Objectives

1. HIV Care Continuum, Men Who Have Sex with Men Only (MSMO) and Men Who Have Sex with Men and Women (MSMW), Georgia, 2012

2. Objectives • Describe the HIV Care Continuum methodology used in Georgia • Compare the Care Continuum for men who have sex with men only (MSMO) with men who have sex with men and women (MSMW) • Discuss potential implications of low percentages of viral suppression on HIV prevention in men and women

3. Georgia HIV/AIDS Surveillance Data Flowchart

4. Background • Name-based reporting of HIV infection began in Georgia in 2004 • Georgia law mandates that laboratory facilities licensed in Georgia report all HIV-related laboratory tests including undetectable viral loads (VL) and that all health care providers submit HIV case report forms to the Georgia Department of Public Health (DPH) HIV/AIDS Epidemiology Section • Data from laboratory tests and case report forms are entered into the eHARS (enhanced HIV/AIDS Reporting System) database • Cross-matches are performed with other DPH databases such as STD, TB, Cancer, ADAP, and CAREWare to obtain additional information • Data are stratified by sex, race/ethnicity, age, transmission category in analyses

5. Number of people living with HIV, by sex, in Georgia, 2012 (N=45,599) Georgia

6. Source: Georgia Department of Public Health, HIV/AIDS Epidemiology Program HIV Surveillance Summary, Georgia, 2012, https://dph.georgia.gov/data-fact-sheet-summaries

7. Case Report Form Risk history

8. Case Report Form Risk History • HIV Case Report Form contains a section on risk factors: • Sex with male • Sex with female • Ever used injection non-prescription drugs (IDU) • Heterosexual relations with person with HIV or at risk • Received transfusion of blood/blood components

9. Case Report Form, Sexual History

10. Risks Noted on the Case Report Form • Of the 34,304 males living with HIV in Georgia in 2012, • “Sex with male” was checked “Yes” and “Sex with female” either checked “No” or blank on the case report form for 14,316 categorized as men who have sex with men only (MSMO) • Both “Sex with male” and “Sex with female” were checked “Yes” on the case report form for 6,360 categorized as men who have sex with men and women (MSMW) • Males with injection drug use (IDU) (N=1,491), sex with men and IDU (N=1,732 ), sex with female only (N=1,438 ), or no boxes checked (N=8,967) were excluded

11. Terminology • This analysis compares the HIV Care Continuum for men who have sex with men only (MSMO) and men who have sex with men and women (MSMW)

12. HIV Care Continuum Methodology, Georgia, 2012 • Adult and adolescent males are defined as those aged >= 13 years • Diagnosed by 12/31/2011, living as of 12/31/2012, including those missing race • Current address within Georgia • Linked to care = CD4 or viral load (VL) within 3 months of diagnosis date including the day of diagnosis for those diagnosed between 01/01/2011 and 12/31/2011, inclusively • Any care >= 1 CD4 or VL in 2012 • Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 • Viral suppression (VS) = VL<200 copies/ml in most recent VL in 2012 • Each bar in the continuum is independent of those preceding it; all percentages are of the total number of persons (N) diagnosed with HIV in each category

13. Adults and adolescents Aged > 13 Yearsliving with Diagnosed HIV, Georgia, 2012 N=46,075 Diagnosed by 12/31/11, living as of 12/31/12 N=2964 Diagnosed in 2011 Current address in Georgia Linked to care= CD4 or VL within 3 months of diagnosis, among those diagnosed 01/01/11-12/31/11 Any care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml on most recent viral load in 2012

14. Proportion of MSMO and MSMW, among MSM, Georgia, 2012 Proportion of males living with HIV, by transmission category, Georgia, 2012 Those reported with injection drug use (IDU), MSM/IDU, heterosexual contact only or no risk reported are not included in the MSMO and MSMW analysis (N= 13,628)

15. HIV Care Continuum, MSMO and MSMW, Georgia, 2012 N=219 Adult and adolescent males >= age 13, diagnosed by 12/31/2011, living as of 12/31/2012 Current address Georgia Linked to care= CD4 or VL within 3 months of diagnosis, among those diagnosed 01/01/11-12/31/11 (N=991) Any care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml on most recent viral load in 2012

16. HIV Care Continuumfor MSMO, by race/ethnicity, Georgia, 2012 N=27 N=550 N= 676 N=131 N=64 N= 1259 Adult and adolescent males >= age 13, diagnosed by 12/31/2011, living as of 12/31/2012 Current address Georgia Linked to care= CD4 or VL within 3 months of diagnosis, among those diagnosed 01/01/11-12/31/11 (N=772) Any care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml on most recent viral load in 2012 *American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islander represent <1% of all persons living with HIV in Georgia and are included in Other/Unknown The majority of Other/Unknown are mixed race or have no race reported

17. HIV Care Continuumfor MSMW, by race/ethnicity, Georgia, 2012 N=167 N=23 N=19 N=10 Adult and adolescent males >= age 13, diagnosed by 12/31/2011, living as of 12/31/2012 Current address Georgia Linked to care= CD4 or VL within 3 months of diagnosis, among those diagnosed 01/01/11-12/31/11 (N=219) Any care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml on most recent viral load in 2012 *American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islander represent <1% of all persons living with HIV in Georgia and are included in Other/Unknown The majority of Other/Unknown are mixed race or have no race reported

18. Viral suppression among MSMO and MSMW, by race, Georgia, 2012 41% VS for Georgia overall Adult and adolescent males >= age 13, diagnosed by 12/31/2011, living as of 12/31/2012 Current address Georgia Viral suppression (VS) = VL<200 copies/ml on most recent viral load in 2012 *American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islander represent <1% of all persons living with HIV in Georgia and are included in Other/Unknown The majority of Other/Unknown are mixed race or no race reported

19. HIV Care Continuum for MSMO, by age, Georgia, 2012 N=16 N=61 N=139 N=258 N=298 Adult and adolescent males >= age 13, diagnosed by 12/31/2011, living as of 12/31/2012 Current address Georgia Linked to care= CD4 or VL within 3 months of diagnosis, among those diagnosed 01/01/11-12/31/11 (N=772) Any care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml on most recent viral load in 2012

20. HIV Care Continuumfor MSMW, by age, Georgia, 2012 N=1439 N=76 N=5 N=33 N=67 N=38 Adult and adolescent males >= age 13, diagnosed by 12/31/2011, living as of 12/31/2012 Current address Georgia Linked to care= CD4 or VL within 3 months of diagnosis, among those diagnosed 01/01/11-12/31/11 (N=219) Any care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml on most recent viral load in 2012

21. Viral suppression among MSMO and MSMW, by age, Georgia, 2012 41% VS for Georgia overall • Adult and adolescent males >= age 13, diagnosed by 12/31/2011, living as of 12/31/2012 • Current address Georgia • Viral suppression (VS) = VL<200 copies/ml on most recent viral load in 2012

22. Summary • Overall, linkage to care, any care, retention in care, and viral suppression are higher for MSMO than for MSMW • The greatest disparity in VS between MSMO and MSMW by race/ethnicity is among those with Other/Unknown race/ethnicity (57% vs 48%), followed by Hispanic/Latinos (55% vs 47%), Whites (51% vs 44%) and Blacks (39% vs 37%) • Linkage, engagement, retention and viral suppression increase with increasing age in both MSMO and MSMW

23. Limitations • Incomplete reporting • Missing data for race/ethnicity • Risk ascertainment on case report form is incomplete • Some men who had male and female sex partners are misclassified as MSMO • Persons who are MSMO and MSMW but for whom we are lacking risk informationmay be different from MSMO and MSMW included in this analysis • Missing viral load reports leads to an underestimation of viral suppression • Persons who have migrated to other states may appear as out of care with no viral suppression

24. Discussion • Higher proportions with detectable viral loads among MSMW creates increased transmission risk to sexual partners • Disparities in viral suppression between MSMO and MSMW have implications for HIV transmission to women • Women account for one in four people living with HIV in the Georgia • Most women (66%) living with HIV in Georgia have no risk reported on the case report form and may be unaware of sexual partners’ risk

25. Recommendations • HIV prevention messages for MSM should include the importance of honest discussions with sexual partners, both male and female • Promote use of HIV services among MSMW as well as MSMO • Identify the specific needs and circumstances of MSMW and address the barriers to care for MSMW

26. Acknowledgements • Publication of this report would not have been possible without the hard work and contribution of the Core Surveillance Unit, HIV Epidemiology Section, Epidemiology Program, Division of Health Protection, Georgia Department of Public Health.