HOUSTON EMA HIV CARE CONTINUUM


What is the Care Continuum?

The HIV Care Continuum, previously known as a Treatment Cascade, was first released in 2012 by the Centers for Disease Control and Prevention (CDC). It represents the sequential stages of HIV care, from being diagnosed with HIV to suppressing the HIV virus through treatment. Ideally, the Care Continuum describes a seamless system of HIV prevention and care services, in which people living with HIV (PLWH) receive the full benefit of HIV treatment by being diagnosed, linked to care, retained in care, and taking HIV medications as prescribed to achieve viral suppression.

The Houston Care Continuum (HCC)

The HCC is a diagnosis-based continuum. The HCC reflects the number of PLWH who have been diagnosed ("HIV diagnosed"); and among the diagnosed, the numbers and proportions of PLWH with records of engagement in HIV care ("Met Need"), retention in care ("Retained in Care"), and viral suppression ("Virally Suppressed") within a calendar year. Although retention in care is a significant factor for PLWH to achieve viral suppression, ‘Virally Suppressed’ also includes those PLWH in the Houston EMA whose most recent viral load test of the calendar year was <200 copies/mL but who did not have evidence of retention in care.

Linking newly diagnosed individuals into HIV medical care as quickly as possible following initial diagnosis is an essential step to improved health outcomes. In the HCC, initial linkage to HIV medical care ("Linkage to Care") is presented separately as the proportion of newly diagnosed PLWH in the Houston EMA who were successfully linked to medical care within one month, three months or within one year after diagnosis.

 

Figure 1: Houston EMA HIV Care Continuum, 2016-2018**

Source: Bureau of Epidemiology and Bureau of HIV/STD and Viral Hepatitis Prevention, Houston Health Department, 2020

 

Measure

Description

Data source

HIV diagnosed

No. of persons living with HIV (PLWH) residing in Houston EMA through end of year (alive)

Texas eHARS data

Met need

No. (%) of PLWH in Houston EMA with met need (at least one: medical visit, ART prescription, or CD4/VL test) in year

Texas DSHS HIV Unmet Need Project (incl. eHARS, ELR, ARIES, ADAP, Medicaid, private payer data)

Linked to care (pie chart)

No. (%) of newly diagnosed PLWH in Houston EMA who were linked to medical care ("Met need") within N months of their HIV diagnosis

Retained in care

No. (%) of PLWH in Houston EMA with at least 2 medical visits, ART prescriptions, or CD4/VL tests in year, at least 3 months apart

Virally suppressed

No. (%) of PLWH in Houston EMA whose last viral load test of the year was ≤200 copies/mL

Texas ELRs, ARIES labs, ADAP labs

 

From 2016-2018, the total number of persons diagnosed with HIV increased each year and the percentage of those with met need, retention, and viral suppression remained relatively constant. 

·       The percentage of newly diagnosed PLWH linked to care within one month of diagnosis decreased from 65% to 60% from 2016 to 2018.

 

Disparities in Engagement among Key Populations

Multiple versions of the HCC have been created to illustrate engagement disparities and service gaps that key populations encounter in the Houston EMA.

It is important to note that available data used to construct each version of the Houston HCC do not portray the need for activities to increase testing, linkage, retention, ART access, and viral suppression among many other at-risk key populations, such as those who are intersex, experiencing homelessness, or those recently released from incarceration.

 

The Houston EMA Care Continuum, by Age

 

Figure 2: Houston EMA HIV Care Continuum by Age Group, 2018**

Source: Bureau of Epidemiology and Bureau of HIV/STD and Viral Hepatitis Prevention, Houston Health Department, 2020

 

Figure 3: Houston EMA HIV Care Continuum by Age Group, 2018**

Source: Bureau of Epidemiology and Bureau of HIV/STD and Viral Hepatitis Prevention, Houston Health Department, 2020

 

·       Younger adults had lower percentages of retention and viral suppression compared to older adults.

·       Middle age adults (25-44 years old) had the lowest proportion of newly diagnosed PLWH who were linked to care within one month of diagnosis when compared to other age groups.

 

The Houston EMA Care Continuum, by Sex Assigned at Birth/Current Gender

 

Figure 4: Houston EMA HIV Care Continuum by Sex Assigned at Birth, 2018**

Source: Bureau of Epidemiology and Bureau of HIV/STD and Viral Hepatitis Prevention, Houston Health Department, 2020

 

·       Females living with HIV in the Houston EMA in 2018 had a slightly higher proportion of individuals with met need and retention in care than males living with HIV, although females had a slightly smaller proportion of viral suppression.

·       The proportion of newly diagnosed females linked to care within the first month after diagnosis was higher than males (66% vs. 58%).

 

Figure 5: Houston EMA HIV Care Continuum by Current Gender, 2018**

Source: Bureau of Epidemiology and Bureau of HIV/STD and Viral Hepatitis Prevention, Houston Health Department, 2020

 

·       Transgender women living with HIV in the Houston EMA in 2018 had the highest proportion of individuals with met need, retention in care, and viral suppression.

·       Transgender men living with HIV in the Houston EMA in 2018 had the lowest proportion of individuals with met need, retention in care, and viral suppression. Extreme caution should be exercised in interpretation, however, due to the very small numbers of transgender men represented in this data.

·       The proportion of newly diagnosed people linked to care within the first month after diagnosis was lower for transgender women compared to cisgender women. However, there were few transgender individuals represented in the data and percentages can vary widely with small increases/decreases.

 

The Houston EMA Care Continuum, by Sex Assigned at Birth and Race/Ethnicity

 

Figure 6: Houston EMA HIV Care Continuum by Sex Assigned at Birth = Male and Race/Ethnicity, 2018**

Source: Bureau of Epidemiology and Bureau of HIV/STD and Viral Hepatitis Prevention, Houston Health Department, 2020

 

Figure 7: Houston EMA HIV Care Continuum by Sex Assigned at Birth = Female and Race/Ethnicity, 2018**

Source: Bureau of Epidemiology and Bureau of HIV/STD and Viral Hepatitis Prevention, Houston Health Department, 2020

 

·       Compared to White (non-Hispanic) and multiracial males, all other males living with HIV had lower proportions of met need, retention in care, and viral suppression in 2018.

·       Among females, Other (non-Hispanic) PLWH had the lowest proportion of individuals with evidence of met need and retention in care while Black and White (non-Hispanic) PLWH had the lowest proportion of individuals with evidence of viral suppression.

·       Among those newly diagnosed with HIV, Hispanic females and White (non-Hispanic) males had the highest proportion linked to care within 1 month of diagnosis.

·       Overall, Other (non-Hispanic) females living with HIV had the lowest proportion of individuals with met need across all birth sex and race/ethnicity groups. However, this group had few individuals and percentages can vary widely with small increases/decreases. White (non-Hispanic) females and Black (non-Hispanic) males living with HIV had the next lowest proportion of individuals with met need.

·       Overall, Other (non-Hispanic) females living with HIV had the lowest proportion of individuals retained in care across all birth sex and race/ethnicity groups. However, this group had few individuals and percentages can vary widely with small increases/decreases. Black (non-Hispanic) males living with HIV had the next lowest proportion of individuals retained in care.

·       Overall, Black (non-Hispanic) males living with HIV had the lowest proportion of individuals virally suppressed across all birth sex and race/ethnicity groups. White (non-Hispanic) males living with HIV had the highest proportion of individuals virally suppressed.

 

The Houston EMA Care Continuum, by Transmission Risk Factor*

*Transmission risk factors that are associated with increased risk of HIV exposure and transmission include men who have sex with men (MSM), people who inject drugs (PWID), MSM who also inject drugs (MSM/PWID), and heterosexual exposure.

 

Figure 8: Houston EMA HIV Care Continuum by Transmission Risk, 2018**

Source: Bureau of Epidemiology and Bureau of HIV/STD and Viral Hepatitis Prevention, Houston Health Department, 2020

 

·       Although MSM have a higher number of PLWH than the other risk groups, the proportion of diagnosed MSM living with HIV with evidence of met need and retention in care is similar to those observed for other risk groups.

·       MSM have a higher proportion of diagnosed PLWH who are virally suppressed but a lower proportion of newly diagnosed PLWH who were successfully linked to care within one month of initial diagnosis. Those with a transmission risk factor of heterosexual contact had the highest proportion of people linked to care within one month of initial diagnosis.

·       Overall, PWID as a primary transmission risk factor exhibited the lowest proportions of individuals with met need and viral suppression.

 

** 2018 data should be used with caution -- it may be underrepresented due to unforeseen data importing issues at Texas DSHS. Updates to 2018 data will occur in the future.

 

Questions about the Houston EMA HIV Care Continuum can be directed to: Amber Harbolt, Health Planner in the Office of Support.