2011 National HIV Prevention Conference. Plenaries. Wednesday.

1. Uses of Strategic Information to
Assess Health Equity
Tiffany LaDanaWest, MPH, MSPH
Bureau Chief, Strategic Information Bureau
District of Columbia, Department of Health

2. Health Inequities in US
 Gender, Race and Socioeconomic Factors that drive health inequities
in US
 Heavily Influence by Environment
 Disease Syndemics
 Access to Prevention, Care and Treatment Services
 Influence Individual Behavior
 Risk Behaviors in social and sexual networks
 Health Seeking Behavior
 Utilization of Prevention, Care and Treatment Services
 Triangulate Syndemic, Behavioral, Service to assess Health Inequities
to target policies and programs populations at greatest need
 Greater Focus on Health Outcomes where inequities exist

3. Cumulative and Annual Diagnosed Number of
AIDS Cases, By Race/Ethnicity and Year, United
States, 1989-2008
Cumulative_v_Dx_with_trails_wmv.wmv

4. Cumulative and Annual Diagnosed Number of
AIDS Cases, By Transmission Category and Year,
United States, 1989-2008
MOT_no_total_wmv.wmv

5. Annually Diagnosed AIDS Cases, by Sex and
Year, United States, 1989-2008

6. Percent Below the Federal Poverty Line, By
Race/Ethnicity and Year, United States, 1989-
2008

7. HIV Infection Among Heterosexuals in Urban
Areas, by Socio-Economic Indicators, 2006-2007,
N=14,837
 National HIV Behavioral Surveillance (NHBS)
 Heterosexuals at High Risk for HIV
 Areas of High Rates of HIV/AIDS and Poverty
 Approximately 2.0% HIV Prevalence
 2.1% Women and 1.9% Men
 4.2% 40-50 year olds, 2.2% 30-39 year olds, 0.6%, 18-29 year
olds
 3.1% Northeast, 2.7% South, Midwest, South, Territories
<1%
*CDC. Characteristics Associated with HIV Infection Among Heterosexuals in Urban Areas with High AIDS Prevalence --- 24 Cities,
United States, 2006--2007. MMWR 2011;60:1045-1049.

8. HIV Infection Among Heterosexuals in Urban Areas,
by Socio-Economic Indicators, 2006-2007,
N=14,837-Structural/Environmental
3.5%
3.0%
2.5%
HIV Prevalence
2.0%
1.5%
1.0%
0.5%
0.0%
*CDC. Characteristics Associated with HIV Infection Among Heterosexuals in Urban Areas with High AIDS Prevalence --- 24 Cities,
United States, 2006--2007. MMWR 2011;60:1045-1049.

9. HIV Infection Among Heterosexuals in Urban
Areas, by HIV Risk Factor, 2006-2007,
N=14,837-Behavioral
5.0%
4.5%
4.0%
3.5%
3.0%
HIV Prevalence
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Used crack cocaine Did not Exchanged sex for Did not Received an STD Had not
money or drugs diagnosis
*CDC. Characteristics Associated with HIV Infection Among Heterosexuals in Urban Areas with High AIDS Prevalence --- 24 Cities,
United States, 2006--2007. MMWR 2011;60:1045-1049.

10. Estimated Number of New HIV Infections among
Men who have Sex with Men, By Age
Estimated Number of New HIV Infections among Men who have Sex with Men (MSM), 2009,
By Race/Ethnicity and Age
* Estimates of New HIV Infections in the United States, 2006–2009, The Center for Disease Control and Prevention Fact Sheet, August 2011

11. Estimated Number of New HIV Infections among
Men who have Sex with Men, By Race
Estimated Number of New HIV Infections among Men who have Sex with Men (MSM), Ages 13-29,
2006-2009, By Race/Ethnicity and Age
* Estimates of New HIV Infections in the United States, 2006–2009, The Center for Disease Control and Prevention Fact Sheet, August 2011

12. Washington DC

13. Overview: HIV/AIDS in District of Columbia
Prevalence of HIV/AIDS in the
District of Columbia, 2009
• 16,721 reported living with HIV/AIDS in the
District at the end of 2009
• 5,505 new HIV cases reported between 2005 and
2009
• 3.2% of the District’s population diagnosed with
HIV/AIDS
• one-third to one-half of people (locally) may be
unaware of their HIV status. (Source: DC NHBS
data)
DC Resident Living with HIV/AIDS as of 2009, by Gender and
Race/Ethnicity
Black Hispanic White Other Total
Male 8,325 756 2,620 350 12,051
Female 4,256 156 141 117 4,670
Total 12,581 912 2,761 467 16,721
14
DC% 75.2% 5.5% 16.5% 2.8% 100.0%
US% (2008) 49.3% 20.0% 27.8% 2.9% 100.0%

14. HIV Prevalence among High Risk
Population, District of Columbia
HIV Prevalence by Sex HIV Prevalence among Study Populations
8.0% and Race/Ethnicity
25.0%
25.0%
7.1%
7.0%
6.0% 20.0%
5.0% 4.7%
15.0%
4.0% 13.0%
3.4%
2.9% 2.8%
3.0% 10.0%
2.1% 7.7%
2.0% 1.8% 6.3%
5.0%
3.9%
1.0%
0.0%
Black All Blacks Hispanic White Black All All Whites 0.0%
Males Males Males Females Hispanics Black MSM White MSM IDU Male Female
Heterosexuals Hterosexuals

15. Syndemics and Service Delivery
 High rates of STDs among  Approximately 91% Health
youth Care Coverage
 High rates of Syphilis,  Generous prevention, care
chronic Hepatitis B and and treatment programs
HIV among MSM and High  No ADAP Waiting List
rates of co-infection  Extensive ADAP formulary
 High rates of chronic
 Generous coverage on local
Hepatitis C among IDU public health insurance
and Heterosexuals programs
 Sub-optimal health
 Poor Healthcare Utlization
outcomes

16. Mean Community Viral Load among Whites
and Blacks Living with HIV/AIDS in DC, 2008
50,000
Mean Community Viral Load (copies/mL)
45,000
40,000 39,173
35,000
30,000
25,000
20,000
18,283
15,000
10,000
5,000
0
White Black
N=762 N=3,395

17. Linkage to Care among Newly Diagnosed
Cases in DC, by Race/Ethnicity, 2005-2009
80.0%
70.0%
Proportion entering care
60.0%
50.0%
40.0% White
Black
30.0%
20.0%
10.0%
0.0%
< 3 months 3-6 months 6-12 months > 1 year
*Entry into care was determine by the date of the first CD4 count or percentage test or viral load
test reported to the DCDOH.

18. Retention in Care and Not in Care among Newly
Diagnosed Cases in DC, by Race/Ethnicity 2005-
2009
18%
16%
14%
12%
10%
Retained in care
8%
No care
6%
4%
2%
0%
White Black
Not in care: absence of any HIV-related laboratory tests indicative of receipt of HIV primary care within the study period
•Continuously in care (retained in care): presence of at least 2 HIV-related laboratory tests within 12 months of the initial linkage laboratory test date,
each 10 to 14 weeks apart (modified HRSA definition)

19. National HIV Behavioral Surveillance Project
(NHBS) Men who have Sex with Men, 2008
Unprotected Receptive Anal Intercourse, Unprotected Insertive Anal Intercourse,
By Race, N=422 By Race, N=422
60.0% 60.0%
56.7%
51.0%
50.0% 50.0%
40.0% 40.0%
30.0% 30.0% 29.0%
25.3%
20.0% 20.0%
10.0% 10.0%
0.0% 0.0%
White MSM Black MSM White MSM Black MSM

20. National HIV Behavioral Surveillance Project
(NHBS) Men who Have Sex with Men, 2008
HIV Prevalence among Study Participants,
30.0% by Race, N=422
26.0%
25.0%
20.0%
15.0%
10.0%
7.9%
5.0%
0.0%
White MSM Black MSM

21. Mean Community Viral Load among White
and Black MSM with HIV/AIDS in DC, 2008
45,000
Mean Community Viral Load (copies/mL)
40,000
35,000
31,404
30,000
25,000
20,000 19,732
15,000
10,000
5,000
0
White MSM Black MSM
N=645 N=901

22. Linkage to Care among Newly Diagnosed
White and Black MSM in DC, 2005-2009
80.0%
70.0%
60.0%
50.0%
40.0% White MSM
30.0% Black MSM
20.0%
10.0%
0.0%
< 3 months 3-6 months 6-12 months > 1 year
Pearson’s Chi-square p value, p=0.0006
Linkage to care was determine by the date of the first CD4 count or percentage test or viral load
test reported to the DCDOH.

23. Retention in HIV Care among Newly Diagnosed
White and Black MSM in DC, 2005-2009
90.0%
80.0%
Proportion of MSM Cases
70.0%
60.0%
50.0%
White MSM
40.0%
Black MSM
30.0%
20.0%
10.0%
0.0%
Retained in Care Sporadic Care No Care
Pearson’s Chi-square p-value, p=0.0020
Continuous care is defined as having evidence (e.g. HIV-related lab test) of at least 2 visits to an HIV medical
provider 10-14 weeks apart. Sporadic care is defined as having only one visit to a provider or 2 visits but more
than 14 weeks apart.

24. Social Determinants of Health

25. Social Determinants of Health (2)

26. Social Determinants of Health (3)

27. Targeted Messaging

28. Targeted Services
Finding Action
General Populations • High burden of disease (HIV, STD, Hep • Opt out routine screening in
C) emergency departments
• Routine GC/CT screening in women
and girls of childbearing age
• Health Behavior and Risk Reduction
• Municipal Condom Distribution:
online, venues, schools
• Increased HIV/STD partner services
MSM • Co morbidities: HIV/Syphilis • Engage w/providers who serve MSM
• High Rates HIV • Encourage routine HIV and syphilis
• High rates of high risk behaviors screening
• Bi-Annual HIV and STD testing
• Messages developed to reduce stigma
• Increase HIV/STD partner services
• Hepatitis A/B Screening/Vaccination
Heterosexuals • High rates HIV, STDs • (General Population Strategies)
• High rates of high risk behaviors • Social Marketing/harm Reduction
• Low risk perception • Integrated Partner Services (PCRS)
29

29. Condom Distribution Locations

30. Geographic Distribution of Substance Abuse Needle Exchange
Programs Overlay - Heroin Arrests in the District of Columbia, 2008
Heroin Arrests
Substance Abuse
Needle Exchange
Programs

31. Involvement in the HIV response
Medical
Fed Gov: $$$, Establishment:
TA, Guidelines Media: info, services, pops
 Dir ads
Families, Social Networks, DC GOVT
Individuals:change Leadership, Academia: TA,
Coordination, Research, Services
NGOs, CBOs: $$$
program, pops
DC Planning
FBOs: Councils:
leaders, Priorities, $
stigma, direction/advice
•Priorities support,
•Experiences & Approaches services
•Reality & Implementation
•Best Practices Private/Business
•Gaps in Service, Effect and insurance, social resp
Intention prevention
•Cost-efficiency, Resources
EVENTUAL IMPACT Preview

32. Conclusions:
 Health Inequalities are associated with both environmental and
social and sexual networks
 Role of Public Health System is to ensure targeted, evidence
scalable strategies that influence positive health outcomes
 Targeted, Integrated Messages and Service Delivery
 Monitoring Evaluation of Health Outcomes to influence Change

33. Special Thank You
 ONAP-LA
 Mario Perez
 George Washington University School of Public Health
 Alan Greenberg, Amanda Castel, Manya Magnus, Irene Kuo
 Emory University CFAR
 Patrick Sullivan, Jeb Jones
 HAHSTA-DC
 Angelique Griffin, Jen Opoku, Sarah Willis, Rowena Samala
 CDC
 Irene Hall, Amy Lansky
 Dad, Mom, Tony-For Believing in Me