Georgia epidemiology report, Vol. 23, no. 6 (June 2007)

June 2007

volume 23 number 06

HIV/AIDS Surveillance

Introduction HIV, or human immunodeficiency virus, is a disease that can be spread through sexual intercourse with an infected partner, sharing needles with an HIV infected person, pregnancy (HIV positive mother to fetus), and transfusion of blood from an HIV positive individual. The HIV virus gradually destroys the immune system, rendering infections difficult to fight. The advanced stage of the disease is referred to as AIDS, or acquired immunodeficiency syndrome.
The Georgia Division of Public Health's HIV/AIDS Epidemiology Section is authorized by law to conduct surveillance for HIV and AIDS along with multiple related illnesses. Data are collected via mandatory laboratory and physician reporting of any test results that indicate HIV infection, such as confirmed positive HIV antibody tests, in addition to all CD4 counts and viral load tests (including undetectable) (O.C.G.A. 24-9-47, 31-22-9.2, Rules and Regulations of the State of Georgia Chapter 290-5-48.11). All of the information collected is completely confidential and secured. HIV Epidemiology staff adheres to strict federal guidelines that prohibit the intentional disclosure of HIV/AIDS data and minimize the possibility of accidental disclosure of confidential data. Currently, Georgia participates in four main HIV/AIDS surveillance activities: core and incidence surveillance, enhanced perinatal HIV surveillance, HIV behavioral surveillance, and the Georgia Medical Monitoring Project. These activities are funded by the Centers for Disease Control and Prevention (CDC) and together comprise Georgia's comprehensive HIV/AIDS surveillance system.
Core and Incidence Surveillance Core and incidence surveillance activities provide the primary source of population-based data on persons infected with HIV or diagnosed with AIDS in Georgia and other states. Core surveillance is performed in all U.S. states and territories. Incidence surveillance activities, aimed at collecting data from newly diagnosed cases, are limited to 34 states, territories, and local areas. Using the information provided by lab and provider reports, core and incidence surveillance allows us to describe the characteristics of persons diagnosed with HIV, determine the percentage of new HIV diagnoses that are recent infections, measure the scope of the HIV epidemic, and evaluate the risk behaviors that lead to HIV infection. The most recent epidemiologic data on reported HIV/AIDS cases in Georgia can be found at http://health.state.ga.us/epi/hivaids/.
Enhanced Perinatal HIV Surveillance Enhanced Perinatal HIV Surveillance in Georgia began in 2006. This activity aims to track the progress in the reduction of mother-tochild (perinatal) HIV transmission. This is achieved through medical record reviews and follow-up of mother/infant pairs to ascertain

maternal HIV infection status prior to birth, new HIV cases, new AIDS cases, AIDS-related deaths, and the use of antiretrovirals and their ability to prevent the transmission of HIV. Additionally, staff members assess potential adverse outcomes related to antiretroviral exposure in both infected and uninfected children over time (short and long term).
HIV Behavioral Surveillance Because the Atlanta Metropolitan Statistical Area (MSA) was one of the 26 MSAs with the greatest number of persons living with HIV/AIDS at the end of 2000, the Georgia Division of Public Health was chosen to participate in the National HIV Behavioral Surveillance System (NHBS). HIV Behavioral Surveillance involves conducting rotating one year cycles of surveillance in three populations who are at high risk for HIV infection, specifically men who have sex with men (MSM), injection drug users (IDUs), and high-risk heterosexuals. This project examines behaviors that put people at risk for HIV infection. The goals are to develop an ongoing surveillance system to establish the prevalence of HIV risk behaviors among high risk groups to use in the development of national and local prevention programs and services; to involve community-based organizations (CBOs) in surveillance and questionnaire design; to work with HIV/AIDS prevention programs to determine exposure to and use of local HIV prevention programs; and to present data on high-risk populations for use in state and local prevention and treatment services planning and evaluation. Select findings from the MSM NHBS cycle are below. A complete report is forthcoming and will be available on our website at http://health.state.ga.us/epi/hivaids/.
2003-2004 MSM Behavioral Surveillance Cycle From December 2003 to October 2004 we interviewed 724 participants who met the eligibility criteria for the MSM cycle of NHBS. Eligible participants were male, HIV negative, 18 years or older, a resident of the Atlanta MSA, and reported having had sex with another male in the year prior to the interview. Most self-identified as homosexual or gay (84%). The largest numbers of participants were between the ages of 25 and 44 (66%). The majority of those interviewed were non-Hispanic Whites (55%). Most participants had some post secondary education (81%). Many were privately insured (73%), although a little over 1/5 had no insurance (21%). Participants were recruited using a venue-based sampling methodology, with the largest group recruited at bars (36%), followed by dance clubs (23%).
Sexual Behaviors Participants were asked whether they had engaged in anal sex with a male in the 12 months prior to the interview. Those who answered yes were asked if their anal sex partners were main partners or

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Percentage of participants

casual partners, as well as if they had engaged in unprotected sex with any of their male anal sex partners. The majority of respondents (86%) reported engaging in anal sex with a male during the year prior to the interview. This behavior was reported more frequently with a main partner (60%) than with a casual partner (52%); these individuals also reported a higher rate of unprotected anal sex (56%) with a main partner than those reporting anal sex with a casual partner (33%).

Figure 1. Percentage of participants who reported having had anal sex with a main or casual partner during the preceding 12 months by race/ethnicity

80% 70%

Main Partner

Casual Partner

60% 50% 40% 30% 20% 10%

40% 18%

23% 42%

38% 28%

25% 25%

20% 31%

16% 38%

8% 45%

15% 40%

0% WWhithe,itneo,n-

BlaBckl,ancokn,- HisHpainsipc a(nn=i5c3) OtheOr/tuhneknro/wn WWhithe,itneo,n-

BlaBclka, ncokn,- HisHpainsicp(ann=5ic3) OtheOr/uthnkenro/wn

nHoisnp-aHnicis(pn=a3n95ic) Hnisopnan-iHc (ins=p2a21n)ic (n=53)

un(kn=n5o5)wn nHoisnp-aHnicis(pn=a3n95ic) Hniospna-nHici(snp=2a2n1)ic (n=53)

un(nk=n5o5)wn

(n=395)

(n=221)

(n=55) (n=395) (n=221)

(n=55)

Protected anal sex

Unprotected anal sex

HIV Risk Behaviors Almost half of respondents (45%) reported engaging in unprotected anal intercourse with a male during the year prior to interview and 17% reported receptive unprotected anal intercourse (37% of all those who reported unprotected anal intercourse). Seven percent reported exchanging sex with a male for drugs, food, or money in the past year (having an exchange partner). Smaller numbers had injected drugs or shared drug injection equipment. Almost a third (31%) had used drugs during sex in the past year.

Figure 2. Number and percentage of participants who reported high HIV risk behaviors during the preceding 12 months-NHBS, Georgia: MSM Cycle (December 2003-October 2004)

350

45%

300

Number of participants

250

31%

200

150

17%

100
50 2%
0 Injected Drugs

<1%
Shared Injection
Drugs

7%

Had an exchange
partner

Had unprotected
anal intercourse

Had receptive unprotected
anal intercourse

Used drugs during sex

HIV Prevention Programs Seventy percent of those interviewed reported participating in some type of HIV prevention service or program during the preceding 12 months (n=509). The majority of those interviewed reported receiving free condoms (68%). Eleven percent of respondents reported participating in individual-level intervention programs and eight percent participated in group-level intervention programs. HIV/AIDS CBOs were the most commonly cited providers of

free condoms and individual-level interventions (32% and 50% respectively). Gay, Lesbian, Bisexual or Transgender Community Health Centers/Organizations were the most commonly reported provider of group-level interventions (38%), followed closely by HIV/AIDS CBOs (36%).

Percentage of participants

Figure 3. Percentage of participants who reported using HIV prevention

programs during the preceding 12 months by race/ethnicity NHBS,

Georgia: MSM Cycle (December 2003-October 2004)
90% 81%

80%

72%

76%

70%

60%

59%

50%

40%

30%

20% 10%

8% 7%

15% 10%

11% 8%

16% 9%

0%

White, non-Hispanic Black, non-Hispanic

(n=395)

(n=221)

Hispanic (n=53)

Other/unknown (n=55)

Free Condoms

Individual-level Intervention

Group-level Intervention

Georgia Medical Monitoring Project (GA MMP) The Georgia Medical Monitoring Project (GA MMP) is the Georgia component of a new supplemental HIV surveillance study that is taking place in 26 states and cities across the U.S. GA MMP uses in-person interviews and medical record abstractions to combine behavioral and clinical information on HIV positive individuals, with the goal of describing clinical outcomes, behaviors, and quality of HIV care. Because of its unique sampling methodology, GA MMP will generate state-level information that is not limited to particular areas of the state or groups of individuals. The resulting data can be used to understand a variety of issues, such as drug adherence, substance abuse, and access to care. Potential stakeholders include local planning councils, care providers, researchers, and organizations serving people living with HIV/ AIDS. Data collection for GA MMP is expected to begin during summer 2007.

Mobility and Access to Care Pilot In preparation for GA MMP, the HIV Epidemiology Section piloted a series of questions that will be appended to the GA MMP interview instrument upon implementation in Georgia. The questions originated from discussions with GA MMP's Community/Provider Advisory Board (CAB) members, who wanted to supplement areas of the national MMP instrument to include questions that focused on positive and empowering factors in patient care. Pilot questions address issues such as HIV/AIDS care accessibility, mobility, and prior risk behaviors. The pilot survey was administered to a convenience sample of patients over 18 years of age currently in care for HIV/AIDS. A total of 155 interviews were conducted with patients at 6 sites. Interviews took place throughout Georgia in addition to the metro-Atlanta area and included rural, urban, and suburban areas. Participants were recruited from publicly-funded clinics that specialize in HIV

Division of Public Health http://health.state.ga.us
Stuart T. Brown, M.D. Director
State Health Officer

Epidemiology Branch http://health.state.ga.us/epi
Susan Lance, D.V.M., Ph.D. Director
State Epidemiologist

Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. Editor Kathryn E. Arnold, M.D.
Cherie Drenzek, D.V.M., M.S. Susan Lance, D.V.M., Ph.D.
Stuart T. Brown, M.D. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer
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Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588
Fax: (404) 657-7517

Georgia Department of Human Resources
Division of Public Health

Please send comments to: gaepinfo@dhr.state.ga.us

medical care in addition to providing ancillary services, such as risk reduction education and case management. As this pilot used convenience sampling, the resulting data may not be representative of all HIV positive individuals receiving care in Georgia.

Figure 5. Migration after HIV diagnosis, GA Mobility and Access to Care Pilot, Dec. 2006 - Jan. 2007
60%
50%

Percentage of participants

Demographics Over half of participants (59%) were recruited from facilities

40% 30%

42%

located outside of the Atlanta MSA. The majority of participants were male (54%), 45% were female and 1% identified as transgender. Most individuals (69%) identified as heterosexual or "straight." The majority of participants were Black or African American (65%), 8% were Hispanic or Latino, 22% White or Caucasian and 5% identified as another race. At the time of interview, 10% of participants were between the ages of 18 and 29,

20% 10%
0%

8% 11%

15%

10%

14%

1%

Living in same GA county where diagnosed

Migrated to another GA county after diagnosis

Migrated to GA from another state after
diagnosis

Migrated to GA from another country after
diagnosis

Atlanta MSA residents Non Atlanta MSA residents

27% were 30-39, 35% were 40-49, 23% were 50-59 and 5% were 60 or older. A little over a quarter of participants (26%) had less than a high school education. Almost all participants (92%) reported income levels below 300% of the Federal Poverty Threshold ($29,919 for 2005, the year for which income was asked).

medical clinics in the year prior to being diagnosed with HIV. As many of those interviewed may have been HIV-positive for some time before becoming aware of their status, determining the types of health care facilities visited preceding their initial diagnosis of HIV allows for the ascertainment of missed opportunities for

testing and identification of areas to increase testing efforts. This

Selected Findings

is of great importance, since early diagnosis has been found to

Approximately 1/5 of participants (n=33) reported being homeless decrease risk behavior and improve health outcomes.

at some time during the year preceding the interview, meaning they were living on the street, in a car, in a shelter, a Single Room

Figure 6. Type of health care facilities visited in the year preceding HIV diagnosis, GA Mobility and Access to Care Pilot, Dec. 2006 - Jan. 2007

Occupancy hotel, or temporarily staying with friends and family. Prior studies have found that homelessness among people living with HIV/AIDS has a negative impact on health outcomes, access

Community hCeoalmthmcuennitteyr/hheeaaltlthhcdeenptte./rg/heenaelrthaldmeepdt.i/cgaelncelirnaicl medical clinic (public so(uprucbel)ic source) Hospital
PrivatePprhivyastieciapnh/yHsMicOia/np/rHimMaOry/pcraimrearcylinciacre(pcrilvinaitce(sporiuvractee) source) STD Clinic 1%

19%

30% 31%

to care and use of antiretroviral medications (Bamberger 2000;

InIfnefectciotiouussDdisiseeaasseeCClilninicic 0

Kushel 2001; McLaughlin 1999).

At a mobile test site (health department van, needle exchange, etc) 0 CCoorrrerecctitoionnaal lfafacciliiltiyty((jajaili/lp/prrisisoonn)) 2%

Emergency room

4%

Most participants (n=127) did not move in the year preceding the interview, although rates of inter-county migration were higher among participants who also reported being homeless during this time. Of those who did change their county of residence, very few reported an HIV-related reason for the move. Regardless of

PPrerennaatatal/lo/obbsstetetrtricicsscclilninicic 1% Family planning clinic 0 DDruruggtrtreeaatmtmeennttcclilninicic 0 Miltary facility 1%
Ininssuuraranncceecclilninicic/e/emmpploloyyeeeecclilninicic 1% Student health clinic 1%
DDididnnoot trerecceeiviveehheeaaltlhthccaarree

22%

whether the move was due to their HIV-status, housing instability may still affect the health of these individuals due to its disrupting

0

10

20

30

40

50

60

Number of participants

effect on utilization of care and adherence to antiretroviral therapies.

The activities described above constitute the central elements of Georgia's HIV/AIDS surveillance system. The information

Figure 4. Moving history in the preceding year, GA Mobility and Access to Care Pilot, Dec. 2006 - Jan. 2007

generated by these projects is used by health care providers, policy makers and other stakeholders to guide HIV/AIDS prevention

140

82%

and care activities throughout the state. More information about

120

the HIV/AIDS Epidemiology Section and our surveillance

activities, as well as links to the latest data and reports, can be

100

found at our website at http://health.state.ga.us/epi/hivaids/

80

60

40

15% 20
3%

0
Moved for non HIV related Moved for HIV related reason reason

Didn't move

Migration patterns post-HIV diagnosis can affect the spread of the

disease across communities, as well as impact the need for health

care resources in different geographic areas. More than half of

participants (n=88) reported currently living in the county in which

they were diagnosed; this was more common among those living

outside of the Atlanta MSA.

Participants most often reported visiting public and private general

References Bamberger, Joshua D., Jay Unick, Pamela Klein, Marcy Fraser, Margaret
Chesney, and Mitchell H. Katz. Helping the Urban Poor Stay With Antiretroviral HIV Drug Therapy. American Journal of Public Health. May 2000. 90(5): 699-701. Kushel, Margot B., Eric Vittinghoff, Jennifer S. Haas. Factors Associated With the Health Care Utilization of Homeless Persons. JAMA. 2001. 285: 200-206. McLaughlin, Thomas J., Stephen B. Soumerai, David Weinrib, Oneksy Aupont, Deborah Cotton. The association between primary source of ambulatory care and access to and outcomes of treatment among AIDS patients. International Journal for Quality in Health Care. 1999. 11(4):293300.
This article was written by Linda Beer, Ph.D., Kelly Jackson, M.P.H., Catherine Carroll, M.A., Richard Dunville, M.P.H., Tamika Hoyte, M.P.H., and R Luke Shouse M.D., M.P.H.

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Number of participants

The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186

PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

June 2007

Volume 23 Number 06

Reported Cases of Selected Notifiable Diseases in Georgia, Profile* for March 2007

Selected Notifiable Diseases
Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for March 2007
2007 41 625 12 0 49 279 13 5 11 1 0 1 0 0 0 84 54 0 4 2 20 0 34

Previous 3 Months Total

Ending in March

2005

2006 2007

100

133

115

8361

10534

7786

25

43

39

6

7

5

164

117

128

3781

5015

3029

43

40

35

24

8

16

70

35

33

4

1

6

1

1

0

7

5

6

1

0

0

11

7

3

0

0

0

192

207

296

104

186

223

34

27

4

123

108

20

95

94

18

246

268

106

0

3

0

113

109

96

Previous 12 Months Total

Ending in March

2005 2006

2007

574

624

562

34214

35449

37240

166

173

271

27

32

41

907

710

652

16082

16941

18406

124

110

117

241

109

63

402

166

203

43

36

43

8

6

7

17

16

20

3

1

4

36

44

27

0

0

0

1932

1950

1925

616

757

1414

116

130

98

486

524

380

347

410

288

932

995

815

5

5

6

528

498

491

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.
** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.
AIDS Profile Update

Report Period
Latest 12 Months**: 5/06-4/07 Five Years Ago:*** 5/02-4/03 Cumulative: 07/81-4/07

Disease Classification
HIV, non-AIDS

Total Cases Reported*

<13yrs >=13yrs Total

23

3,019

3,042

AIDS

10

HIV, non-AIDS -

1,908 -

1,918 -

AIDS

2

HIV, non-AIDS 252

AIDS

275

1,495 10,487 36,469

1,497 10,739 36,744

Percent Risk Group Distribution (%)

Female MSM

IDU

MSM&IDU HS

30

32

7

2

14

Unknown 44

Perinatal 0.7

Race Distribution (%)

White Black Hispanic

20

75

5

Other <1

28

33

8

2

-

-

-

-

12

45

0.5

22

71

6

1

-

-

-

-

-

-

-

26

36

9

3

33

30

8

3

20

44

15

5

17

35

-

19

75

5

1

12

47

2

22

74

3

1

14

21

0.7

31

66

3

<1

Yrs - Age at diagnosis in years

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section ** Due to a change in the surveillance system, case counts may be artificially low during this time period

***HIV, non-AIDS was not collected until 12/31/2003

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