Income(from interview)Odds Ratio = 1.8 (1.2 – 2.7)

26. Access to Services

27. Access to services • Service gap = person claimed to have needed the service, but was unable to get it • Services include: • Case management, counseling, ADAP, medication reminders, peer support, dental, mental health, substance abuse counseling, SSDI, domestic violence services, housing, meals, home health services, transportation, childcare, interpreter • Percent of respondents with gap for each service ranged from 1% to 17% • Total service gap for individual participants ranged from zero to five

28. Access to services

29. Access to services(from interview)Odds Ratio = 4.7 (2.0 – 11.0)

30. Summary of Associations

31. Significant associations • Among 250 participants with a Surveillance Period Visit Form (SPVF) and Medical History Form (MHF), there were 40 who did not have an HIV viral load test during the Surveillance Period. • There were Standard Interview forms completed for 180 participants. Of these 180, there were 24 who did not have an HIV viral load test during the Surveillance Period.

32. Strength of significant associations between viral suppression and various factors

33. Strength of significant associations between viral suppression and various factors

34. Strength of significant associations between viral suppression and various factors

35. Other associations between viral suppression and various factors

36. Conclusions • MMP is a complex survey that provides a wealth of medical and behavioral information about HIV-positive people in care • Two major components include interview and medical record abstraction • HIV viral load suppression among persons in care is associated most strongly with ARV use, also with drug and alcohol use, income and access to support services • Coming soon: demonstration project of sampling from eHARS rather than through three stages

37. Acknowledgements • Community and provider advisors: • Mark Garrett, Dr. Brad Roter, Dr. Julie Dombrowski • Public Health – Seattle & King County: • Elizabeth Barash, Susan Buskin, Shirley Zhang, Winnie Alston, Lexa Moongrace • Washington State Department of Health: • Maria Courogen, Leslie Pringle, Elizabeth Mack, Katie Heidere, Shawn McBrien, Susan Bosse • MMP Team at the Centers for Disease Control and Prevention, especially our project officer, Dr. Linda Beer

38. Questions?