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Impact of Age and Race on New HIV Infections among Men who have Sex with Men in Los Angeles County 2008-2010

Shoshanna Nakelsky, MPH Division of HIV and STD Programs Los Angeles County Department of Public Health

Overview

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Background

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LAC Population

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MSM

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HIV Incidence Surveillance System Methods Results

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New HIV cases diagnosed

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HIV incidence estimates for young MSM Conclusions

Los Angeles County

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Most populous county in U.S. – nearly 10M Area: 4,000 square miles City of LA (4M) plus 88 incorporated cities and unincorporated areas One of the most racially and ethnically diverse areas in U.S.

Urban, suburban, and rural areas

2013 Estimated Number of Persons Living with HIV in Los Angeles County (LAC) 2,000 10,500 45,500 Estimated ~ 58,000 living with HIV in LAC (1) Estimate that 18.1% of HIV+ in LA County are unaware of their infection; from CDC estimate.

(2) Of 4,200 notifications pending investigation, estimate about 2,000 who have detectable VL or confirmatory test to be unduplicated cases.

Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

New HIV Diagnoses By Gender LAC, 2010 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

New HIV Diagnoses by Age Group LAC, 2010 35% 31% 30% 28% 25% 25% 20% 15% 15% 10% 5% 0% 1% 13-17 18-29 30-39 40-49 Age Group (years) 50+ Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

New HIV Diagnoses by Race/Ethnicity LAC, 2010 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 25% 24% 46% 4% 1% White Black Latino Asian/PI AI/AN Race/Ethnicity Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

Mode of Transmission among Newly Diagnosed Cases, LAC 2010 MSM = Men who have sex with men; IDU = Injection drug use HET = heterosexual transmission risk Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

New HIV Diagnoses among MSM by Age Group, LAC 2010 40% 35% 30% 25% 20% 15% 10% 5% 0% 36% 29% 23% 0.5% 13-17 18-29 30-39 Age Group (years) 40-49 11% 50+ Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

Proportion of Young MSM (18-29 years) by Race, LAC 2010 Fig 1. Total LAC Population Fig 2. New HIV Diagnoses 4% 14% 9% 26% 20% 23% 56% 50% Black Latino White Other Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

HIV Incidence Surveillance (HIS)

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National effort developed and funded by the Centers for Disease Control and Prevention (CDC)

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Provides first reliable and scientifically valid estimates of newly acquired infections

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Estimates HIV incidence for those who:

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Test Early

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Test Late Never Test

HIV Incidence Surveillance (2)

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Estimates the number and rate of new HIV infections

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Improves ability to allocate resources for prevention and care

Methods: Analysis Population

Eligibility for inclusion in the estimation process:

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Resided in LAC at the time of HIV diagnosis Diagnosed in 2008-2010 18-29 years of age Male Sex with males as a risk factor

Data Sources: Enhanced HIV/AIDS Reporting System (EHARS)

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Demographic Data

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Age Race/ethnicity Mode of transmission

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HIV/AIDS Diagnosis Data

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HIV diagnosis date AIDS diagnosis date Proportion of cases diagnosed with AIDS within 6 months of HIV diagnosis (late detection)

Data Sources: HIV Incidence Surveillance

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Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS)

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HIV testing and treatment history

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History of previous negative test results Date of most recent negative test result Time between last negative and first positive test

Methods

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Rates calculated using:

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Denominators for rates assumed 8.2% of males aged 18-29 years were MSM*

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California State Department of Finance population estimates

Lieb, 2011 16

Results: 2010 HIV Incidence Estimates

Rates and 95% CI of new HIV Infection among MSM by Age Group, LAC 2010 20 15 10 12 11 5 2 0 18-29 years 30-39 years Age Group 40+ years Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

Proportion of Estimated HIV Infections in MSM aged 18-29 years by Race, LAC 2010 23% 7% 20% 50% Black Latino White Other Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

Estimated HIV Incidence Rates and 95% CI for YMSM age 18-29 years by Race, LAC 2010 50 40 30 20 29 10 13 11 0 White Black Race/Ethnicity Latino Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

Results: Combined Year HIV Incidence Estimates

Rate and 95% CI of new HIV Infection by Age Group, LAC 2008-2010 16 14 12 10 8 6 4 2 0 8 2 8 11 13-29 years 13-17 years 18-24 years 25-29 years Age Group Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

Rate of New HIV Infection among Young MSM by Race/Ethnicity and Age Group, 2008-2010

25 *

20 15 10

8 9 8 11 8 Black Latino White

2 4

18-29 30-39 Age Group (years) 40+ *Rate for black MSM significantly different from other MSM.

Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

Rate of new HIV Infection among Young MSM by Race/Ethnicity and Age Group, 2008-2010 * Age Group (years) *Rate for black MSM significantly different from other MSM.

Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

Key Findings

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In LAC, the rate of incidence among 13-17 year old MSM is low compared with 18-29 year old MSM.

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HIV incidence estimates confirm that MSM ages 18 29 years are at the highest risk for new HIV infections

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The magnitude of the racial/ethnic disparity for young Black MSM compared with Whites and Latinos is largest for 18-24 year olds

Discussion

Possible Reasons for Increased Risk Among Black YMSM

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Age of sexual debut

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Increased partner age

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Most likely to have Black partners

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Decreased engagement in HIV care

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Undiagnosed HIV Infection Late Detection Less Retention in Care Less Viral Load Suppression

Millett et al, 2012 27

Linkage to Care* Among MSM Reported with HIV, by Race/Ethnicity, LAC 2010 100 80 75 82 79 82 83 86 60 40 20 0 18-29 years N=454** Age Group 30+ years N=743** *Linked to care <3 months of diagnosis MSM diagnosed in 2010.

** Number of people diagnosed with HIV from 1/1/2010-12/31/2010 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

Black Latino White

Viral Load Suppression* Among MSM Living with HIV Race/Ethnicity, LAC 2010 100 81 85 80 69 69 69 60 40 47 Black Latino White 20 0 18-29 years N=1,111** Age Group 30+ years N=15,638** *Viral load suppression defined as VL <200. ** Number of people living with HIV at the end of 12/31/2010 Source: LAC Division of HIV and STD Programs, reported as of 12/31/2012.

Limitations

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Missing Data

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Variation by Race/Ethnicity Assumptions of Multiple Imputation Technique

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Sample Size

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Assumptions of Incidence Methodology

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No Change in Testing Behavior

Conclusions

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The risk of new HIV infection among YMSM varies by both age and race/ethnicity

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Black MSM are at an increased risk of new HIV infection across age groups

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Black MSM, age 18-24 years, show most dramatic disparity in risk compared with Latino and White peers

Conclusions (cont’d)

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Research is needed to better understand contributing factors.

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Retention in care

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Quality of care

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Adherence to antiretroviral therapy

Acknowledgements

Los Angeles County

HIV Incidence Surveillance Team Trista Bingham, PhD Deanna Lewis Randi Kendrick

Core HIV Surveillance

Douglas Frye, MD Yunyin Hu

Long Beach Health Department Pasadena Health Department Centers for Disease Control and Prevention

Thank You!

For more information contact: Shoshanna Nakelsky HIV Incidence Surveillance Coordinator [email protected]

213.351.8154