Texas HIVSTD Epidemiology Update

1
Texas HIV/STD Epidemiology Update

• 16th Texas HIV/STD Conference
• May 19, 2008

2
Outline

• Overview
• HIV/AIDS Case Surveillance
• Perinatal HIV/AIDS
• HIV Incidence/Drug Resistance
• STD Surveillance

3
History

• 1981 AIDS first reported
• 1983 Texas adds AIDS to list of reportable
  conditions
• 1993 Low CD4 count added to AIDS case definition

4
History

• 1996 Highly Active Antiretroviral Therapy
  (HAART) introduced
• 1999 Texas implements HIV reporting by name and
  Enhanced Perinatal Surveillance
• 2005 Incidence surveillance implemented
• 2007 Drug resistance surveillance implemented

5
HIV/AIDS Case Surveillance Data Sources
Corrections
Active Surveillance
Provider Reports
Registries (e.g. birth, death)
Local/Regional HIV/AIDS Reporting System (HARS)
Laboratory Reports
Public Health Follow-up
Texas HARS
CDC HARS National
6
Key HIV/AIDS Case Surveillance Data Collected

• Demographic Characteristics
• sex, race/ethnicity, age, locality
• Risk
• Opportunistic illnesses
• Virologic and immunologic status

7
HIV/AIDS Case Surveillance Data

• HIV surveillance data only include persons who
  have been tested and reported and thus may not
  represent all persons who are infected

8
Definitions

• Incident Cases Number of new HIV infections per
  year
• Diagnosed Cases Number of HIV cases diagnosed in
  a given year a person may have been infected
  with HIV many years before being diagnosed
• Reported Cases Number of HIV cases reported in a
  given year a person may have been diagnosed in
  an earlier year
• Living Cases (prevalence) All persons living
  with HIV/AIDS, regardless of when they acquired
  their infection or were diagnosed

9
USA Reported Cases

• As of end year 2006, 961,315 AIDS cases have been
  reported in the United States
• Of these cases 7 were reported in Texas
• As of end year 2006, 287,954 HIV cases have been
  reported in the United States
• Of these cases 9 were reported in Texas
• Includes 45 states with name-based reporting as
  December 2006

10
Texas The Big Picture

• Since 1980, gt102,000 Texans have been diagnosed
  with HIV/AIDS
• gt39,000 Texans with HIV/AIDS have died
• As of year end 2007, 62,805 Texans were living
  with HIV/AIDS

11
Persons Living with HIV/AIDS, Texas 1987N1,204
12
Persons Living with HIV/AIDS, Texas 1997N16,184
13
Persons Living with HIV/AIDS, Texas 2007N62,805
14
New AIDS Cases, Deaths, and Persons Livingwith
AIDS, Texas, 1980-2007
Living with AIDS
New AIDS Cases

Deaths among AIDS Cases
06-07 vital records review of death has not
yet occurred
15
Texas The Big Picture

• HAART is here, but in 2007
• 2,661 Texans were diagnosed with AIDS
• 676 Texans with HIV/AIDS died
• 4,391 Texans were newly-diagnosed with HIV
• 28 of Texans who first leaned they had HIV in
  2007 were diagnosed with AIDS at that time

2007 vital records review of death has not
occurred, so this is likely to be an
underreporting of deaths
16
Newly-diagnosed HIV/AIDS Cases,Texas, 1999-2007
17
HIV/AIDS in Texas

• Nita Ngo
• May 19, 2008

18
HIV/AIDS in Texas, 2007

• 62,805 persons were known to be living with
  HIV/AIDS and the overall rate was 262 cases per
  100,000 persons
• Males represented the majority of the living
  cases (78) and new diagnoses (77) of HIV/AIDS
• African-Americans continue to be
  disproportionately impacted by HIV, with a rate
  of 883 persons living with HIV/AIDS per 100,000
• Mode of transmission varied among
  races/ethnicities
• Male-to-male sex more frequently reported among
  White and Hispanic men

19
Proportion of AIDS Cases by Race/Ethnicity Texas,
1990-2007
20
Race/Ethnicity of New HIV/AIDS Case Texas, 2007
Texas Population n23,904,380
HIV/AIDS Cases n4,391
27
42
29
2
21
Age and Race/Ethnicity of New HIV/AIDS Cases
Texas, 2007
22
HIV/AIDS by Gender in Texas

• Males account for more than three-quarters of
  newly diagnosed AIDS cases
• Females represent an increasingly greater
  proportion of newly diagnosed AIDS cases
• HIV/AIDS has affected African-American women
  disproportionately
• Represent 12 of female population
• Make up 60 of living cases among women
• A greater proportion of men were diagnosed at
  25-44 years of age compared to women

23
AIDS Cases Diagnosed in Texas1990-2007
24
Proportion AIDS Cases that were Female Texas,
1990-2007
25
Race/Ethnicity of New HIV/AIDS CasesTexas, 2007
Females n1,014
Males n3,377
23 per 100,000
96 per 100,000
18 per 100,000
26
HIV/AIDS and Mode of TransmissionTexas, 2007

• Male-to-male sexual contact was the most common
  mode of transmission
• The majority of HIV/AIDS cases among women
  attributed to heterosexual contact
• Heterosexual transmission and injection drug use
  account for a greater share of infections among
  African-American men
• Injection drug use more common mode of
  transmission among white women

27
Proportion of AIDS Cases by Transmission Category
Texas, 1990-2007
Heterosexual contact with person known to have
or to be at high risk for HIV infection
28
HIV/AIDS Cases by Transmission Category Texas,
2007
Females
Males
Heterosexual contact
Male-to-male sexual contact
Injection drug use (IDU)
Other/Unknown
Male-to-male sexual contact IDU
Heterosexual contact with person known to have
or to be at high risk for HIV infection Includes
hemophilia, blood transfusion, perinatal
exposure, and risk factor not reported or
identified
29
HIV/AIDS Cases Among Males by Transmission
Category and Race in Texas, 2007
16
24
27
5
6
3
3
3
9
11
8
12
70
58
47
Includes hemophilia, blood transfusion,
perinatal exposure, and risk factor not
reported or identified
30
Female HIV/AIDS Cases by Transmission Category
and Race in Texas, 2007
Heterosexual contact with person known to have
or to be at high risk for HIV infection Includes
hemophilia, blood transfusion, perinatal
exposure, and risk factor not reported or
identified
31
HIV/AIDS in the Texas Border Counties 2007

• 15 border counties represented 6 of all newly
  diagnosed HIV/AIDS cases
• Majority of cases were among Hispanics (86)
• Hispanics accounted for 88 of border population
• Rate of diagnosis among Hispanics was 9.5 per
  100,000
• A greater proportion of cases were diagnosed
  between ages 25-34 compared to those residing in
  non-metropolitan areas
• A greater proportion of cases were attributed to
  male-to-male sexual contact and heterosexual
  contact, compared to cases in non-metropolitan
  areas

32
Texas Border Counties
33
HIV/AIDS Cases by Region Texas, 2007
Texas
4,391 (18.3 per 100,000)
Metropolitan
2,585 (25.0 per 100,000)
Non-metropolitan
1,579 (4.5 per 100,000)
Border
277 (9.6 per 100,000)
Excludes border counties
34
HIV/AIDS Cases by Age in Texas Border Counties,
2007
Non-metropolitan
Border
Excludes border counties
35
HIV/AIDS Cases by Transmission Category in Texas
Border Counties, 2007
2
3
4
3
5
19
19
16
21
27
32
22
50
43
34
Excludes border counties
36
Contact Information

• Nita Ngo
• nita.ngo_at_dshs.state.tx.us
• 512.533.3057

37
Enhanced Perinatal Surveillance, Texas, 1999-2006

• Elvia Ledezma, Epidemiologist
• HIV/STD Epidemiology and Surveillance
• Texas Department of State Health Services
• elvia.ledezma_at_dshs.state.tx.us
• 512-533-3045

38
General Definitions

• Perinatal Exposure-Any child born to an HIV
  infected woman
• Infected-Any child born to an HIV infected woman
  and determined to be HIV positive
• Not Infected (Seroreverter)- Any child born to an
  HIV infected woman and determined to be HIV
  negative
• Indeterminate- Any child born to an HIV infected
  woman with insufficient test history to determine
  his/her HIV status.

39
EPS Background Information

• What is EPS?
• How is EPS data collected?
• How is EPS data used?

40
General Description of the HIV Perinatal Epidemic
in Texas
41
Prevalence of Perinatal HIV/AIDS,Texas, 2007

• 530 perinatally infected persons are living with
  HIV/AIDS (through 2007)
• 31 estimated persons living with AIDS

42
Perinatally Exposed and Infected Children, Texas,
1999-2007
n11
n10
n5
43
Births to HIV Women, 1999-2007
44
Infection Rates by Select Areas, Texas, 2006-2007
High Population Counties (1)
Low Population Counties (2)
(1) - Harris, Dallas, Tarrant, Bexar, Travis,
Hidalgo (2) - Johnson, Van Zandt, Bell,
Jefferson, Robertson, Grayson, Dallam - Based
on counties with an infected child in 2006-2007.
45
Preventative Factors Related to the Decrease in
Perinatal Transmission of HIV
46
Prevention of Perinatal HIV Transmission

• Receipt of antiretroviral therapy (ART)
• Receipt of prenatal care
• Breastfeeding
• Timing of HIV diagnosis

47
Receipt of ARV among HIV Women Delivering and
Proportion of Infected Children, Texas, 1999-2006
ARV-Antiretroviral Therapy
48
Prevention of Perinatal HIV Transmission

• Receipt of antiretroviral therapy (ART)
• Receipt of prenatal care
• Breastfeeding
• Timing of HIV diagnosis

49
Adequacy of Care among HIV Women Delivering and
Proportion of Infected Children, Texas, 1999-2006
Based on the Kessner Index
50
Prevention of Perinatal HIV Transmission

• Receipt of antiretroviral therapy (ART)
• Receipt of prenatal care
• Breastfeeding
• Timing of HIV diagnosis

51
Breastfeeding Practices among Births to HIV
Women Delivering and Proportion of Infected
Children, Texas, 1999-2006
52
Prevention of Perinatal HIV Transmission

• Receipt of antiretroviral therapy (ART)
• Receipt of prenatal care
• Breastfeeding
• Timing of HIV diagnosis

53
Timing of HIV Diagnosis among HIV Women
Delivering and Proportion of Infected Children,
Texas, 1999-2006
54
Race/Ethnicity

• Proportion of infected infants
• 7 Hispanic, 4 African American, 2 White
• HIV women delivering an infected infant
• Hispanic and Whites are 2.5 times more likely to
  not receive ART at any interval than African
  Americans
• Hispanic and Whites are 5 times more likely to
  breastfeed than African Americans
• Hispanics 3 times more likely to be diagnosed
  after delivery than African Americans

55
Summary

• The number of perinatally infected children has
  increased from 2005 to 2007
• HIV women delivering an infected infant
  (1999-2006) are
• Predominantly Black women. Hispanic women are
  also disproportionately affected
• Predominantly receiving inadequate prenatal care
• Predominantly diagnosed at delivery or after
  delivery
• More likely to have not received ART at all three
  intervals
• More likely to have breastfed
• Earlier encounters with HIV positive pregnant
  women decreases the likelihood of perinatally
  infected children
• Early diagnosis of HIV
• Ensure ART intake
• Counseling on breastfeeding practices

56
Texas HIV Perinatal Work Group
57
Contact Information

• Tammy Sajak
• [phone]
• Tammy.Sajak_at_dshs.state.tx.us
• Elvia Ledezma
• [phone]
• Elvia.Ledezma_at_dshs.state.tx.us

58
HIV Incidence and Drug Resistance Surveillance

• Douglas Schuster
• 16th Texas HIV/STD Conference
• May 19, 2008

59
HIV Incidence Surveillance (HIS)

• Background 40,000 persons in U.S. estimated to
  be newly infected annually, but more precise
  estimates needed
• Purpose to provide national and area-specific
  population-based estimates of the number of new
  HIV infections per year
• Until recently, no way to tell recent from
  long-term infection

60
HIV Incidence Methodology
Two Elements are needed for incidence estimates
STARHS Results
Testing History Information Gathered
by Provider/Counselor/ Surveillance
HIV INCIDENCE ESTIMATION
61
Representativeness of Presented Data

• CDC population incidence estimate is in review
• Describes the group of people who tested
  positive, not the general population
• Presented data from partner laboratories
• Houston program is funded separately by CDC but
  data are shared

62
Overview of Data (June 1, 2005 - May 13, 2008)

• Newly diagnosed HIV/AIDS cases
• Leftover specimen used for additional testing
  through partner labs
• Tested using new incidence lab test

63
Overview of STARHS Results(June 1, 2005-May 13,
2008)

• 11,278 newly diagnosed cases
• 949 shipped to CDC-contracted laboratory for
  STARHS testing by UT Southwestern or DSHS

70 Long Term 30 Recent
64
Texas STARHS Results by Sex (June 1, 2005-May
13, 2008)
Data provided by the HIV/STD Epidemiology
Surveillance Group, Department of State Health
Services. The results based on specimens from
participating labs and are not generalizable to
the general population.
65
Texas STARHS Results by Race/Ethnicity (June 1,
2005-May 13, 2008)
Data provided by the HIV/STD Epidemiology
Surveillance Group, Department of State Health
Services. The results based on specimens from
participating labs and are not generalizable to
the general population.
66
Texas STARHS Results by Mode of Exposure (June
1, 2005-May 13, 2008)
Data provided by the HIV/STD Epidemiology
Surveillance Group, Department of State Health
Services. The results based on specimens from
participating labs and are not generalizable to
the general population.
67
Texas STARHS Results by Age Group (June 1,
2005-May 13, 2008)
Data provided by the HIV/STD Epidemiology
Surveillance Group, Department of State Health
Services. The results based on specimens from
participating labs and are not generalizable to
the general population.
68
Urban Rural Continuum

• Broadest definition
• Five most populous counties Bexar, Dallas,
  Harris, Tarrant and Travis 29 recent
• All other counties 28 recent
• Other subgroups of rural
• Counties not covered by a local or regional
  surveillance office (often referred to as
  Cactus) 18 recent

69
Results by Selected Reporting Areas
70
Variant, Atypical, and Resistant HIV Surveillance
(VARHS)
71
VARHS

• Goal genetic sequence from virus at time of
  diagnosis for all newly diagnosed cases
• Test looks at genetic code of the virus HIV
• Mutations lead to antiretroviral drugs resistance
• People with drug-resistant virus can transmit it
  to others who will also become drug resistant

72
VARHS

• Resistance surveillance is important for
  individual patients as well as public health
• Track impact of transmission of drug resistant
  virus in the population
• Awareness of resistance means better outcomes,
  less cost for treatment, focused interventions
• Future standard of care

73
Three Major Types of Antiretroviral Drugs

• PI protease inhibitor
• N-RTI nucleoside reverse transcriptase
  inhibitor
• NN-RTI non-nucleoside reverse transcriptase
  inhibitor

74
VARHS Overview

• 297 tested from DSHS and Dallas County Labs (via
  UT Southwestern)
• 61 (20) results indicate drug resistance

75
Drug Resistant-HIV by Persons/Drug Class
76
HIV-1 Types, Groups Subtypes
77
HIV Subtypes
78
Non-B Subtypes Among Newly Diagnosed Cases in
Texas

• Cases
• Tested Subtype
• 264 B
• 10 C
• 2 G
• 3 D/B
• 2 K/C
• 1 D
• 1 CRF01-AE

79
VARHS Summary

• Provides insight into transmission patterns of
  resistant virus
• Distribution of HIV subtypes
• Related risk factors
• Geographic region influences
• Prevalence of drug resistance in communities
• Increases understanding of HIV mutations
  associated with resistance
• Some clients may benefit from this testing for
  their HIV treatment

80
HIV Incidence and Drug Resistance Surveillance

• Douglas Schuster

81
STDs in Texas, 2007

• Ed Weckerly, Epidemiologist
• HIV/STD Epidemiology and Surveillance
• Texas Department of State Health Services
• ed.weckerly_at_dshs.state.tx.us
• 512-533-3050

82
Chlamydia
83
Chlamydia Cases by Year of ReportTexas, 1988-2007
84
Chlamydia Cases by Year of ReportTexas, 1993-2007
85
Chlamydia Case Rates by Year of Report and Race
- Texas, 1993-2007
African American
Hispanic
White
Rate Cases per 100,000 population.
86
Chlamydia Case Rates by County -Texas, 2007
87
Chlamydia
Wild Fact!
88
Syphilis
89
Primary and Secondary Syphilis Cases by Year of
Report - Texas, 1971-2007
90
Primary and Secondary Syphilis Cases by Year of
Report - Texas, 1998-2007
91
PS Syphilis Case Rates by Year of Report and
Sex - Texas, 1998-2007
Male
Female
Rate Cases per 100,000 population.
92
MSM PS Syphilis by Year of Report - Texas,
2000-2007
93
PS Syphilis Case Rates by Year of Report and
Race/Ethnicity - Texas, 1998-2007
African American
Hispanic
White
Rate Cases per 100,000 population.
94
PS Syphilis Case Rates by County -Texas, 2007
95
Syphilis
Wild Fact!
96
Gonorrhea
97
Gonorrhea Cases by Year of ReportTexas, 1971-2007
98
Gonorrhea Case Rates by Year of Report and
Race/Ethnicity - Texas, 1993-2007
African American
White
Hispanic
Rate Cases per 100,000 population.
99
Gonorrhea Cases by Age Group and Race/Ethnicity -
Texas, 2007
100
Gonorrhea Case Rates by County -Texas, 2007
101
Gonorrhea
Wild Fact!
102
HIV/STD Reports

• DSHS Website (http//www.dshs.state.tx.us/hivstd
  - Reports)
• Texas HIV/STD Surveillance Reports
• HIV/STD Program Annual Reports
• DSHS Epi Annual Report (http//www.dshs.state.tx.u
  s/idcu/data/Annual/2000s/2006/)
• CDC Surveillance Reports (http//www.cdc.gov/datas
  tatistics/)