Epidemiology of HIV in NSW residents newly diagnosed with HIV infection up to 31 December 2013

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1 Epidemiology of HIV in NSW residents newly diagnosed with HIV infection up to December 0 Sections Page Summary Time trend in the HIV epidemic in NSW 4 Demographics of NSW residents newly diagnosed with HIV 6 4 HIV risk exposure characteristics of NSW residents newly diagnosed with HIV to December 0 HIV testing history and timeliness of diagnosis in NSW residents newly diagnosed 6 Type of doctors newly diagnosing HIV 8 7 Uptake of antiretroviral therapy (ART) within six months of 0 diagnosis and impact on HIV viral load 8 Local health district of residence level data 4 9 Data on female NSW residents newly diagnosed with HIV 8 infection to December 0 0 Data on child NSW residents newly diagnosed with HIV infection to December 0 4

2 . Summary Since the mid-980s HIV infection has been a notifiable condition under the NSW Public Health Act. HIV reference laboratories are required to report all confirmed HIV infections to NSW Health using national case definitions. Laboratories must also send a Notification of HIV infection form to the diagnosing doctor to inform them their patient was confirmed to be HIV-infected and seek detailed demographical, clinical and HIV risk behaviour information about the patient. Doctors are required to complete the epidemiological information on the case form and forward it to NSW Health. Data are entered into the NSW HIV database and analysed to monitor and understand the epidemic and provide evidence based information for public health action. The Notification of HIV infection form was modified so that in 0 for the first time treatment information and viral load would be reportable at the time of diagnosis. In this report we include notifications on NSW residents (based on reported postcode of residence at the time of diagnosis) newly diagnosed with HIV up to December 0. In 0, 4 NSW residents were newly diagnosed with HIV infection and notified to NSW Health, which was a 4% increase on the previous five year mean for 008 to 0 (n=4). The agestandardised rate of new diagnoses per 00,000 in 0 was 4.9 per 00,000. The age-standardised rate of new diagnoses has been largely stable for more than ten years. Of 4 NSW residents newly diagnosed with HIV in 0, 0 (%) were aged 0 to 9 years, 0 (9%) were 0 to 9 years, 90 (%) were 0 to 9 years, 89 (%) were 40 to 49 years and 64 (8%) were 0 years and over. Compared with the 008 to 0 five year mean, in 0 the number of new diagnoses declined in 0 to 9 year olds (%) and rose in those 0 years and over (%). In 0 the age group specific rates per 00,000 of new diagnoses were similar for the age groups 0 to 9, 0 to 9 and 40 to 49 years. In 0, 9% of NSW residents newly diagnosed with HIV were male, similar to the 008 to 0 five year mean (9%). In 0,.% of all NSW residents newly diagnosed were reported as being Aboriginal people, the same proportion as for the five year mean 008 to 0. However among women newly diagnosed with HIV in 0, the proportion who were Aboriginal people (.%) was about four-fold the proportion of the NSW female population estimated to be Aboriginal people (.%, Census 0). In 0, 4% of NSW residents newly diagnosed with HIV infection had been born in Australia, similar to the 008 to 0 five year mean (6%). In 0, (%) of the people newly diagnosed resided in South Eastern Sydney (SES) Local Health District (LHD), similar to the 008 to 0 five year mean ( people). A further 90 (%) of the 0 new diagnoses resided in Sydney LHD, also similar to the five year mean (88 people) (Figure 7). The age-standardised rates in SES and Sydney LHDs were very similar and much higher than the rates for all other LHDs. In the other LHDs, the main observed increases in the number of new diagnoses in 0 compared with the 008 to 0 five year mean, were in South Western Sydney (SWS) LHD and Hunter New England (HNE) LHD. Most LHDs other than SES and Sydney LHD had similar age-standardised rates. Of 4 NSW residents newly diagnosed with HIV in 0, 78 (79%) were reported to be men who have sex with men (MSM), 6 (7%) reported heterosexual contact as their HIV risk exposure, 8 (%) reported being a person who injected drugs (PWID), (%) had an unknown or unreported HIV risk

3 exposure, one case was acquired through mother to child transmission (MTC) that had occurred overseas and one case was acquired through an other type of exposure. This was a similar pattern compared to the 008 to 0 five year period (MSM 78%; Hetero-sex 7%; PWID %; and MTC, other and unknown each 0%). Independent of where born, of all 4 people newly diagnosed in 0, (64%) likely acquired HIV in Australia, 7 (%) likely acquired HIV overseas and 4 (%) were unknown. Among all 4 NSW residents newly diagnosed in 0, 0 (0%) reportedly tested HIV negative within months of diagnosis, the same proportion as for the 008 to 0 five year period. In 0 7% of NSW residents newly diagnosed reportedly had never had a HIV test prior to diagnosis, slightly more than % for 008 to 0. Among the 78 MSM newly diagnosed in 0, 0 (7%) reportedly tested HIV negative within months of diagnosis and 7% had never had a HIV test prior to diagnosis, similar to that for MSM between 008 to 0. Among all 4 NSW residents newly diagnosed in 0, (6%) had evidence of late diagnosis, the same proportion with evidence of late diagnosis between 008 and 0. Evidence of late diagnosis was defined as a CD4 count less than 0 cells/µl or an AIDS defining illness within three months of diagnosis, in the absence of a laboratory confirmed negative HIV test in the months prior to diagnosis. General medical practitioners unspecialised in HIV (GP non-art prescriber) made 9 (9%) of the new diagnoses in NSW residents in 0 and they referred two thirds of these people to sexual health clinics for ongoing management of HIV. Doctors in sexual health clinics (SHC) made 0 (9%) of the new diagnoses and retained most of these clients. General medical practitioners specialised in HIV and specially registered to prescribe antiretroviral therapy (GP s00) made (6%) of the new diagnoses in 0 and retained most of these clients. Doctors within hospital settings made 4 (%) of the new diagnoses and retained or referred most of these within the hospital setting. A few (9) people were diagnosed by immigration services and most were referred to sexual health clinics for follow up. Data on antiretroviral therapy (ART) commencement, CD4 count and viral load at least six months post diagnosis are now collected via prescribing doctors who complete a standardised HIV sixmonthly follow up form. Of the 4 NSW residents newly diagnosed in 0, (88%) had a sixmonthly follow-up form completed by their prescribing doctors at the time of this analysis. Of these new diagnoses in 0, 49% () had commenced ART within three months of diagnosis and 60% (86) had commenced ART within six months of diagnosis. Of the newly diagnosed persons for whom six monthly follow-up forms were available, 0 had results available for CD4 count at diagnosis. Of those with a CD4 count less than 00 cells/µl at diagnosis, 84% had commenced ART within three months of diagnosis and a further eight per cent had commenced ART within six months of diagnosis. Of those with a CD4 count at diagnosis between 0 and 00 cells/µl, 8.% (84) had commenced ART within three months of diagnosis and a further.8% (7) had commenced ART within six months of diagnosis. Of the newly diagnosed people in 0 on ART at six-monthly follow up, 00 had post ART viral load results available. Post ART viral load was undetectable ( 0 copies/ml) in 6 people (8.%).

4 Number of new diagnoses Age standardised rate per 00,000. Time trend of the HIV epidemic in NSW The number of NSW residents newly diagnosed with HIV infection peaked in 987 at 66 notifications (8. new diagnoses per 00,000 population), a couple of years after the first test for HIV became widely available. In the ensuing ten years notifications of new diagnoses decreased considerably (Figure ). By 997, the year after triple therapy antiretroviral regimens became available to treat HIV infection, the new diagnoses count was down to 44, and since then the annual new diagnoses count has not exceeded this level, with 00 having the lowest new diagnoses count (07) to date. The rise in cases in 0 (n=409) was predominantly among men who have sex with men resident in inner metro Sydney (and South Western Sydney) with a higher proportion in early stage infection (see Figure 7, and 6). In 0, 4 NSW residents were newly diagnosed with HIV infection and notified to NSW Health, which was a 4% increase on the previous five year mean for 008 to 0 (n=4) (Figure ). The age-standardised rate of new diagnoses per 00,000 in 0 was 4.9 per 00,000. The age standardised rate of new diagnoses has been stable for more than ten years, with the only significant rise being between the rates for the years 00 and 0 (Figure and Table ). Figure. Number and age standardised rate per 00,000 of NSW residents newly diagnosed with HIV infection January 98 to December : SSO* promotes condoms 984: HIV test; homsexuality decriminalised in NSW 986: Blood screening 987: Mono therapy for HIV 988: NSW Needle and syringe program roll out : Dual therapy for HIV 996: Triple therapy for HIV (HAART). Prostitution decriminalised in NSW Number new diagnoses Lower 9% CI Age standardised rate Upper 9% CI Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 Rates were age-standardised using the Australian population as at 0 June 00. 4

5 Table. Number and age standardised rate per 00,000 (9% Confidence Intervals [CI]) of NSW residents newly diagnosed with HIV infection January 98 to December 0 Number new HIV diagnoses Age standardised rate Lower 9% CI Upper 9% CI Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04

6 . Demographics of NSW residents newly diagnosed with HIV Of 4 NSW residents newly diagnosed with HIV in 0, 0 (%) were aged 0 to 9 years, 0 (9%) were 0 to 9 years, 90 (%) were 0 to 9 years, 89 (%) were 40 to 49 years and 64 (8%) were 0 years and over. Compared with the 008 to 0 five year period, in 0 the number of new diagnoses declined in 0 to 9 year olds (% for 008 to 0) and rose in those 0 years and over (% for 008 to 0) (Figure ). In 0 the age group specific rates per 00,000 of new diagnoses were similar for the age groups 0 to 9, 0 to 9 and 40 to 49 years (Figure ). Figure. Number of NSW residents newly diagnosed with HIV infection January 004 to December 0 by age at diagnosis to 9 years 0 to 9 years 0 to 9 years 40 to 49 years 0 years and over Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 6

7 Age group specific rate per Figure. Age group specific rates per 00,000 population for new diagnoses of HIV infection January 004 to December Rates were age-standardised using the Australian population as at 0 June 00. In 0, 9% of NSW residents newly diagnosed with HIV were male, similar to 9% for the 008 to 0 five year period (9%) (Figure 4). The rise in male cases in 0 was predominantly among men who have sex with men resident in inner metro Sydney with a high proportion in early stage infection (see Figure 7, and 6). The number and proportion of infections in females per year remains steady; 8% of people newly diagnosed in 0 were female, similar to 9% for 008 to 0. In 0,.% of NSW residents newly diagnosed were reported as being Aboriginal people, the same proportion as for the five year period 008 to 0 (Figure ). In the 0 Census it was estimated that Aboriginal people comprised.% of the NSW population. However there is a differential in the burden of new HIV diagnoses when gender and Aboriginal people status are examined together. Among 4 males newly diagnosed with HIV in 0, (.%) were Aboriginal people, compared with.% from 008 to 0. Among 7 females newly diagnosed in 0, (.%) were Aboriginal people, compared with 4% from 008 to 0. Aboriginal women comprise an excessive proportion of new HIV diagnoses among women relative to percentage of women in NSW estimated to be Aboriginal people (.%, 0 Census). 7

8 Percentage of new diagnoses Number of new diagnoses Figure 4. Number of NSW residents newly diagnosed with HIV infection January 004 to December 0 by gender Male Female Transgender Unknown Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 Figure. Percentage of NSW residents newly diagnosed with HIV infection January 004 to December 0 by reported Aboriginal person status 00% 90% % 70% 60% 0% 40% Not stated Non-Aboriginal person Aboriginal person 0% 0% 0% 0% Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 8

9 Number of new diagnoses In 0, 4% of NSW residents newly diagnosed with HIV infection were born in Australia, similar to the 008 to 0 five year period (6%) (Figure 6 and Table ). Figure 6. Place of birth of NSW residents newly diagnosed January 004 to December Born in Australia Born overseas Unknown Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 Table. Region of birth* of NSW residents newly diagnosed with HIV infection in 0 and comparison with the 008 to 0 five year mean Region of birth 0 % mean % % change Australia 90 4% 90. 6% 0% South-East Asia 44 %.4 0% % Oceania 4 7% 4% 60% North-East Asia 6% 4.4 4% % Central and South America 0 6% 0.6 % 89% North-West Europe 6 %.8 7% -% Sub-Saharan Africa 9 %. 4% -4% North Africa & Middle East 9 % 6. % 4% Southern & Eastern Europe 6 % 0. % -4% Northern America %.6 % -% Southern and Central Asia %.8 % -4% Caribbean 0 0% 0.8 0% -00% Unknown 4 % 9.8 % -9% Total 4 00% 4 00% 4% Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 * Regions of birth. See Australian Bureau of Statistics, Standard Australian Classification of Countries (SACC). ** Region of birth (ABS SACC); Australia, Oceania and Antarctica, North-West Europe, Southern and Eastern Europe, North Africa and The Middle East, South-East Asia, North-East Asia, Southern and Central Asia, Americas, Sub-Saharan Africa. The top ten countries of birth for NSW residents newly diagnosed in 0, after Australia (N=90), were New Zealand (6), Philippines (4), Brazil (), Thailand (0), China (0), United Kingdom (9), Indonesia (9), Fiji (7), Malaysia (6) and United States of America () and Vietnam () ranked tenth. 9

10 Age-adjusted rate per 00,000 Number of new diagnoses In 0, (%) people newly diagnosed were resident in South Eastern Sydney (SES) Local Health District (LHD), similar to the 008 to 0 five year mean ( people). A further 90 (%) of the 0 new diagnoses resided in Sydney LHD, also similar to the 008 to 0 five year mean (88 people) (Figure 7). The age-standardised rates in SES and Sydney LHDs were very similar and much higher than the rates for all other LHDs (Figure 8 and 0). The increased number of notifications in 0 mainly occurred among MSM resident in SES and Sydney LHD, with a higher proportion than normal in early stage infection (see Figure 7, and 6). Figure 7. Number of people newly diagnosed with HIV infection January 004 to December 0 resident in South Eastern Sydney (SES) and Sydney local health districts (LHD) SES LHD Sydney LHD Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 Figure 8. Age-standardised rates per 00,000 population of new HIV diagnoses January 004 to December 0 among residents of South Eastern Sydney (SES) and Sydney LHD SES LHD Sydney LHD Rates were age-standardised using the Australian population as at 0 June 00. 0

11 Number of new diagnoses In the other LHDs, the main observed increases in the number of new diagnoses at LHD level in 0 compared with the 008 to 0 five year mean, were in South Western Sydney (SWS) LHD (% increase) and Hunter New England (HNE) LHD (9% increase) (Figure 9). From 004 to 0 the age standardised rate of new diagnoses within each LHD has remained stable and not varied up or down significantly (data not shown). Figure 9. Number of people newly diagnosed with HIV infection January 004 to December 0 resident in other LHDs* Northern Sydney Western Sydney South Western Sydney Hunter New England Illawarra Shoalhaven Central Coast Northern NSW Nepean Blue Mountains Mid North Coast Western NSW Southern NSW Murrumbidgee-Albury Far West Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 *excludes 0 cases of unknown LHD of residence Age standardised rates per 00,000 of new diagnoses per LHD in 0 were similar in Sydney and SES LHDs and higher compared with all other LHDs (Figure 0). Age standardised rates per 00,000 of new diagnoses in LHDs other than Sydney and SES LHDs were mostly similar (Figure 0).

12 Figure 0. Age-standardised rates per 00,000 of new HIV diagnoses in 0 among residents in each of the local health districts (LHD) Sydney South Eastern Sydney South Western Sydney Mid North Coast Northern Sydney Western Sydney Southern NSW Hunter New England Illawarra Shoalhaven Northern NSW Central Coast Western NSW Murrumbidgee-Albury Nepean Blue Mountains Far West NSW* Age Standardised Rate (per 00,000) Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 Rates were age-standardised using the Australian population as at 0 June 00. At a cruder geographical level than the LHD, in 0, of 4 (6%) people newly diagnosed resided in inner metro Sydney (SES and Sydney LHDs), 96 (7%) in outer metro Sydney (Northern Sydney, South Western Sydney, Western Sydney, Central Coast, Illawarra Shoalhaven and Nepean Blue Mountains LHDs) and 4 (%) in regional or rural NSW (Far West, Hunter New England, Mid North Coast, Murrumbidgee, Northern NSW, Southern NSW and Western NSW LHDs) (Figure ). The age-standardised rate of new diagnoses per 00,000 population for outer metro Sydney are similar to that for regional or rural NSW (Figure ).

13 Age-adjusted rate per 00,000 Number of new diagnoses Figure. Number of people newly diagnosed with HIV infection January 004 to December 0* by area of residence** Inner metro Sydney LHD Outer metro Sydney LHD Regional or rual LHD Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 *excludes 0 cases of unknown LHD of residence. **Inner metro LHDs: South Eastern Sydney, Sydney; Outer metro LHDs: Northern Sydney, South Western Sydney, Western Sydney, Central Coast, Illawarra Shoalhaven, Nepean Blue Mountains; Rural & Regional LHDs: Far West, Hunter New England, Mid North Coast, Murrumbidgee, Northern NSW, Southern NSW, Western NSW Figure. Age-standardised rate per 00,000 population of new HIV diagnoses January 004 to December 0* by area of residence** 0 Inner metro Sydney Outer metro Sydney 0 Regional or rural NSW NSW Rates were age-standardised using the Australian population as at 0 June 00.

14 Table. Tabulated demographic characteristics of NSW residents newly diagnosed with HIV infection by year of diagnosis, to December 0 Characteristics Gender n= % n=4 % n=07 % n=0 % n=409 % n=4 % n=69 % Male 9 90.% % 8 9.9% % 7 9.0% 4 9.% 9 9.9% Female 9.8% 9.7% 7.% 6.4% 6 8.8% 7 7.6% % Transgender 0 0.0% 0.6% 0.7% 0 0.0% 0.% 0.8% 47.% Unknown 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 8 0.% Aboriginal person status Aboriginal 8.% 9.7% 7.%.%.7% 8.% 4 0.9% person Non-Aboriginal 0 9.6% 94.% % 97.6% 9 9.6% 4 96.% % person Not stated 6 4.9% 0.0% 9.9% 0.9% 7.7%.4% 69 4.% Age group (years) 0 to % 0.% 0.% 0 0.0% 0 0.0% 0 0.0% 40 0.% to % 0.% 0 0.0% 0 0.0% 0 0.0% 0.% 0.% 0 to % 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0.% to 9 0.9% 0.9%.6% 6.8% 9.% 9.% 0.8% 0 to 4 9.0% 4 0.% 9 9.4% 4 0.% % 7 0.% 0.% to % 7 7.% 6 8.% 6 7.0% % 64 8.% 7 9.8% 0 to 4 44.% 4.9% % % 70 7.% 48.6% 8 0.0% to % 8 7.4% 44 4.% 9 7.9% 6.4% 4.9% 8 6.7% 40 to % 7 7.% 6.9% 44.% 47.% 44.4% 07.% 4 to % 0 9.0% 0 9.8% 6 7.9% 8 9.% 4.7% 08 7.% 0 to % 8 8.4% 7.% 7.6% 8 6.8% 7.% 7 4.% to 9 0.%.6% 7.% 0.0% 4.4% 6.% 409.4% 60 to % 0.%.6% 0.6%.% 6.7% 09.% 6 to % 4.% 6.0% 0.6% 4.0% 9.% 7 0.7% 70 to %.% 0.% 0.% 0 0.0% 0.% 4 0.% 7 to % 0 0.0% 0 0.0% 0.% 0.7% 0.% 0 0.% 80 to % 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 6 0.0% 8 to % 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0.0% 90 and over 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0.0% Unknown 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 86 0.% LHD of residence SES 7 6.0% 08.% 0.8% 8 8.8% 0 6.7%.% 79.% Sydney % % 77.% 8.% 7.% 90.4% 70 6.% Northern Sydney 7.7% 8.4% 9 6.% 4 7.%.6%) 6 7.% 97.% Western Sydney 6 8.0% 6.6% 0 6.% 9.4% 6.% 6 7.% 667.9% SWS 6 4.9% 6.% 7.% 8.% 7.6% 9 8.% 9.% Hunter New 4 4.% 6 4.8% 6.% 0.0% 4.4% 8.% 46.6% England Nepean Blue 7.% 0.9%.0% 4.%.% 0.8% 47.% Mountains Illawarra Shoalhaven 0.9%.% 8.6%.% 9.% 7.0%.% Central Coast 6.8%.%.6% 4.% 0.4%.4% 8.% Northern NSW 4.% 4.% 9.9%.%.%.4% 80.% Mid North Coast 8.% 6.8%.0% 4.% 0.7% 6.7% 0.8% Western NSW 0.9% 0.9% 4.% 0.9% 7.7%.4% 6 0.7% Murrumbidgee 0.9% 0.% 6.0% 0.6% 0.7% 0.6% 7 0.% Southern NSW 0.9% 6.8% 0.% 0.6% 7.7% 4.% 0 0.% Albury 0 0.0% 0.% 0.% 0 0.0% 0.% 0.% 0.% Far West 0 0.0% 0.6% 0 0.0% 0 0.0% 0.% 0 0.0% 8 0.0% Justice Health 0.% 0.% 0.% 0 0.0% 0.% 0.% 0.0% Unknown.4% 0.6% 0.% 0.% 0.% 0.% % Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 4

15 Number of new diagnoses 4. HIV risk exposure characteristics of NSW residents newly diagnosed with HIV to December 0 Of 4 NSW residents newly diagnosed with HIV in 0, 78 (79%) were reported to be men who have sex with men (MSM), 6 (7%) reported heterosexual contact (HETS or hetero-sex) as their HIV risk exposure, 8 (%) reported being a person who injected drugs (PWID), (%) had an unknown or unreported HIV risk exposure, one case was acquired through mother to child transmission (MTC) that had occurred overseas and one case was acquired through an other type of exposure (Figure ). This was a similar pattern compared to the 008 to 0 five year period (MSM 78%; Hetero-sex 7%; PWID %; and MTC, other and unknown each 0%) (Table ). Figure. Number of NSW residents newly diagnosed with HIV infection January 004 to December 0 by self-reported HIV risk exposure Men who have sex with men (MSM) Hetero-sex only 00 0 Person who injected drugs (PWID) 00 Mother to child transmision Other Unknown Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August Table. HIV risk exposure reported by NSW residents newly diagnosed with HIV to December 0 Characteristics HIV risk group n= % n=4 % n=07 % n=0 % n=409 % n=4 % n=69 % MSM 6 7.6% 0 6.9% 8 74.% 68 8.% % % % MSM + inject.4% 7.% 8.6% 0.0%.9% 4 4.0% 47.8% drugs Hetero-sex % 7.% 6.6% 4.4% 7.9% 6 7.% 7 9.0% PWID.7%.% 9.9% 8.4% 0.4% 8.% 49.% Haemophilia, 0 0.0% 0.% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 76.6% coagulation disorders, blood tissue recipient MTC 0 0.0% 0.6% 0.% 0 0.0% 0 0.0% 0.% 4 0.% Other 0 0.0% 0.6% 0.% 0.% 0.% 0.% 4 0.% Unknown 0.6% 6.8% 9.9% 0.6% 0.4%.4% 44 0.%

16 Percentage of new diagnoses Independent of where born, of all 4 people newly diagnosed in 0, (64%) likely acquired HIV in Australia, 7 (%) likely acquired HIV overseas and for 4 (%) place of acquisition was unknown. Of 90 people newly diagnosed who were born in Australia, 4 (7%) likely acquired HIV in Australia and (%) likely acquired HIV overseas (Figure 4). Of people newly diagnosed who were born in a country with a general HIV adult prevalence estimate of % or more ( high prevalence ), 6 (9%) likely acquired HIV in Australia and (%) likely acquired HIV overseas. Of 9 people newly diagnosed who were born in a country with a general HIV adult prevalence estimate of less than % ( low prevalence ), 74 (%) likely acquired HIV in Australia and 4 (%) likely acquired HIV overseas. Figure 4. Percentage of NSW residents newly diagnosed with HIV infection in 0 (n=4) by where infection was likely acquired in those born in Australia or overseas 00% 90% 80% 70% 60% 0% 40% 0% 0% 0% 0% Born in Australia 6 Born OS HIV prev >% 4 74 Born OS HIV prev <=% Born Australia or overseas (OS) Unknown Unknown Acquired overseas Acquired in Australia Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 6

17 Percentage of new diagnoses Independent of where born, of 78 MSM newly diagnosed in 0, 9 (69%) likely acquired HIV in Australia and 4 (%) likely acquired HIV overseas. Of 6 MSM newly diagnosed who were born in Australia, (78%) likely acquired HIV in Australia and (7%) likely acquired HIV overseas (Figure ). Of 4 MSM newly diagnosed who were born in a country with a general HIV adult prevalence estimate of % or more ( high prevalence ), (6%) likely acquired HIV in Australia and (6%) likely acquired HIV overseas. Of 06 MSM newly diagnosed who were born in a country with a general HIV adult prevalence estimate of less than % ( low prevalence ), 6 (9%) likely acquired HIV in Australia and (4%) likely acquired HIV overseas. Figure. Percentage of all NSW residents newly diagnosed with HIV infection in 0 and who reported being MSM (n=78), by where infection was likely acquired in those born in Australia or overseas 00% 90% 80% 70% 60% 0% 40% 0% 0% 0% 0% 4 Born in Australia 4 Born OS HIV prev >% 8 6 Born OS HIV prev <=% Born Australia or overseas (OS) Unknown Acquired overseas Acquired in Australia Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 7

18 Percentage of new diagnoses Independent of where born, of 6 heterosexually acquired HIV new diagnoses, (4%) were likely acquired HIV in Australia and (%) likely acquired HIV overseas. Of 6 heterosexually acquired HIV new diagnoses who were born in Australia, 4 (4%) likely acquired HIV in Australia and 0 (8%) likely acquired HIV overseas (Figure 6). Of 7 heterosexually acquired HIV new diagnoses who were born in a country with a general HIV adult prevalence estimate of % or more ( high prevalence ), (4%) likely acquired HIV in Australia and 6 (86%) likely acquired HIV overseas. Of 8 heterosexually acquired HIV new diagnoses who were born in a country with a general HIV adult prevalence estimate of less than % ( low prevalence ), 0 (6%) likely acquired HIV in Australia and 6 (7%) likely acquired HIV overseas. Figure 6. Percentage NSW residents newly diagnosed with HIV infection in 0 with reported heterosexual exposure to HIV (n=6), by where infection was likely acquired in those born in Australia or overseas 00% 90% 80% 70% 60% 0% 40% 0% 0% 0% 0% 0 4 Born in Australia 6 Born OS HIV prev >% 6 0 Born OS HIV prev <=% Born Australia or overseas (OS) Unknown Acquired overseas Acquired in Australia Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 8

19 Number of new diagnoses Number of new diagnoses While numbers remain low, in 0, there is a small increase in the number of Australian born, heterosexually acquired new diagnoses who acquired their infection overseas (Figure 7). Figure 7. Number of NSW newly diagnosed with HIV infection January 008 to December 0 born in Australia and who reported heterosexual exposure to HIV, by place likely infected Acquired Australia Acquired overseas Unknown Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 Most new diagnoses in Australian born MSM in 0 were acquired in Australia (Figure 8). Figure 8. Number of NSW newly diagnosed with HIV infection January 008 to December 0 born in Australia and who reported being MSM, by place likely infected Acquired Australia Acquired overseas Unknown Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 9

20 Table 4. Demographics of the main affected risk groups and all newly diagnosed with HIV infection in 0 and a comparison with the 008 to 0 five year mean mean mean mean mean MSM MSM HETS HETS PWID PWID All All Number n=78 % n=66 % n=6 % n=8 % n=8 % n=0 % n=4 n=4 Gender Male 7 99% % 7 6%. 4% 7 88% % Female 0 0% % % %.6 6% 7 0. Transgender % 0% 0% 0 0% 0 0% 0 0% Age in years 0 to 9 6 %.8 % %. % 0 0% 0 0% to 9 9 % 76. 9% 8 %.8 7% %.8 8% to 9 7 6% 89 4% 4 % 7. 0% %.4 4% to % 6.4 % 7 8%. % 6% 0% and over 4 %. % 9 %. 9% 0 0% 0.8 8% Aboriginal person Yes Aboriginal %.8 % 8% % %. % 8 8 person No 7 98%. 9% 6 9%.6 97% 7 88% % 4 4 Not stated 4 % 7.6 % 0% % 0% 0. % 9 Place of birth Australia 6 6% % 6 4% 0.6 6% 6 7% % High prev. 4 % 0.8 4% 7 % 6.8 9% 0 0% 0. % 9. country* Low prev. country 06 8% 86.4 % 8 46% 9 % %.4 4% 9.8 Unknown % 8.6 % 0%. % % 0 0% Area of residence**: Inner metro 8 67% % 6% 6 8% 4 0%.4 4% 0.4 Sydney Outer metro 67 4%. 0% 4% 0.8 % %.8 8% Sydney Regional and 9% 4 9% % 0.4 8% 0 %. % rural NSW Other 0%.6 % % 0.4 % 0 0% 0.6 6% 4 Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 *High prevalence country refers to countries with a general HIV adult prevalence estimate % or over; Low prevalence country refers to countries with a general HIV adult prevalence estimate less than % **Inner metro LHDs: South Eastern Sydney, Sydney; Outer metro LHDs: Northern Sydney, South Western Sydney, Western Sydney, Central Coast, Illawarra Shoalhaven, Nepean Blue Mountains; Rural & Regional LHDs: Far West, Hunter New England, Mid North Coast, Murrumbidgee, Northern NSW, Southern NSW, Western NSW 0

21 Table. Other characteristics of the main affected risk groups and all newly diagnosed with HIV infection in 0 and a comparison with the 008 to 0 five year mean mean mean mean mean MSM MSM HETS HETS PWID PWID All All Number n=78 % n=66 % n=6 % n=8 % n=8 % n=0 % n=4 n=4 Likely place acquired HIV Australia 9 69% % 4% 8.8 % 8 00% % 04 Overseas 4 % 4 % % 7 47% 0 0% 0.8 8% Unknown 46 7%.4 % 4 7%.8 0% 0 0%.4 4% 4 7. Past testing history Tested less than 0 7% % %.4 9% 0 0%. % 0 04 months ago Tested or 09 9% % 6 6% 6% 0 0%.6 6% 7. more months ago Never tested 48 7% 4 6% 7 6% 4 4% 4 0%.6 6% Unknown 9 7% 7.8 0% 8%. % 4 0%.6 6% Diagnosed late* Yes 84 0% 7.4 8% 7% 8.8 0% 8% 4. 4% No 86 67% 77 67% 8%. 44% 4 0% % 09 Unknown 8 %. % %.6 6% %. % 4 0 CD4 count at diagnosis 00 and over 08 9% 0.8 4% 0 6%. 6% % 0% % 60 % 8% 9.4 6% %.6 6% % 4. 7% 9 %.4 % %.4 4% Less than 00 7 % 4 % 7 8% 6.6 9% %.8 8% 6.8 Unknown 4%.6 6% 4 7% 4 7% %. % 8 Diagnosing doctor type GP non-art 96 % 8.8 % 7 6% 0.4 % 8%.8 8% prescriber Sexual Health 9 % % 9 % 8.6 % %.6 6% Clinic GP s00** 9% 6.4 4% 0%.8 % % 0.6 6% 66 Hospital %.8 % 0 6% 7. 0% %.0 0% 4 4 Immigration 4 % 7.0 % 4 7% 7.6 % 0% 0. % Unknown 0 0%.8 % 0 0%.0 % % 0.8 8% 4 Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 *Evidence of late diagnosis was defined as a CD4 count less than 0 cells/µl or an AIDS defining illness within three months of diagnosis, in the absence of a laboratory confirmed negative HIV test in the months prior to diagnosis. **A GP s00 is a private, general medical practitioner who is authorised to prescribe antiretroviral therapy under Section 00 highly specialised drugs program of the Pharmaceutical Benefits Scheme. Other or unknown include primarily forensics, interstate doctors and blood bank

22 Percentage of new diagnoses. HIV testing history and timeliness of diagnosis in NSW residents newly diagnosed Among all 4 NSW residents newly diagnosed in 0, 0 (0%) reportedly tested HIV negative in the months prior to diagnosis, the same proportion as for the 008 to 0 five year period (Figure 9). In 0 7% of NSW residents newly diagnosed reportedly had never had an HIV test prior to diagnosis, slightly more than % between 008 and 0. Figure 9. Percentage of all NSW residents newly diagnosed with HIV infection January 008 to December 0 by past HIV testing history 00% 90% 80% 70% 60% 0% 40% 0% Unknown Never had HIV test before Tested or more months ago 0% 0% % Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 0 Tested less than months ago

23 Percentage of MSM new diagnoses Among 78 MSM newly diagnosed in 0, 0 (7%) reportedly tested HIV negative within months of diagnosis, the same proportion as for MSM between 008 to 0 (Figure 0). In 0 7% of MSM newly diagnosed reportedly had never had an HIV test prior to diagnosis, similar to 6% of MSM from 008 to 0. Figure 0. Percentage of MSM newly diagnosed with HIV infection January 008 to December 0 by past HIV testing history 00% 90% 80% 70% 60% 0% Unknown Never had HIV test before 40% 0% Tested months or more ago 0% 0% Tested less than months ago 0% Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04

24 Per cent of new diagnoses Among all 4 NSW residents newly diagnosed in 0, (6%) had evidence of late diagnosis, the same proportion with evidence of late diagnosis from 008 to 0 (Figure ). Figure. Percentage and number of NSW residents newly diagnosed with HIV infection January 004 to December 0 by evidence of late diagnosis* 00% 90% 80% 70% % 0% Unknown 40% 0% No evidence late Evidence late 0% % 0% Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 *Evidence of late diagnosis was defined as a CD4 count less than 0 cells/µl or an AIDS defining illness within three months of diagnosis, in the absence of a laboratory confirmed negative HIV test in the months prior to diagnosis. Among MSM newly diagnosed, the older the age group at diagnosis, the greater the percentage within each age group with evidence of late diagnosis (Figure ). The 0 to 9 year age group were excluded from Figure 8 due to very low numbers. 4

25 Median CD4 count Percentage of new diagnoses late diagnosed Figure. Percentage of NSW residents newly diagnosed with HIV infection January 008 to December 0 who were MSM by age group and evidence of late diagnosis* 0% 4% 40% % 0% % 0% % % 6% % 4% 48% 4% 8% % % % 6% 4% 4% 8% 0% % % 4% 9% % 40% % 6% 6% 0 to 9 years 0 to 9 years 40 to 49 years 0 years and over 0% % 0% Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04. The median CD4 count at diagnosis was higher for MSM compared with all new diagnoses and for new diagnoses reported to have resulted from heterosexual exposure to HIV (Figure ). Figure. Median CD4 count (cells/µl) among NSW residents newly diagnosed with HIV infection January 008 to December 0 for all new diagnoses and two major risk exposure groups All new diagnoses MSM only Hetero-sex only Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04

26 Percentage of new diagnsoses Among all 4 NSW residents newly diagnosed in 0, (4%) had a CD4 count at diagnosis of 00 or over, 8 (4%) 0 to 499, 74 (%) 00 to 49, 6 (6%) less than 00 and 8 (%) had no CD4 count at diagnosis reported (Figure 4). This was similar for each CD4 count category of the 008 to 0 five year period (8% had a CD4 count 00 or over, % 0 to 499, 8% 00 to 49, 8% less than 00 and 7% no CD4). In 0 7% of new diagnoses had a CD4 less than 0, similar with 4% between 008 and 0. Figure 4. CD4 count (cells/µl) at diagnosis among NSW residents newly diagnosed January 004 to December 0 00% 90% 80% % 60% 0% 40% 0% 0% 0% Missing Less than or over 0% Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 6

27 Percentage of new diagnoses Among all 4 NSW residents newly diagnosed in 0, 47 (4%) had some evidence of early stage infection and (4%) had some evidence of advanced stage infection, similar to the proportion thought to be in early (44%) and advanced (6%) stage infection at diagnosis from 008 to 0 (Figure ). Figure. Proportion of NSW residents newly diagnosed with HIV infection January 008 to December 0 by stage of infection at diagnosis 00% 90% 80% 70% 60% 0% 40% 0% 0% 0% Early CD4 00+ CD CD Advanced Unknown 0% Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 *Stage of infection is currently defined as follows: Early = Seroconversion like illness or a previous negative or indeterminate HIV test within months of diagnosis, irrespective of CD4 count or report of an AIDS defining illness within three months of diagnosis. Advanced = CD4 count < 00 cells/µl or an AIDS defining illness within three months of diagnosis, excluding Early category. CD and CD4 0+ exclude Early and Advanced categories. 7

28 Percentage of new diagnoses in MSM Among 78 MSM newly diagnosed in 0, (49%) had some evidence of early stage infection and 0 (%) had some evidence of advanced stage infection, similar to the proportion of MSM thought to be in early (%) and advanced (%) stage infection at diagnosis for the 008 to 0 five year period (Figure 6). Figure 6. Proportion of NSW residents newly diagnosed with HIV infection January 008 to December 0 who were MSM, by stage of infection at diagnosis 00% 90% 80% 70% 60% 0% 40% 0% 0% 0% 0% Early CD4 00+ CD CD Advanced Unknown Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 *Stage of infection is currently defined as follows: Early = Seroconversion like illness or a previous negative or indeterminate HIV test within months of diagnosis, irrespective of CD4 count or report of an AIDS defining illness within three months of diagnosis. Advanced = CD4 count < 00 cells/µl or an AIDS defining illness within three months of diagnosis, excluding Early category. CD and CD4 0+ exclude Early and Advanced categories. 6. Doctors who made new HIV diagnoses in 0 General medical practitioners unspecialised in HIV (GP non-art prescriber) made 9 (9%) of the new diagnoses in NSW residents in 0 and they referred two thirds of these people to sexual health clinics for ongoing management of HIV (Table 6). Doctors in sexual health clinics (SHC) made 0 (9%) of the new diagnoses and retained most of these clients. General medical practitioners specialised in HIV and specially registered to prescribe antiretroviral therapy (GP s00) made (6%) of the new diagnoses in 0 and retained most of these clients. These GPs s00 (the bulk of whom work in SES LHD) almost exclusively only diagnose HIV in MSM (Figure 7). Doctors within hospital settings made 4 (%) of the new diagnoses. Most of the few (9) people diagnosed by immigration services were referred to a sexual health clinic for follow up. 8

29 Number of new diagnoses Table 6. Type of diagnosing doctor of NSW residents newly diagnosed with HIV infection in 0 and where people newly diagnosed were referred for ongoing management Type of diagnosing doctor Referred to SHC Referred to hospital Referred to GP s00 Assumed to be retained by diagnosing service GP non-art prescriber 87 6% 4 4% 9% 4% 9 9% Sexual Health Clinic (SHC) % 0 0% % 97 9% 0 9% GP s00* % 4% 4% 48 87% 6% Hospital 7% 6 6% 4% 4 % 4 % Immigration 8 89% % 0% 0 0% 9 % Other 7% 0 0% 0 0% % 4 % Total 07 0% % 9 % 7 49% 4 00% Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 **A GP s00 is a private, general medical practitioner who is authorised to prescribe antiretroviral therapy under Section 00 highly specialised drugs program of the Pharmaceutical Benefits Scheme. Other or unknown include primarily forensics, interstate doctors and blood bank Figure 7. Type of diagnosing doctor of NSW residents newly diagnosed in 0 by HIV exposure Total MSM Hetero-sex PWID Mother to child Reported HIV risk exposure Other or unknown GP not s00 Sexual Health Clinic GP s00 Hospital Immigration Other Date source: NSW HIV/AIDS database, Health Protection NSW, extracted August 04 9

30 Percent of notifications per quarter 7. Uptake of antiretroviral therapy (ART) within six months of diagnosis and impact on HIV viral load Data on initiation of ART is available from enhanced surveillance information collected about people newly diagnosed with HIV from 0 January 0 onwards. Data on ART commencement, CD4 count and viral load at least six months post diagnosis is recorded via prescribing doctors who complete a standardised HIV six-monthly follow up form. Of the 4 NSW residents newly diagnosed in 0, (88%) had a six-monthly follow-up form completed by their prescribing doctors at the time of this analysis. Of these new diagnoses in 0, 49% () had commenced ART within three months of diagnosis and 60% (86) had commenced ART within six months of diagnosis (Figure 8). For the 0% () for which ART status was unknown, all had No as the answer for the question Is this patient currently in your care for HIV infection on the follow-up form. Figure 8. Time from diagnosis to commencement of ART among of 4 NSW residents newly diagnosed with HIV in 0 and with six-monthly follow up completed, by quarter diagnosed 00% 90% 80% 70% 60% 0% 40% 0% 0% 0% 0% First Quarter 0 Second Quarter Third Quarter 0 Quarter diagnosed 8 8 Fourth Quarter 0 ART status unknown Not on ART at 6 month follow-up Commenced ART between -6 months Commenced ART within months Data source: NSW HIV/AIDS database, Health Protection NSW, extracted November 04 0

31 Percent notifications within CD4 category Of the newly diagnosed persons for whom six monthly follow-up forms were available, 0 had results available for CD4 count at diagnosis. Of those with a CD4 count less than 00 cells/µl at diagnosis, 84% had commenced ART within three months of diagnosis and a further eight per cent had commenced ART within six months of diagnosis (Figure 9). Of those with a CD4 count at diagnosis between 0 and 00 cells/µl, 8.% (84) had commenced ART within three months of diagnosis and a further.8% (7) had commenced ART within six months of diagnosis. Lower CD4 counts at diagnosis are associated with earlier commencement of ART. The PBAC restriction on the prescription of ART for asymptomatic people with HIV with a CD4 count less than 00 cells/µl was lifted in April 04, by which time the majority of people diagnosed in 0 had already been diagnosed more than six months previously. Figure 9. CD4 count at diagnosis among 0 of 4 NSW residents newly diagnosed with HIV in 0 who had a six-monthly follow up and CD4 count at diagnosis completed, by time to ART 00% 90% 80% 70% 60% ART status unknown 0% 40% 0% 0% 0% 0% 6 Missing Less than and 00 CD4 count at diagnosis (cells/µl) over Not on ART at 6 month follow-up Commenced ART between -6 months Commenced ART within months Date source: NSW HIV/AIDS database, Health Protection NSW, extracted November 04

32 Of the newly diagnosed persons for whom six monthly follow-up forms were available, 0 had results available for viral load at diagnosis (Figure 0). Of those with a viral load at diagnosis greater than 0, 6.% had commenced ART within three months of diagnosis and a further 9% had commenced ART within six months of diagnosis. Of those with a viral load between 0 and 0 at diagnosis, 4.7% (84) had commenced ART within three months of diagnosis and a further % () had commenced ART within six months of diagnosis. Figure 0. Time from diagnosis to commencement of anti-retroviral therapy in NSW residents newly diagnosed with HIV in 0 by viral load at diagnosis (n=) >0 Data source: NSW HIV/AIDS database, Health Protection NSW, extracted November 04 Viral load after ART initiation The goal of ART is to reduce the HIV viral load to both minimise the effects of the virus and reduce the risk of HIV transmission (Figure ). Of the newly diagnosed people in 0 on ART at six-monthly follow up, 00 had pre and post ART viral load results available. Time from ART commencement was calculated as difference in days between the most recent viral load specimen date and the date ART was commenced. The median time on ART was 4 days. Viral load not detected was defined as a viral load reported as 0 copies/ml or Not Detected. Viral load not detected was reported in 6 people (8.%). Of the people with a detectable viral load at a time point more than 80 days after commencement of ART, 6.4% (4) had a viral load less than 00 copies/ml, and 6.6% (7) had a viral load between 00 and,000 copies/ml.

33 Log 0 viral load (copies/ml) Number of notifications Figure. Number of people newly diagnosed with HIV in NSW in 0 with a detectable or undetectable post ART viral load, by time from commencement of ART to follow-up* <0 days -90 days 9-80 days >80 days Time from commencement of ART Viral load not detected Viral load detected (>0 copies/ml) Data source: NSW HIV/AIDS database, Health Protection NSW, extracted November 04 *Data on viral load was reported for 00 of people newly diagnosed in 0 on ART at six-monthly follow-up Of the newly diagnosed persons who had commenced ART, pre and post ART commencement viral load results were available for 00 (9.9%). Of these 60% (0) had been on ART for greater than 80 days. Change in viral load was calculated as the difference in log 0 viral load between pre- ART specimen and most recent (post-art) specimen as reported on six monthly follow-up forms. Reduction in viral load was seen in all cases, the median reduction is shown (Figure ). The median time between tests was 0 days. T-tests showed the difference in change between groups was statistically significant (p<0.0) for all comparisons except 9-80 days vs > 80 days. Figure. Median reduction in viral load (log0) by time from commencement of antiretroviral therapy; as reported at six monthly follow up (n= 99) <0 days -90 days 9-80 days >80 days Time from commencement of ART Median reduction

34 8. Local health district level data The following figures describe characteristics of NSW residents newly diagnosed with HIV infection by their Local Health District (LHD) of residence. From the figures are excluded one new diagnosis made in Justice Health and one of unknown LHD. Figure. Percentage of NSW residents newly diagnosed in each LHD in 0 by gender Murrumbidgee-Albury Nepean Blue Mountains Southern NSW Northern NSW Central Coast Western NSW Mid North Coast Illawarra Shoalhaven Hunter New England Western Sydney Northern Sydney South Western Sydney Sydney South Eastern Sydney % 0% 40% 60% 80% 00% Percentage new diagnoses Male Female Transgender Figure 4. Percentage of NSW residents newly diagnosed in each LHD in 0 by age group Murrumbidgee-Albury Nepean Blue Mountains Southern NSW Northern NSW Central Coast Western NSW Mid North Coast Illawarra Shoalhaven Hunter New England Western Sydney Northern Sydney South Western Sydney Sydney South Eastern Sydney % 0% 40% 60% 80% 00% Percentage new diagnoses

35 Figure. Percentage of NSW residents newly diagnosed in each LHD in 0 by place of birth Murrumbidgee-Albury Nepean Blue Mountains Southern NSW Northern NSW Central Coast 4 Western NSW Mid North Coast Illawarra Shoalhaven Hunter New England Western Sydney 4 Born Australia Born overseas Unknown Northern Sydney South Western Sydney 0 9 Sydney 4 44 South Eastern Sydney 9 6 0% 0% 40% 60% 80% 00% Percentage new diagnoses Figure 6. Percentage of NSW residents newly diagnosed in each LHD in 0 by HIV risk exposure Murrumbidgee-Albury Nepean Blue Mountains Southern NSW 4 Northern NSW Central Coast 4 Western NSW Mid North Coast Illawarra Shoalhaven Hunter New England Western Sydney Northern Sydney MSM Hetero-sex PWID Other or unknown Mother to child South Western Sydney 7 Sydney 80 7 South Eastern Sydney 0 0% 0% 40% 60% 80% 00% Percentage

36 Figure 7. Percentage of NSW residents newly diagnosed in each LHD in 0 by type of diagnosing doctor Murrumbidgee-Albury Nepean Blue Mountains Southern NSW Northern NSW Central Coast Western NSW Mid North Coast Illawarra Shoalhaven Hunter New England Western Sydney Northern Sydney GP not s00 SHC GP s00 Hospital Immigration Blood Bank South Western Sydney 8 7 Forensics Sydney 9 7 South Eastern Sydney % 0% 40% 60% 80% 00% Percentage Figure 8. Percentage of NSW residents newly diagnosed in each LHD by CD4 count at diagnoses, 0 Murrumbidgee-Albury Nepean Blue Mountains Southern NSW Northern NSW Central Coast Western NSW Mid North Coast Illawarra Shoalhaven Hunter New England Western Sydney Northern Sydney South Western Sydney Sydney South Eastern Sydney Unknown CD4 < 00 CD CD CD % 0% 40% 60% 80% 00% Percentage 6

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