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 The Georgia Epidemiology Report Via E-Mail To better serve our readers, we would like to know if you would prefer to receive the GER by e-mail as a readable PDF file. If yes, please send your name and e-mail address to Gaepinfo@dhr.state.ga.us. | Please visit, http://health.state.ga.us/epi/manuals/ger.asp for all current and past pdf issues of the GER. 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 -2 - 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. -3 - 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 - 4 -