HIV care cascades for New York City overall and Ryan White clients: A first look

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1 HIV care cascades for New York City overall and Ryan White clients: A first look HIV Health & Human Services Planning Council Needs Assessment Committee June 13, 2013 Ellen Wiewel & Laura McAllister Hollod INTRODUCTION 1

2 What is the HIV Care Cascade? Continuum of care for persons living with HIV The ultimate goal in the cascade is viral load suppression Visual depiction of the proportion of individuals in a population who make it to the next step in the continuum of care and treatment A first step to help identify areas where PLWH may fall off the continuum Variations on the cascade have been prepared nationally (e.g. CDC and HRSA), locally across the U.S. and internationally Why is the HIV Care Cascade important to the Needs Assessment Committee? One tool among many that tells the story of client engagement and clinical health outcomes Framework for thinking about the HIV service system as a whole: from diagnosis to treatment success Looking across demographic groups can be a starting point for investigating barriers to care and needs among specific populations Does not tell the story of engagement in supportive services or other quality of life indicators 2

3 Preparing the NYC Ryan White Cascade This analysis includes Ryan White Part A (RW) clients enrolled at any time in 2011, and entered into eshare* eshare data was matched to NYC HIV Surveillance Registry (HSR) Complex algorithm matches on identifiers: name, DOB, SSN, etc. Tri County clients included in NYC surveillance records only if diagnosed or received care in NYC For comparability with the New York City (NYC) Care Cascade (all PLWHA in NYC), the same methodology was applied to the RW Care Cascade For cascade outcome measures, we used mandatory reporting of viral load (VL) and CD4 tests in the HSR (i.e. not Primary Care Status Measures reported in eshare/airs) *Note: AIRS data has not been matched to the surveillance registry as of June Thus, some clients who were enrolled in 2011 and not entered in eshare are missing from this analysis. This could apply to clients closed out of their programs before those programs transitioned to eshare (e.g., in March or October 2011) and also clients in programs that began the transition to eshare during Comparing Ryan White to All NYC PLWH RW Care Cascade is a subset of the NYC Care Cascade By definition, RW clients were in the HIV services system in NYC in 2011 Enrollment in a RW service indicates some form of HIV supportive service interaction in NYC Most 2011 RW clients would likely have been living in NYC in 2011 These clients were theoretically more likely to have interacted with an HIV service provider for at least some part of 2011 All PLWH in NYC (113,319) All 2011 RW Clients (~20,000) All RW Clients Matched to HSR (12, 513) *9 match rate. See note on previous slide. NYC Care Cascade includes all PLWH who are diagnosed, reported, and presumed to be living as of 12/31/2011 Unascertained moves or deaths are possible, especially for non RW clients Some individuals in the NYC Care Cascade may no longer have been living in NYC in 2011 RW clients may be distinct from other PLWH in NYC in terms of socio economic status, access to insurance and overall health 3

4 Demographics of Ryan White vs. All NYC PLWH RW PLWH (N=12,513) All NYC PLWH (N=113,319) Male 7,850 (6) 80,921 (71%) Black or Hispanic 10,920 (87%) 87,355 (77%) Less than 45 years old 4,888 (39%) 41,959 (37%) Foreign born 2,366 (19%) 20,686 (18%) HIV, non AIDS 3,763 (31%) 46,237 (41%) MSM Transmission 3,307 (27%) 39,846 (3) IDU Transmission 2,994 () 20,115 (18%) Heterosexual Transmission 2,977 (24%) 22,103 (2) POPULATION WIDE CASCADES 4

5 , , Estimated HIVinfected Estimate based on 86% of infected being diagnosed 86% of infected 95,683 73% of infected 84% of diagnosed 71,489 54% of infected 63% of diagnosed 7 of linked to care HIV diagnosed Ever linked to HIV care Engaged in HIV care in 2011 Reported to HSR Any lab test from Any lab test in & presumed to , be living as of days post HIV 12/31/2011 diagnosis NYC: The largest drop is from ever linked to engaged. 64,548 49% of infected 57% of diagnosed 9 of engaged in care Presumed ever started on ART Any suppressed VL ( 200 copies/ml) from ,191 38% of infected 44% of diagnosed 78% of started on ART Suppressed viral load ( 200 copies/ml) Most recent VL in 2011 was 200 copies/ml ,153 12, % of enrolled 11,794 97% of enrolled 98% of linked to care 10,450 86% of enrolled 89% of engaged in care 6,886 57% of enrolled 66% of started on ART Enrolled in Ryan White in 2011 Reported to HSR & presumed to be living as of 12/31/2011, & enrolled in Ryan White in 2011 Ever linked to HIV care Any lab test from , 8 days post HIV diagnosis Engaged in HIV care in 2011 Any lab test in 2011 Presumed ever started on ART Any suppressed VL ( 200 copies/ml) from RW: The largest drop is from ever on ART to suppressed. Suppressed viral load ( 200 copies/ml) Most recent VL in 2011 was 200 copies/ml 5

6 SUBGROUP CASCADES By Sex Diagnosed Linked to care Engaged in care Started ART Virally suppressed % 86% 62% 5 67% 61% 44% 4 Male (N = 80,921) Female (N = 32,398) NYC: Care cascades look similar, with females doing somewhat better. 6

7 By Sex Enrolled Linked to care Engaged in care Started ART Virally suppressed % 10 97% 97% 8 88% 56% 58% Male (N = 7,850) Female (N = 4,303) RW: Success at each step of the cascade is similar for males and females. By Race/Ethnicity Diagnosed Linked to care Engaged in care Started ART Virally suppressed % 84% 8 83% 64% 6 57% 42% 59% 58% 54% 46% 47% 62% 57% 49% Black (N = 50,573) Hispanic (N = 36,782) White (N = 23,313) Other or (N = 2,651) NYC: Blacks are least likely to be suppressed; whites are least likely to engage in care. 7

8 By Race/Ethnicity Enrolled Linked to care Engaged in care Started ART Virally suppressed % 99% 99% 99% 97% 98% 96% 96% 8 88% 86% 83% 53% 6 67% 68% Black (N = 6,511) Hispanic (N = 4,409) White (N = 1,018) Other or (N = 215) RW: Blacks and Hispanics are less likely than whites to be suppressed. By Age as of 12/31/2011 Diagnosed Linked to care Engaged in care Started ART Virally suppressed % 86% 88% 86% 81% 7 67% 49% 33% 6 51% 39% 63% 64% 62% 59% 59% 56% 57% 5 48% 46% 47% 42% 0 24 (N = 4,750) (N = 12,534) (N =24,675) (N = 41,061) (N = 23,126) 65 (N = 7,173) NYC: With increased age, both ART and suppression more likely among engaged. 8

9 By Age as of 12/31/2011 Enrolled Linked to care Engaged in care Started ART Virally suppressed % 99% 99% 99% % 96% 97% 97% 98% 98% 96% 93% 88% 8 73% 74% 68% 78% % (N = 645) (N = 1,545) (N = 2,698) (N = 4,548) (N = 2,245) 65 (N = 472) RW: With increased age, both ART and suppression more likely among engaged. By Place of Birth Diagnosed Linked to care Engaged in care Started ART Virally suppressed % 87% 83% 82% 64% 57% 67% 61% 63% 59% 57% 56% 43% 43% 48% 4 US born (N = 63,375) US dependency (N = 5,932) Foreign born (N = 20,686) (N = 23,326) NYC: Care cascades are similar across groups, with foreign born slightly more likely to be suppressed. 9

10 By Place of Birth Enrolled Linked to care Engaged in care Started ART Virally suppressed % 99% 99% 99% 97% 96% 97% 98% 84% 87% 88% 91% 69% 63% 52% 52% US born (N = 7,325) US dependency (N = 825) Foreign born (N = 2,366) (N = 1,637) RW: Foreign born clients do better at ART and suppression. By Clinical Status as of 12/31/2011 Diagnosed Linked to care Engaged in care Started ART Virally suppressed % 8 58% 67% 62% 49% 48% 4 HIV, non AIDS (N = 46,237) AIDS (N = 67,082) NYC: AIDS diagnosed clients are more likely to start ART. Once on ART, non AIDS clients are more likely to be suppressed. 10

11 By Clinical Status as of 12/31/2011 Enrolled Linked to care Engaged in care Started ART Virally suppressed % % 98% 9 56% 57% HIV, non AIDS (N = 3,763) AIDS (N = 8,390) RW: AIDS diagnosed clients are more likely to start ART. Once on ART, non AIDS clients are more likely to be suppressed. By HIV Transmission Risk Diagnosed Linked to care Engaged in care Started ART Virally suppressed % 77% 9 84% 82% % 48% 59% 5 63% 48% 64% 59% 58% 53% 38% 36% 42% MSM (N = 39,846) IDU (N = 20,115) Heterosexual (N = 22,103) Perinatal or Other (N = 2,740) NYC: Cascades are similar across risk groups, with IDU having a large drop from ART to suppression. (N = 28,515) 11

12 HIV Transmission Risk Enrolled Linked to care Engaged in care Started ART Virally suppressed % 10 99% 99% 99% 97% 98% 97% 97% 97% 83% 89% 86% 89% 86% 61% 58% 58% 51% 49% MSM (N = 3,307) IDU (N = 2,994) Heterosexual (N = 2,977) Perinatal or Other (N = 364) RW: Cascades are similar across risk groups, with IDU having a large drop from ART to suppression. (N = 2,511) Discussion RW clients have high linkage and engagement in care, and are most likely to fall off at ART and suppression Overall in NYC, PLWH fall off at the linkage step, which may reflect unascertained moves and deaths Compared to NYC overall, those RW clients who were started on ART were less likely to achieve VL suppression in 2011 In both populations, the shape and distribution of the cascades is similar when broken down by subgroup Younger, black, and IDU PLWH showed the greatest drops in the cascade for NYC overall and RW 12

13 THANK YOU Appendix I A: Cascade Loss Rates by Subgroup, NYC Loss Rates are a way of understanding what proportion of people within a given subgroup fell off the cascade at various stages. When looking at the cascade it can sometimes be difficult to determine the magnitude of a drop within each subgroup in comparison to the drop for another group at the same stage. The loss rates are calculated by dividing the number of individuals lost at the current step by the number of individuals in the previous step. 13

14 Loss Rates, by Sex 3 26% 26% 23% 21% 2 16% 1 14% 8% Male Female Diagnosed & not linked Linked & not engaged Engaged & not on ART ART & not suppressed 3 3 Loss Rates, by Race/Ethnicity 31% % 16% 16% 1 24% 23% 11% 9% 7% 9% 26% 23% 14% 13% Black Hispanic White Other or Diagnosed & not linked Linked & not engaged Engaged & not on ART ART & not suppressed 14

15 Loss Rates, by Age as of 12/31/ % % 26% 24% 23% 19% 18% 18% 14% 14% 12% 26% 21% 11% 7% 24% 24% 23% 18% 14% % Diagnosed & not linked Linked & not engaged Engaged & not on ART ART & not suppressed Loss Rates, by Place of Birth 3 27% 24% 23% 29% 2 18% 17% 17% 19% US born 1 14% 13% 11% 9% 6% US dependency Foreignborn Diagnosed & not linked Linked & not engaged Engaged & not on ART ART & not suppressed 15

16 Loss Rates, by Clinical Status as of 12/31/ % % 1 22% 16% 19% 24% HIV, non AIDS AIDS 6% Diagnosed & not linked Linked & not engaged Engaged & not on ART ART & not suppressed 4 Loss Rates, by Risk 4 39% % 3 23% 26% 23% 23% 23% 24% 22% MSM % 16% 18% 11% 9% 7% 9% 16% IDU Heterosexual Perinatal or Other Diagnosed & not linked Linked & not engaged Engaged & not on ART ART & not suppressed 16

17 Appendix I B: Subgroup Distribution in Each Cascade Step, NYC The stacked bar graphs demonstrate the demographic breakdown of the people who are in each step of the cascade. By looking at the proportion of subgroups in each step of the cascade we can get an idea about the composition of the population that succeeds in each step of the cascade. A large difference in the distribution of subgroups in the stacked bar graphs in this section might indicate that the population that is succeeding or failing along the cascade is demographically different from the population at other steps. For a sense of the overall population breakdown by subgroup you can simply look at the first bar in each chart. 10 Distribution by Sex in Each Step % 29% 3 31% 29% % 71% 7 69% 71% Female Male 2 Diagnosed Linked to care Engaged in care Started ART Virally suppressed 17

18 Proportion in Each Step, by Race/Ethnicity % 2% 2% 2% 3% 21% 21% 19% 2 22% % 32% 33% 34% 34% Other or White % 42% Hispanic Black Diagnosed Linked to care Engaged in care Started ART Virally suppressed Proportion in Each Step, by Age as of 12/31/ % 6% 6% 6% 7% % 22% % 37% 37% 22% 23% 22% 38% 37% 21% 21% % 11% 11% 4% 4% 4% 4% 3% Diagnosed Linked to care Engaged in care Started ART Virally suppressed 18

19 Proportion in Each Step, by Place of Birth % 2 19% 2 21% % 18% 18% 18% 2 6% 6% 56% 57% 57% 56% 54% Foreignborn US dependency US born Diagnosed Linked to care Engaged in care Started ART Virally suppressed 10 Proportion in Each Step, by Clinical Status as of 12/31/ % 6 62% 6 64% 6 5 AIDS % 4 38% 3 36% Diagnosed Linked to care Engaged in care Started ART Virally suppressed 19

20 Proportion in Each Step, by Risk % 23% 23% 24% 2% 2% 2% 2% 2% 2 21% 22% 22% 21% 18% 16% 17% 17% % 36% 3 38% Perinatal or Other Heterosexual IDU MSM Diagnosed Linked to care Engaged in care Started ART Virally suppressed Appendix II A: Cascade Loss Rates by Subgroup, Ryan White Loss Rates are a way of understanding what proportion of people within a given subgroup fell off the cascade at various stages. When looking at the cascade it can sometimes be difficult to determine the magnitude of a drop within each subgroup in comparison to the drop for another group at the same stage. The loss rates are calculated by dividing the number of individuals lost at the current step by the number of individuals in the previous step. 20

21 Loss Rates, by Sex % % Male Female 1% Enrolled & not linked 2% 2% Linked & not engaged Engaged & not on ART ART & not suppressed Loss Rates, by Race/Ethnicity 4 38% 3 32% % 18% Black 1 14% 12% 11% Hispanic White 1% 1% 1% Enrolled & not linked 1% 2% 2% 3% 2% Linked & not engaged Engaged & not on ART ART & not suppressed Other or 21

22 Loss Rates, by Age as of 12/31/ % 38% 37% 3 32% 3 27% 23% 23% 2 18% % 1% 1% 1% Enrolled & not linked 3% 2% 2% 3% 1% 2% Linked & not engaged 13% 9% Engaged & not on ART 2% ART & not suppressed Loss Rates, by Place of Birth % % % 7% 21% US born US dependency Foreignborn 1% 2% 3% 1% 1% 2% 1% 2% Enrolled & not linked Linked & not engaged Engaged & not on ART ART & not suppressed 22

23 Loss Rates, by Clinical Status as of 12/31/ % % % HIV, non AIDS 8% AIDS 2% Enrolled & not linked 3% 2% Linked & not engaged Engaged & not on ART ART & not suppressed 5 Loss Rates, by Risk % % 32% 3 27% MSM 2 IDU 1 1% 2% 2% 3% 2% 3% 1% 1% 1% Enrolled & not linked Linked & not engaged 14% 11% 11% 9% 8% Engaged & not on ART ART & not suppressed Heterosexual Perinatal or Other 23

24 Appendix II B: Subgroup Distribution in Each Cascade Step, Ryan White The stacked bar graphs demonstrate the demographic breakdown of the people who are in each step of the cascade. By looking at the proportion of subgroups in each step of the cascade we can get an idea about the composition of the population that succeeds in each step of the cascade. A large difference in the distribution of subgroups in the stacked bar graphs in this section might indicate that the population that is succeeding along the cascade is demographically different from the population at other steps. For a sense of the overall population breakdown by subgroup you can simply look at the first bar in each chart. 10 Proportion in Each Step, by Sex % 36% 36% 36% 7 6 Female Male % 64% 64% 64% 2 Enrolled Linked to care Engaged in care Started ART Virally suppressed 24

25 Proportion in Each Step, by Race/Ethnicity % 2% 2% 2% 2% 8% 8% 8% 8% % 36% 36% 37% 38% Other or White % 54% 53% 53% 5 Hispanic Black Enrolled Linked to care Engaged in care Started ART Virally suppressed Proportion in Each Step, by Age as of 12/31/ % 4% 4% 4% % 19% 19% 2 22% % 37% 37% 38% 36% % 22% 22% 22% 21% % 13% 13% 11% 11% 4% Enrolled Linked to care Engaged in care Started ART Virally suppressed 25

26 Proportion in Each Step, by Place of Birth % 13% 14% 14% % 19% 2 2 7% 7% 7% 7% 24% 6% % 5 Foreignborn US dependency US born Enrolled Linked to care Engaged in care Started ART Virally suppressed 10 Proportion in Each Step, by Risk % 21% 21% 21% 21% 3% 3% 3% 3% 3% 24% 22% 27% 27% 27% 26% 29% Perinatal or Other Heterosexual IDU MSM Enrolled Linked to care Engaged in care Started ART Virally suppressed 26

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