an epidemiological profile of hiv/aids in the atlanta ema...

1

An Epidemiological

Profile of

HIV/AIDS

in the Atlanta EMA

2007 - 2011

Authors

Department of Family and Preventive MedicineSoutheast AIDS Training and Education Center (SEATEC)

Emory University School of MedicineBruce M. Whyte, MD

Michael DeMayo, MPHAlecia McFarlane, MPHBrittany Copeland, BSShaily Krishnan, MPH

HIV/AIDS Surveillance OfficeGeorgia Department of Public Health

Rod Lambert, MPHDeepali Rane, MS, BS, MPH

Denise Hughes, BAEugene Pennisi, MPH

Jane Kelly, MD

Additional support

HIV/AIDS Epidemiological UnitGeorgia Department of Public Health

Greg Bautista

This Profile was produced for the Fulton County Ryan White Part A Programunder grant number H89HA00007 from the

HIV/AIDS Bureau of the Health Resources and Services Administration

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Profile of the General Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 The EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Gender, Race/Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Ages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Uninsured Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Persons Diagnosed with HIV in the EMA, 2007 – 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 HIV/AIDS in the EMA, Surveillance Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 HIV/AIDS in the EMA, Georgia and the U.S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Year Diagnosed and Stage of Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Race/ Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Ages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Transmission Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 MSM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 IDU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Heterosexuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 NIR/NRR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 CD4 Counts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Persons Living with HIV in the EMA, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Race/Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Ages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Transmission Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 MSM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 IDU, Heterosexuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 NIR/NRR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Ryan White Clients in the EMA, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Ryan White Funded Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Clients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Income and Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Gender, Race/Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Ages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Transmission Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Co-morbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 HIV Continuum of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Behavioral Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Table of Contents

Table 1. County Populations by Gender, 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Table 2. Population of the EMA by Gender, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Table 3. Total Population by Race/Ethnicity Percentage, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Table 4. HIV/AIDS in the US, Georgia and the EMA, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Table 5. Race/Ethnicity of People with HIV, 2007 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . 21Table 6. Median ages People with HIV and General Population, EMA, 2007 – 2011 . . . . . . . . . 23Table 7. Race/Ethnicity by Age Groups, Gender, 2007 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . 24Table 8. Other Transmission Categories, 1981 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Table 9. HIV by Transmission Category, Year of Diagnosis, 2007 – 2011 . . . . . . . . . . . . . . . . . . . 26Table 10. HIV in MSM, 2007 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Table 11. Age at Diagnosis, MSM, 2007 - 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Table 12. MSM by Race/Ethnicity, 2007 - 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Table 13. HIV among IDU, 2007 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Table 14. Heterosexual HIV Infection, 2007 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Table 15. Pediatric Cases by Race/Ethnicity and Year, 2007 – 2011, EMA . . . . . . . . . . . . . . . . . 31Table 16. No Identified or No Reported Risk, 2007 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . 32Table 17. CD4 Counts at Diagnosis by Risk, Year, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Table 18. Top Ten Rankings of HIV/AIDS as Cause of Death, EMA . . . . . . . . . . . . . . . . . . . . . . . . 34Table 19. Numbers of PLWA and PLWH non-AIDS, 2007 – 2011, EMA . . . . . . . . . . . . . . . . . . . . 36Table 20. Gender of PLWA and PLWH non-AIDS, 2007 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . 38Table 21. Race/Ethnicity of PLWA and PLWH non-AIDS, 2007 – 2011, EMA . . . . . . . . . . . . . . . . 39Table 22. Median Ages of PLWA and PLWH non-AIDS, 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . 40Table 23. Transmission Categories of all PLWH, 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Table 24. Transmission Categories, Race/Ethnicity, Gender, PLWH and PLWH non-AIDS, 2011 42Table 25. Transmission Categories All PLWH, Year of Diagnosis, 2007 - 2011, EMA . . . . . . . . . . 43Table 26. All PLWH, IDU and HET, 2007 - 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Table 27. Persons Living with HIV Disease, NIR and NRR, 2007 - 2011, EMA . . . . . . . . . . . . . . . 45Table 28. Ryan White Clients and the General Population Basic Demographics . . . . . . . . . . . . 48Table 29. Ryan White Clients by Gender, Race/Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Table 30. Age Distribution, PLWH, Ryan White Clients, 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . 51Table 31. Transmission Categories of Ryan White Clients, 2011, EMA . . . . . . . . . . . . . . . . . . . . 52Table 32. Transmission Categories, Race/Ethnicity, Gender, Ryan White Clients, 2011, EMA . . 53Table 33. HIV, Newly Diagnosed Cases of STIs in Ryan White Clients, 2011 . . . . . . . . . . . . . . . . 54Table 34. Unprotected Sex among MMP Participants, Georgia, 2009, 2010 . . . . . . . . . . . . . . . 62Table 35. Viral Suppression among MMP Participants, Unprotected Sex, 2009, 2010 . . . . . . . 63Table 36. Recreational Drug Use among MMP Participants, Georgia, 2009, 2010 . . . . . . . . . . . 63Table 37. Alcohol Use among MMP Participants, Georgia 2009, 2010 . . . . . . . . . . . . . . . . . . . . 64Table 38. HIV and HCV Prevalence among IDU’s by Race/Ethnicity . . . . . . . . . . . . . . . . . . . . . . . 65

Tables

Figure 1. The Atlanta EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Figure 2. Age Distribution, General Population, EMA, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Figure 3. Median Household Income and 300% FPL for 2 Persons, EMA, 2011 . . . . . . . . . . . . . 14Figure 4. Uninsured Rate with EMA Median, EMA, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Figure 5. AIDS, HIV non-AIDS, 1981 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Figure 6. AIDS and HIV non-AIDS, 2007 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Figure 7. HIV by Gender, 1981 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Figure 8. HIV by Gender, 2007 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Figure 9. HIV by Race/Ethnicity, 1981 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Figure 10. Ages People with HIV, General Population, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Figure 11. Heterosexual Cases, 2007 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Figure 12. Pediatric Cases, 1982 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Figure 13. CD4 Counts by Race/Ethnicity, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Figure 14. CD4 Counts by Transmission, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Figure 15. HIV/AIDS Mortality Rates, US, GA, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Figure 16. PLWH 2007 – 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Figure 17. PLWH by Zip Code, 2011, EMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Figure 18. Ryan White Clients, 2007 - 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Figure 19. Ryan White Clients and the General Population, 2011, EMA . . . . . . . . . . . . . . . . . . . 48Figure 20. Median Income and Lack of Health Insurance, Ryan White Clients 2011 . . . . . . . . . 49Figure 21. Ryan White Clients by Gender, 2007, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Figure 22. Ages of Persons with HIV, PLWH, Ryan White Clients, 2011, EMA . . . . . . . . . . . . . . . 51Figure 23. PLWH in Counties of the EMA, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Figure 24. Syphilis in Counties of the EMA, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Figure 25. Gonorrhea in Counties of the EMA, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Figure 26. Chlamydia in Counties of the EMA, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Figure 27. Cascade, All EMA and Ryan White Clients, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Figure 28. Cascade Ryan White Clients by Gender, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Figure 29. Cascade by Race/Ethnicity, EMA, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Figure 30. Cascade by Race/Ethnicity, Ryan White Clients, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . 60Figure 31. Cascade Ryan White Clients by Age, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Figure 32. Cascade, MSM, EMA and Ryan White Clients, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . 61Figure 33. Cascade, HET, EMA and RW Clients, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Figure 34. Condom Use among MSM, Georgia, 2009, 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Appendix A. Population of the EMA by Race/Ethnicity, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . 67Appendix B. Median Ages in Years by County, EMA, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Appendix C. Proportions of Age by County in the EMA, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Appendix D. Household Income by County, General and RW Populations, 2011 . . . . . . . . . . . . 70Abbreviations Used in this Profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Figures

7 Executive Summary

This report is the first comprehensive epidemiological profile of the HIV/AIDS epidemic in the Atlanta Eligible Metropolitan Area (EMA). Although HIV Surveillance Reports have consistently been produced by the Georgia Department of Public Health (GDPH) HIV/AIDS Epidemiology Program (HAEP) for the state of Georgia, no integrated epidemiological profile focused on the 20 county Atlanta EMA, the epicenter of the HIV epidemic in the southern United States, has been developed. As part of increased efforts to better monitor and track the epidemic, the GDPH HAEP has worked diligently to improve the reporting system in the state, and thereby the accuracy and utility of surveillance data.

Data used in this report were provided by the Centers for Disease Control and Prevention (CDC) and the GDPH HAEP. The profile includes surveillance data through December 31, 2011 by diagnostic category for persons living with HIV not AIDS (PLWH non-AIDS) and AIDS (PLWA), newly diagnosed cases, and cumulative cases. A period of five years (2007-2011) is used to depict trends across different sub-populations affected by the HIV/AIDS epidemic. Additional data from the Fulton County Ryan White Part A Program’s CAREWare database are presented on clients receiving services through agencies funded through the federal Ryan White HIV/AIDS Program. Finally, data from the HIV Care Continuum Surveillance Report Adults and Adolescents, Georgia 2011 published by the GDPH, HAEP are used to describe linkage to and retention in care and viral suppression among targeted sub-populations in the EMA.

Report Highlights: Approximately 69% of cumulative HIV/AIDS cases in the state of Georgia through the end of 2011 were from the 20 county Atlanta EMA. The epidemic continues to have a disproportionate impact among Blacks (60%) and males (82%). Over the five year period 2007 – 2011, Blacks comprised an average of 62% of cases, compared to just 13% for Whites, 5% among Hispanics and 2.5% among multiracial groups. This burden can be seen in almost all aspects of the disease, from clinical markers such as CD4 and viral load, to lower rates of viral suppression when considering the HIV Continuum of Care.

People living with all stages of HIV disease (PLWH) in the Atlanta EMA are being diagnosed at an earlier age than has previously been observed. Particularly among males, the age of first diagnosis has decreased over the 2007-2011 period from 36 years to 33 years. Black males having sex with males (MSM) have seen a dramatic increase in HIV cases from 53% in 2007 to 66% in 2011, further evidence of the continued burden of the disease among the Black community in the Atlanta EMA. Blacks also have much lower rates of engagement and retention in care, as seen in the section on the HIV Continuum of Care. However, viral suppression overall for PLWH in the EMA that are engaged in care is quite high (63%) compared to all PLWH in the EMA (31%), which is strong evidence of the effectiveness of the Ryan White funded service delivery system.

We hope this report will serve to enhance planning efforts for both Ryan White funded agencies, the Metropolitan Atlanta HIV Health Services Planning Council, and prevention partners throughout the Atlanta metropolitan region. We will continue to work with the GDPH HAEP to study trends in the disease and to update this report biannually to ensure the most accurate and timely data are available.

8

A Profile

of the

General Population

of the Atlanta EMA

2007 - 2011

9 The EMA

The Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB), a branch of the US Department of Health and Human Services (DHHS), is responsible for providing funding to care for persons infected with HIV who could not otherwise afford care. Funds are awarded under the Ryan White HIV/AIDS Treatment Extension Act and are made to Eligible Metropolitan Areas (EMA). An EMA is defined by HRSA and requires a total population of at least 50,000 using current Census data and at least 2,000 reported and confirmed cases of AIDS in the most recent 5 years. Atlanta was among the first EMAs to receive funding under Part A of the Ryan White Program in 1991 together with 15 other EMAs. In 2011 there were 24 EMAs and 32 Transitional Grant Areas (TGAs) receiving funding.

The Atlanta EMA consists of 20 counties centered on Atlanta and located in north Georgia (Table 1, Figure 1). Those counties are listed below. The EMA covers approximately 6,209 square miles and includes the lower foothills of the Appalachian Mountains and the escarpment below those mountains. The Atlanta EMA is similar to the US Atlanta Metropolitan Statistical Area which consists of 22 counties.

The total population of the EMA in 2007 was 4,893,068. By 2011 this had increased to 5,201,413. In 2011, 986,057 were less than 13 years of age. Five counties demonstrated an increase in total population of 10% or more, Coweta, Forsyth, Fulton, Henry and Paulding. Detailed tables can be found in the Appendices.

Table 1. County Populations by Gender, 2011, EMACounties Males Females County % of EMABarrow 34,522 35,390 1.3%Bartow 49,603 50,818 1.9%Carroll 54,229 56,930 2.1%Cherokee 107,917 110,369 4.2%Clayton 125,506 136,026 5.0%Cobb 339,335 358,218 13.5%Coweta 63,502 66,127 2.5%DeKalb 336,338 363,555 13.4%Douglas 64,230 69,125 2.6%Fayette 52,084 55,700 2.1%Forsyth 90,374 91,466 3.5%Fulton 464,205 485,394 18.3%Gwinnett 406,953 417,988 15.9%Henry 99,446 107,914 4.0%Newton 48,034 52,780 1.9%Paulding 70,303 73,239 2.8%Pickens 14,421 14,994 0.6%Rockdale 40,800 44,965 1.6%Spalding 31,027 33,006 1.2%Walton 41,242 43,338 1.6%Total 2,534,071 2,667,342 100%

10 The EMA

Figure 1: The Atlanta EMA

11 The General Population of the EMA, Gender, Race/Ethnicity

Gender In The EMA

The total population of the EMA in 2011 was 5,201,413 including 986,057 who were aged less than 13 years (Table 1). Males accounted for 49% and females 51% of the population. Variation among the counties in the proportions of males and females were minimal and no more than 2%. Detailed numbers for each county can be found in Appendix A.

Table 2. Population of the EMA by Gender, 2011Adults, adolescents and children

Males FemalesNumber % Number %

EMA 2,534,071 49 2,667,342 51

Race/Ethnicity In The EMA

A description of the racial and ethnic breakdown of the population of the EMA uses the definitions from the Office of Budget and Management that are consistent with data published by the Centers for Disease Control and Prevention (CDC) and the HIV/AIDS Epidemiology Program (HAEP) of the Georgia Department of Public Health (GDPH).

Definition of Race/Ethnicity

All individuals are asked to self describe their origin or race using the following definitions:

American Indian, Alaskan Native (Race)Origin in peoples of North, Central and South America and who maintain tribal affiliation or community attachment

Asian (Race)Origins in peoples of the Far East, Southeast Asia and the Indian subcontinent

Black/African American (Race)Origins in any black racial groups of Africa

Throughout this Profile the racial group Black will be used alone

Native Hawaiian, Other Pacific Islander (Race)Origins in peoples of Hawaii, Guam, Samoa or other Pacific Islands

White (Race)Origins in peoples of Europe, the Middle East or North Africa

Hispanic (Ethnicity) Those who regard their heritage to be of Hispanic or Latino origin

(as defined by the Office of Budget and Management, 1997)

12 The General Population of the EMA, Race/Ethnicity

Overall, the population of the EMA is 50% White, 32% Black, 11% Hispanic, 5% Asian, 2% Multiracial and less than 1% American Indian, Alaskan Native, Native Hawaiian or Pacific Islander (Table 3) . There is marked variation among counties in the EMA (Appendix A):

• Whites accounted for 94% of the population in Pickens County and 15% in Clayton County;

• Blacks accounted for 64% in Clayton County and 1% in Pickens County;

• Hispanics accounted for 21% in Gwinnett County and 3% in Pickens County

• Asians accounted for 11% in Gwinnett County and less than 1% in Pickens County;

• Multiracial/Other was the designation in 2% of the population in about half of the counties.

In the 5 year period covered in this Profile, the proportion of Blacks increased by 6% in Rockdale County and 3% in Forsyth County. In 5 counties there was no change. There was a decrease in the proportion of Whites by 7% in Clayton County and 4% in Douglas and Gwinnett Counties. In only two counties did the proportion not change.

The changing Asian population, although actual numbers were relatively small, was most marked as a proportional change. The largest change was a 58% increase in Forsyth County, followed by Pickens County (33%), Coweta County (30%) and Paulding County (27%). There were minimal changes in all other racial groups.

Those of Hispanic origin have increased throughout Georgia and the EMA as they have throughout the USA. In 2007 there were 474,076 Hispanics living in the EMA that accounted for 10% of the total population. This increased to 565,625 in 2011 that accounted for 11% of the total population. The increase in number represented a 19% increase. Variation between counties was large:

• Gwinnett County had the highest proportion of Hispanics in 2011 at 21%;

• Clayton County had 14%;

• Cobb County had 13%;

• Cherokee, DeKalb, Forsyth and Rockdale Counties, all had 10%;

• Spalding and Walton Counties had 4%; and

• Pickens County had the lowest proportion of Hispanics with 3%;

Detailed numbers for each county can be found in Appendix A.

Table 3. Total Population by Race/Ethnicity Percentage, EMA

White Black Asian Other Race Hispanic2007 52% 32% 5% 2% 10%2011 50% 32% 5% 2% 11%Percentages across years do not add to 100% as Hispanic includes those who self assign as White

and Hispanic, Black and Hispanic, etc. Hispanic and Race are not mutually exclusive.

13 The General Population of the EMA, Ages

Data on age of the total population of the EMA are based on ages in 2011. The median age of all residents in the EMA in 2011 was 35.7 years (Appendix B). Those residing in Fayette County had the oldest median age at 43.1 years and those in Clayton County the youngest at 31.7 years.

Males tended to be younger than females (34.5 years compared to 36.8 years). The youngest males were found in Clayton County at 30.0 years and the oldest in Pickens County at 42.1 years. The youngest females were in Clayton County at 33.2 years and the oldest in Fayette County at 44.1 years.

Whites were generally older than Blacks (38.9 years compared to 31.9 years). The county with the oldest Whites was Rockdale County (45.8 years) and oldest Blacks was Fayette County (38.5 years). The county with the youngest Whites was Paulding County (35.1 years) and for Blacks was Carroll County (27.4 years).

The age group with the least variation among counties was the 40-49 year group in which there was only 3% difference between the counties, followed by the 13-19 group with 4% difference, 50-59 group with 5%, less than 13 group with 6% and 20-29 with 8%. The greatest variation in age group among the counties was the 60 and over group with a 14% spread (Appendix C).

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Barrow Bartow Carroll

Cherokee Clayton

Cobb Coweta DeKalb

Douglas FayeAe Forsyth Fulton

GwinneA Henry

Newton Paulding Pickens

Rockdale Spalding Walton

Figure 2. Age DistribuOon, General PopulaOon, EMA, 2011

0-‐19 yrs

20's

30's

40's

50+

14 The General Population of the EMA, Income

The median household income (total income of all household members, Appendix D) in the general population of the EMA in 2011 was $53,237. There was great variation between counties:

• Lowest household incomes were $41,163 in Spalding County and $42,936 in Clayton County;

• Highest household incomes were $88,262 in both Forsyth and Fulton Counties and $81,498 in Fayette County. The next highest was $65,423 in Cobb County;

• Lowest per capita incomes were $18,835 in Clayton County and $19,547 in Spalding County;

• Highest per capita incomes were $35,405 in Fayette County and $35,277 in Forsyth and Fulton Counties. The next highest was $33,514 in Cobb County with a notable drop to Cherokee County with $29,968.

The Federal Poverty Level (FPL) in 2011 for a household of one person was $10,890 and for 2 persons was $14,710. At 300% of FPL these convert to $32,670 ($10,890 x 3) for one person and $44,130 ($14,710 x 3) for two persons.

In the general population, median incomes in Spalding and Clayton Counties were less than 300% of FPL for a household of 2 persons. In all other counties the median income was greater than 300% of FPL.

$-‐

$10,000.00

$20,000.00

$30,000.00

$40,000.00

$50,000.00

$60,000.00

$70,000.00

$80,000.00

$90,000.00

Barrow Bartow Carroll

Cherokee Clayton Cobb

Coweta DeKalb Douglas FayeDe Forsyth Fulton

GwinneD Henry

Newton Paulding Pickens

Rockdale Spalding Walton

Figure 3. Median Household Income and 300% FPL for 2 Persons, EMA, 2011

Median HH Income FPL 2 persons

15 The General Population of the EMA, Uninsured Rates

The median proportion of the general population in the EMA without health insurance of any type in 2011 was 21%. There was a wide range in uninsured rates from 10% to 23% (see Figure 4):

• The highest rate of uninsured was 23% in Barrow, Clayton, DeKalb, Fulton and Gwinnett Counties;

• The lowest uninsured rate was 10% in Fayette County followed by 13% in Forsyth County, 16% in Henry and Paulding Counties and 17% in Coweta and Cherokee Counties.

• Three counties with the highest uninsured rates of 23% also had the highest number of reported cases of HIV: Fulton County (20,694 cases), DeKalb County (10,365 cases), and Gwinnett County (2,061);

• Clayton County also had an uninsured rate of 23% and had the 5th highest number of cases;

• Cobb County had a rate of 20% and the 4th highest number of cases of HIV, 2,820 cases.

In Figure 4 below:

• the solid black line is the EMA wide median uninsured rate of 20%;

• the grey bars are the uninsured rate in each county in the EMA;

• the darker orange bars represent the number of reported cases of HIV through December 2011 and use the axis on the right. The number of cases from Fulton, DeKalb and Gwinnett Counties have been reduced to only one tenth of their true number in order to display the relative differ-ences in the numbers of cases in each county and to highlight the concentration of cases in those 3 counties (lighter orange bars). Unadjusted numbers of cases for each county can be found in Appendix D.

23%

21% 21%

17%

23%

20%

17%

23%

20%

10%

13%

23% 23%

16%

21%

16%

20% 21%

22%

20%

0

500

1,000

1,500

2,000

2,500

3,000

0%

5%

10%

15%

20%

25%

Barrow

Bartow

Carroll

Cherokee

Clayton Cobb

Coweta

DeKalb

Douglas

Faye>e

Forsyth

Fulton

Gwinne>

Henry

Newton

Paulding

Pickens

Rockdale

Spalding

Walton

Figure 4. Uninsured Rate, EMA Median, HIV Cases, 2011

16

Persons Diagnosed

with HIV

in the Atlanta EMA

2007 - 2011

17 HIV/AIDS in the EMA, Surveillance Methods

Reporting of cases of AIDS has been a legal requirement in Georgia since 1982. Since January 1, 2004, Georgia has had a dual reporting system that legally requires name-based reporting by both health care providers and laboratories of both AIDS and HIV infection that had not progressed to AIDS (O.C.G.A. §31-12-2(b)). All health care providers diagnosing and/or providing care to a patient with HIV have the obligation to report the case to the Georgia Department of Public Health (GDPH) using the HIV/AIDS Case Report Form. Case report forms are mandated to be completed within seven (7) days of diagnosing a patient with HIV and/or AIDS or within seven (7) days of assuming care of an HIV positive patient who is new to the provider, regardless of whether the patient has previously received care elsewhere. These data are captured in the enhanced HIV/AIDS Reporting System (eHARS) maintained by the GDPH HAEP.

All laboratories certified and licensed by the State of Georgia are required to report laboratory test results indicative of HIV infection to the HAEP, such as positive Western Blot results, all detectable and undetectable viral loads, all CD4 counts, and all viral nucleotide sequence results.

Recent improvements in the Georgia Electronic Laboratory Reporting (ELR) system have facilitated use of laboratory-based measures for linkage and retention in care. Although other measures such as missed appointments, health care visit consistency, and gaps in care may be assessed at individual health care facilities, it is difficult to accurately gather these measures on a statewide or EMA basis in Georgia.For these reasons, HIV Continuum of Care measures later in this report rely on laboratory data-driven definitions. In addition, multiple measures, such as linked to care at different time points (e.g., within 3 and 12 months of diagnosis), minimally engaged in care (at least one CD4 or viral load in 12 months) as well as the HRSA medical visit performance measure number 5 (at least two CD4 or viral load measures at least three months apart within a 12 month period) could be useful to various stakeholders in monitoring impact of effort to improve outreach, testing, and care.

Efforts are underway to further promote HIV testing in Georgia, identify those with acute infection, link and retain persons living with HIV in medical care, achieve higher rates of viral suppression overall, and eliminate disparities in HIV testing, treatment and care. Late diagnosis of HIV infection contributes to poorer outcomes for infected individuals and impedes HIV prevention efforts. Earlier diagnosis provides opportunity for interventions for viral suppression for the benefit of the individual and for reduced HIV transmission for the benefit of the community.

18 HIV/AIDS in the EMA, Georgia and the U.S.

Since the first cases of AIDS in 1981 and through 2011 there have been 1,172,321 cases reported in the U.S. and its Territories and Puerto Rico. In the same time period there were 41,217 reported cases in Georgia of which 29,576 or 69% were reported from the EMA (Table 4).

The Southeastern U.S. accounts for 447,686 reported cases of AIDS through 2011 or 38% of all cases, compared to the Northeastern U.S. (29%), Western U.S. (20%) and the Midwestern U.S. (10%).

Reporting of cases of AIDS was legally required beginning in 1982. Voluntary reporting of HIV non-AIDS was replaced in 2004 with name-based mandatory reporting. Therefore, HIV surveillance reports prior to 2004 were almost solely those of AIDS cases.

There are several caveats to interpreting these data:• There are increasingly large numbers (and percentages) of cases in which the probable

transmission category has not been identified (No Identified Risk (NIR) or No Reported Risk (NRR));

• The number and percentages of cases attributed to heterosexual transmission must be viewed cautiously as many are partnered with IDU, MSM or with a partner with known HIV infection.

Table 4. HIV/AIDS in the US, Georgia and the EMA, 2011Cumulative AIDS Cases, 2011 Newly Diagnosed HIV/AIDS Cases, 2011

Atlanta EMA#

(29,576)Georgia#

(41,217)US*

(1,172,321)Atlanta EMA

(2,0071)Georgia(3,023)

US*(49,273)

N % % % N % % %

GenderMale 24,200 82 78 80 1,614 80 77 79

Female 5,376 18 21 20 380 19 23 21

Race/EthnicityBlack 17,748 60 66 42 1,120 56 56 46

White 8,389 28 27 38 173 9 10 28

Hispanic 1,155 4 4 17 106 5 5 22

Other 2,284 8 3 541 27 29 4

Missing 67 3

Transmission CategoryMSM 13,875 47 42 48 547 27 26 62

IDU 3,438 12 12 16 19 <1 1 8

MSM/IDU 1,484 5 5 7 9 <1 <1 3

Heterosexual 2,479 8 12 19 29 1 3 27

Perinatal 165 <1 1 10 <1 <1

Other/NIR/NRR 8,135 28 29 10 1,393 69 70 <11 Total EMA number includes 13 with missing gender, 67 missing race/ethnicity

* Centers for Disease Control and Prevention. HIV Surveillance Report, 2011;Vol 23

19 HIV/AIDS in the EMA, Georgia and the U.S., Year Diagnosed

The first case of AIDS in the Atlanta EMA was diagnosed in 1981. In 2007 there were 2,282 newly diagnosed cases of HIV infection in the EMA. These included 1,046 cases of AIDS and 1,235 cases of HIV non-AIDS. In 2011 there were 2,005 newly diagnosed cases of HIV infection of which 617 were AIDS and 1,388 cases of HIV non-AIDS (Figure 6).

The dramatic increase in HIV non-AIDS cases in 2004 compared to the prior years was a result of the newly introduced requirements for reporting these cases (Figure 5).

New cases of HIV infection that first presented as AIDS accounted for 1,046 cases (46%) in 2007 and 617 in 2011 (31%)(Figure 6) suggesting earlier detection and reporting of HIV infection.

Noticeable is the changing method of diagnosing and reporting cases of HIV infection. There is an increasing trend towards diagnosis of new AIDS cases using laboratory results and not clinical manifestations. In 2007, 82% of new AIDS cases were diagnosed initially on laboratory findings. This increased to 85% in 2011 reflecting a greater awareness of the disease and earlier identification. Also noticeable is fewer people are diagnosed as AIDS at their initial diagnosis:

• 352 of 2,281 cases in 2007 were AIDS (15%) and 220 of 2,006 cases in 2011 were AIDS (11%).

46% 1,046

46% 974

43% 831

38% 690

31% 617

54% 1,235

54% 1,163

57% 1,108

62% 1,147

69% 1,388

-‐

500

1,000

1,500

2,000

2,500

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

2007 2008 2009 2010 2011

Figure 6. AIDS & HIV non-‐AIDS, 2007 -‐ 2011, EMA HIV non-‐AIDS% AIDS% All cases

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

1981

1984

1987

1990

1993

1996

1999

2002

2005

2008

2011

Figure 5. AIDS, HIV non-‐AIDS,1981 -‐ 2011, EMA

AIDS HIV non-‐AIDS

20 HIV/AIDS in the EMA, Gender

The first cases of HIV infection were identified in males in 1981. Since then males have been affected in far greater numbers and proportions than females. In the EMA between 1981 and 2011 a total of 33,009 males and 8,064 females have been dignosed with HIV.

Between the start of 2007 and the end of 2011 there have been 7,936 males and 2,116 females diagnosed with HIV. Over the five years, the proportion represented by females has declined from 21% to 19%. Although small in number, there were 96 persons cumulatively reported who identified as being transgender. Forty-two (42) of these were Female-to-Male and the remaining 54 Male-to-Female. It is likely there are more transgender persons currently in the EMA than have been reported since there are 119 in care at Ryan White facilities compared to 96 reported (see section on Ryan White clients). It may be that clients are more comfortable with their care providers than surveillance staff and, therefore, more likely to disclose their gender status to their providers.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011

Figure 7. HIV by Gender, 1981-‐2011, EMA

Male Female

21% 488

22% 466

21% 400

21% 382

19% 380

76% 1,742

77% 1,640

77% 1,491

79% 1,449

80% 1,614

23

14

19

23 21

0

5

10

15

20

25

0%

20%

40%

60%

80%

100%

2007 2008 2009 2010 2011

Figure 8. HIV by Gender, 2007 -‐ 2011, EMA Males Females Transgender

21 HIV/AIDS in the EMA, Race/Ethnicity

Table 5. Race/Ethnicity of People with HIV, 2007-2011, EMADiagnosis Year 2007 2008 2009 2010 2011

N % N % N % N % N %Blacks 1,402 61 1,401 66 1,238 64 1,130 62 1,120 58Whites 364 16 311 15 246 13 215 12 173 9Hispanic 137 6 106 5 116 6 98 5 106 5Other 15 <1 3 <1 7 <1 13 <1 18 <1Multiracial 59 3 57 3 37 2 33 2 30 2Missing 305 13 249 12 296 15 322 18 493 25Totals 2,282 2,132 1,940 1,811 1,940

Blacks have been disproportionately impacted by HIV disease in the EMA. Since 1981 in the EMA:

• Blacks account for 25,966 cases or 63% of all cases; among the general popula-tion Blacks account for 32% (Table 3).

The other two major populations represented in the EMA have consistently been lower than their overall population size.

• Whites account for 10,554 cases or 26% of cases com-pared to 50% in the general population;

• Hispanics account for 1,715 cases or 4% compared to 11% of the general population.

The same trend is found in cases of HIV diagnosed in each year since 2007. Specifically:

• Blacks comprise an average of 62% of cases in 2007 - 2011; Whites comprise an average of 13%;

• Hispanics comprise an average of 5% and Multiracial persons comprise an average of 2.5%.

The number in which race or ethnicity is not known or not reported has increased as a proportion from 13% in 2007 to 25% in 2011. Based on completeness of surveillance activities in previous years, it is likely that the majority of these cases are Black. Diagnoses of HIV infection among other racial/ethnic groups in the EMA have consistently been small. A subtotal of 152 have been American Indian, Alaskan Native, Native Hawaiian, Pacific Islander or Asian since the first reported cases in 1981. There have been 56 reported cases among these minority groups in the period 2007 - 2011. Because of such small numbers, further analyses have not been performed.

0%

10%

20%

30%

40%

50%

60%

70%

80%

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

Figure 9. HIV by Race/Ethnicity, 1981 -‐ 2011, EMA

Hispanic Black White

22 HIV/AIDS in the EMA, Ages

19%

10%

6%

6%

7%

7%

8%

8%

7%

6%

5%

4%

6%

3%

10%

16%

19%

18%

14%

9%

5%

3%

20% 15% 10% 5% 0% 5% 10% 15% 20%

0-‐12 13-‐19 20-‐24 25-‐29 30-‐34 35-‐39 40-‐44 45-‐49 50-‐54 55-‐59 60-‐64 65-‐69 70+

Figure 10. Ages People with HIV, General PopulaEon, EMA 2011

General PWH

The general population includes a large number of people aged less than 13 years (19%). The remainder of the population is somewhat evenly distributed across age groups greater than 12 years. The median age of the general population in 2011 was 35.7 years.

However, among people with HIV disease:

• Less than 1% were aged less than 13 years;

• 26% were aged between 20 and 29 years compared to 12% of the general population;

• 37% were aged between 30 and 39 years compared to 14% of the general population; and

• 23% were aged between 40 and 49 years compared to 16% of the general population.

People diagnosed with HIV infection are markedly younger, median age 34 years, than the general population of the EMA, median age of nearly 36 years. There were 1,730 males in 2007 newly diagnosed with HIV infection in whom the median age was 36 years. In 2011 there were 1,611 newly diagnosed males with a median age that declined to 33 years. Among females there were 486 newly diagnosed cases in 2007 among whom the median age was 37 years. Their median age increased among the 371 newly diagnosed females in 2011 to 39 years, Table 6.

In 2007 the youngest males were Hispanic (23 years) followed by Black males (33) and White males (40). By 2011 the youngest males were Black (29 years) followed by Hispanic males (31) and White males(41).As with males, the youngest females were Hispanic in 2007 (36 years) followed by Black females (37) and White females (40). By 2011 Hispanic females were still the youngest (33 years) followed by Black females (41) and White females (41), see Table 6.


Table 6. Median Ages, People with HIV & General Population, EMA, 2007 - 2011

2007 2008 2009 2010 2011 General*Age Cases Age Cases Age Cases Age Cases Age Cases Age

All cases# 36 2,271 36 2,123 35 1,935 34 1,832 34 2,006 36.3All females 37 486 38 461 37 398 38 378 39 371 37.3All males 36 1,730 36 1,628 34 1,484 32 1,436 33 1,611 35.1Females

Black 37 379 39 355 38 298 38 258 41 236 34

White 40 34 38 42 38 23 39 27 41 21 40.5

Hispanic 36 21 26 11 29 16 40 11 33 21 25.4Males

Black 33 1,006 33 1,032 31 924 29 859 29 872 30

White 40 323 40 262 41 220 39 185 41 150 38.5

Hispanic 23 112 33 93 32 95 31 84 31 82 25.4# includes those with missing gender

* general population of the EMAAge means median age at first diagnosis of HIV

In general, people diagnosed with HIV infection have become younger at first diagnosis over the five year period. The median age was 36 in 2007 and 34 in 2011. Males have tended to be younger over the five year period:

• Males of all races and ethnicities were 36 years of age in 2007, 36 in 2008, 34 in 2009, 32 in 2010 and 33 in 2011. By comparison the median age of all males in the general population was 35.1 in 2011;

• Blacks were 33 years of age in 2007 and 2008, 31 years in 2009, 29 years in 2010 and 29 years in 2011. By comparison the median age of all Black males in the general population was 30 years in 2011; and

• Whites were 40 years of age in 2007 and 2008, 41 years in 2009, 39 years in 2010 and 41 years in 2011. By comparison the median age of all White males in the general population was 38.5 years in 2011.

In contrast, females have become older:

• Females of all races and ethnicities were 37 years of age in 2007, 38 years in 2008, 37 years in 2009, 38 years in 2010 and 39 years in 2011. By comparison the median age of all females in the general population was 37.3 years in 2011;

• Black females were 37 years of age in 2007, 39 years in 2008, 38 years in 2009, 38 years in 2010 and 41 years in 2011. By comparison the median age of all Black females in the general population was 34 years in 2011; and

• White females were 40 years of age in 2007, 38 in 2008 and 2009, 39 in 2010 and 41 in 2011. By comparison the median age of all White females in the general population was 40.5 in 2011.


Table 7. Race/Ethnicity by Age Groups, Gender, 2007-2011, EMA0-12 13-19 20-29 30-39 40-49 50-59 60-69 >69

Black

M 2007 <1% 5% 35% 27% 23% 7% 2% <1%M 2011 <1% 5% 42% 19% 23% 8% 2% <1%F 2007 1% 6% 22% 27% 27% 14% 2% <1%F 2011 2% 4% 19% 22% 27% 22% 5% <1%

White

M 2007 <1% 1% 15% 32% 36% 12% 4% <1%M 2011 <1% 3% 21% 20% 33% 20% 3% 1%F 2007 <1% 6% 23% 14% 40% 14% 3% <1%F 2011 <1% <1% 18% 41% 18% 23% <1% <1%

Hispanic

M 2007 2% <1% 32% 37% 24% 7% <1% <1%M 2011 <1% 5% 35% 39% 16% 2% 2% 1%F 2007 <1% 8% 31% 31% 15% 12% 4% <1%F 2011 5% 5% 27% 32% 27% <1% 5% <1%

There have been some changes in the age distribution of people with HIV disease over the five year period 2007 - 2011. Among males aged 13 to 30 years between 2007 and 2011:

• Black males increased from 40% to 47%; and

• White males increased from 16% to 24%.

Among females aged 13 to 30 years between 2007 and 2011:

• Hispanic females decreased from 39% to 32%;

• Black females decreased from 28% to 23%; and

• White females decreased from 29% to 18%.

In contrast among males aged between 40 and 59 years between 2007 and 2011:

• Hispanic males declined from 31% to 18%;

• Black males remained static at 30%; and

• White males increased from 48% to 53%.

Among females aged 40 to 59 years between 2007 and 2011:

• Hispanic females remained static at 27%;

• Black females increased from 41% to 49%;

• White females declined from 54% to 41%.

25 HIV/AIDS in the EMA, Transmission Categories

The transmission categories (previously referred to as risk groups) used here are virtually unchanged since the beginning of the epidemic. They are :

• Men who have Sex with Men (MSM);

• Injecting Drug Users (IDU);

• Heterosexual (HET);

• Men who have Sex with Men and who are also Injecting Drug Users (MSM+IDU);

• Those in whom the mode of transmission of HIV has not been determined, No Identified Risk (NIR);

• Those in whom no mode of transmission has been reported, No Reported Risk (NRR); and

• Those infected prior to or during birth (PERI).

In this report, there are many transmission categories in which the case numbers are too low for analysis. These include blood recipients, recipients of blood clotting factors and organ recipients. Those categories will not be discussed here other than to show them in a single table below. The only categories discussed in this report are those in the box to the left. Some of those have been collapsed with others.

Cases of perinatal transmission will be discussed separately. These are infants and children who were infected during the mother’s pregnancy and/or during child birth. Some were identified at the time of birth and some not detected for many years, even in some after they turned 13 years.

Since 1981, 156 cases in the EMA had the transmission category identified but which was not listed due to such small numbers. These include recipients of infected blood, blood clotting factors and/or organs. There have been no reported cases among recipients of blood or blood clotting factor in adults or children since 2005.

Table 8. Other Transmission Categories, 1981 - 2011, EMAAdult Child

Clotting factor Blood/organ recipient Child clotting factor Child blood recipient62 89 3 2

26 HIV/AIDS in the EMA, All Transmission Categories

Table 9. HIV by Transmission Category by Year of Diagnosis, 2007 - 20112007 2008 2009 2010 2011N % % N % % N % % N % % N % %

MSM 784 34 86 646 30 87 645 33 88 513 28 88 548 27 89

IDU 26 1 3 27 1 4 17 1 2 16 1 3 19 1 3

MSM + IDU 26 1 3 18 1 2 19 1 3 11 1 2 9 <1 1

HET 61 3 7 45 2 6 41 2 6 33 2 6 29 1 5

PERI >13 1 <1 <1 0 -- -- 0 -- -- 1 <1 <1 1 <1 <1

NIR 1,064 48 1,149 54 859 44 1,032 56 1,294 65

NRR 311 1 245 11 351 18 224 12 92 5

PERI 5 <1 <1 7 <1 <1 5 <1 <1 7 <1 1 6 <1 1

Child, NIR 3 <1 0 <1 2 <1 0 <1 1 <1

Total 2,281 2,137 1,939 1,837 1,999There were no cases of transmission in adults or children via blood transfusions, blood clotting factors, organ transplants, or

other forms of HIV transmission in this period.% proportion of cases including all NIR and NRR

% proportion of cases after removing all NIR and NRR

There is little change in the modes of probable transmission in the five year period. MSM remains the largest single category of transmission reported. This has decreased as an overall proportion of all cases in which transmission category was identified from 34% in 2007 to 27% in 2011. However, based on previous epidemiological investigations, the majority of cases within the NIR/NRR group are likely to be MSM.

HET transmission is the second highest identified mode of transmission although this accounts for only 5 - 7% of all cases in which transmission category was identified. This has not changed appreciably in this five year period.

IDU likewise has changed little accounting for 1% throughout this five year period as does MSM+IDU as a combined mode. If the two categories of IDU and HET are combined, heterosexual transmission is common to both and could then account for 2 - 4% of all cases. Similarly if IDU and MSM/IDU are combined, drug use could account for 2% of all cases.

Transmission to newborns, children and young adolescents, although small has been consistent in the five years. There were 9 cases in 2007 and 8 in 2011 with similar numbers in each year in between.

If those in the NIR, NRR and Child NIR groups are excluded the proportions change markedly;

• MSM account for 86% of cases in 2007 increasing to 89% in 2011;

• HET account for 7% in 2007 decreasing to 5% in 2011; and

• IDU account for 3% throughout the period.

27 HIV/AIDS in the EMA, MSM

There was a total of 18,175 MSM diagnosed with HIV infection through 2011 or 45% of all cases. This percentage increased to 67% when only reports with a transmission category were included. The actual number of cases of HIV infection among MSM has declined in the five year period from a high of 784 in 2007 to 548 in 2011. The proportion represented by MSM of all cases has declined from 34% to 27%. However the proportion of MSM of all cases in which transmission category was reported has increased from 86% in 2007 to 89% in 2011 (Table 9).

Although not great in number, MSM who also use drugs intravenously, MSM+IDU, have a common transmission mode of sex with men, in addition to Injecting Drug Use. If those cases are added to those of solely MSM, the proportion of men in whom one risk factor is sex with other men decreases each year (Table 10). Overall, MSM have shown a trend to be younger in the last five years. The median age of MSM in 2007 was 36 years which declined to 21 years in 2011. The distribution by age based on their age at first diagnosis of any HIV disease has also changed:

• All MSM aged 13 - 19 years accounted for 5% of cases diagnosed in 2007 and 7% in 2011;



• All MSM aged 40 -49 years accounted for 21% of cases diagnosed in 2007 and 15% in 2011; and

• All MSM aged 50 years or more accounted for 6% of cases diagnosed in 2007 and 5% in 2011.

Table 10. Diagnosis of HIV Infection among MSM, 2007 - 2011, EMA2007 2008 2009 2010 2011

N % N % N % N % N %MSM 784 34 646 30 645 33 513 28 548 27

MSM + IDU 26 1 18 1 19 1 11 1 9 <1MSM, MSM+IDU 810 35 664 31 664 34 524 28 557 28

Table 11. Diagnosis of HIV Infection among MSM by Age, 2007 - 2011, EMAAll MSM General Popn

2007 2008 2009 2010 2011 2011N % N % N % N % N % %

<13 0 0 0 0 0 1913-19 42 5 37 6 39 6 34 6 40 7 1020-29 303 37 252 38 295 44 252 48 289 52 1230-39 251 31 176 27 160 24 116 22 116 21 1440-49 167 21 155 23 128 19 94 18 84 15 1550-59 37 5 35 5 40 6 25 5 22 4 1360-69 10 1 7 1 2 <1 3 1 5 1 970+ 0 -- 2 <1 0 -- 0 -- 1 <1 6

28 HIV/AIDS in the EMA, MSM

Table 12. Dioagnosis of HIV Infection among MSM by Race/Ethnicity, 2007 - 2011, EMA

All MSM2007 2008 2009 2010 2011N % % N % % N % % N % % N % %

Black 481 21 53 403 19 54 453 23 62 364 20 63 403 21 66White 198 9 22 167 8 22 117 6 16 92 5 16 85 4 14

Hispanic 63 3 7 40 2 5 49 3 7 37 2 6 34 2 6% proportion of cases including all NIR and NRR

% the proportion of MSM after removing all NIR and NRR

In the five years from 2007 to 2011, Black MSM have remained fairly steady as a proportion of all cases reported at about 21%. However, when looking at only those cases in which transmission category was reported, Black MSM have increased dramatically from 53% in 2007 to 66% in 2011 (Table 12):

• in 2007 Black MSM represented 53% of reported cases;

• in 2008 this proportion increased to 54%;

• in 2009 it increased to 62%;

• in 2010 it increased to 63%; and

• in 2011 it had further increased to 66%.

At the same time the proportion of MSM that were White has declined:

• in 2007 White MSM made up 22%;

• in 2008 this was still 22%;

• in 2009 it had declined to 16% where it remained for 2010; and

• in 2011 it further declined to 14%.

In this same time interval, the proportion of MSM that were Hispanic remained static around 6%.

As seen from Table 9, there were large numbers of people with HIV reported with either no identified tranmssion category or if known it had not been reported. The two most common methods to distribute those have resulted in similar results:

1 . One method used by CDC relies on multiple imputations that uses several variables about a person and determines statistically the most likely transmssion category; and

2. After removing the NIR and NRR cases, the distribution of cases by transmission category is calculated and those proportions are then applied back to the NIR and NRR cases. This is the method used in this profile and is found in Table 12 and other Tables in orange highlights.

29 HIV/AIDS in the EMA, IDU

Table 13. Diagnosis of HIV Infection among IDU, 2007 - 2011, EMA2007 2008 2009 2010 2011

N % % N % % N % % N % % N % %

IDU 26 1 3 27 1 4 17 1 2 16 1 3 19 1 3MSM + IDU 26 1 3 18 1 2 19 1 3 11 1 2 9 <1 1All IDU 52 2 6 45 2 6 36 2 5 27 1 5 28 1 5Males # 14 54 20 74 9 53 10 62 10 53Females # 12 46 7 26 8 47 6 38 9 47

Black # 17 65 16 59 9 53 9 56 13 68

White # 5 19 7 26 5 29 4 25 4 21

Hispanic # 2 8 1 4 2 12 1 6 1 6Median Ages in Years

All IDU 39 30 35 40 34Males 38 30 33 40 33Females 45 25 37 47 46

Blacks 44 28 38 52 45

Whites 39 31 32 38 30% proportion of cases including all NIR and NRR

% proportion of cases after removing all NIR and NRR# number of cases of IDU and the proportion of all IDU cases only

There were 26 cases of HIV diagnosed in 2007 among IDU, 1% of all cases in 2007. This number dropped to 19 in 2011, still 1%. There were an additional 26 MSM+IDU in 2007 and 9 in 2011. If those two categories are combined there were 52 cases of HIV involving IDU in 2007 (2% of cases) and 28 in 2011 (1% of cases). However, the cases in 2007 represented 6% of all cases in which transmission category was reported and 5% of cases in 2011.

Among solely IDU cases:

• Males comprised 14 cases (54% of IDU) in 2007 and 10 (53%) in 2011;

• Females comprised 12 cases in 2007 and 9 in 2011;

• Black IDU accounted for 17 cases (65% of all IDU) in 2007 and 13 cases (68%) in 2011;

• White IDU comprised 5 cases (19% of all IDU) in 2007 and 4 cases (21%) in 2011. Hispanic IDU account for the remainder each year.

The median age of all IDU has dropped from 39 years in 2007 to 34 years in 2011. This is largely seen among male IDU as female IDU have remained a similar age in 2007 and 2011. Blacks have also remained a similar age and Whites have become younger at 30 years in 2011 compared to 39 years in 2007.

Caution should be used in these interpretations as numbers are not large and are potentially subject, therefore, to variations and errors.

30 HIV/AIDS in the EMA, Heterosexuals

Cases diagnosed among those in whom the transmission was likely heterosexual contact with a person known to have HIV or be in a high risk group (MSM or IDU), consistently contributed less than 5% of all cases. In 2007 there were 61 newly diagnosed HET cases, 45 in 2008, 41 in 2009, 33 in 2010 and 29 in 2011. The proportion attributed to heterosexual activities declined from 3% in 2007 to 1% in 2011. When cases of NIR and NRR are removed, the proportion of cases attributed to HET increased to 7% in 2007 and 5% in 2011.

The majority of HET cases in the EMA were female. In 2007 female HET cases made up 66% of all HET cases, 64% in 2008, 61% in 2009, 67% in 2010 and 52% in 2011. The constancy of these proportions except for 2011 has existed since prior to 2007. The proportion in 2011 will likely increase as more cases of NIR/NRR status are resolved.

The majority were also Black. They represented 93% of all HET cases in 2007, 80% in 2008, 78% in 2009, 73% in 2010 and 62% in 2011. Similarly to gender, race and ethnicity of these cases will likely change in 2011 as investigations of more cases are completed.

Although the numbers are small, the median age of those diagnosed in 2007 was 27 years, in 2008 was 39, 2009 was 32, 2010 was 38 and it was 42 years in 2011.

Table 14. Diagnosis of HIV Infection among Heterosexuals, 2007 - 2011, EMA2007 2008 2009 2010 2011N % % N % % N % % N % % N % %

HET 61 3 7 45 2 6 41 2 6 33 2 6 29 1 5Male 21 34 16 36 16 39 11 33 14 48Female 40 66 29 64 25 61 22 67 15 52Black 57 93 36 80 32 78 24 73 18 62White 1 5 2 5 6

Median Ages in Years27 39 32 38 42

% proportion of cases including all NIR and NRR% proportion of cases after removing all NIR and NRR

0%

1%

2%

3%

4%

0

10

20

30

40

50

60

70

2007 2008 2009 2010 2011

Figure 11. Heterosexual Cases, 2007 -‐ 2011, EMA

HET Number HET %

31 HIV/AIDS in the EMA, Pediatrics

Since the start of the epidemic in the Atlanta EMA there have been 312 pediatric cases reported. A pediatric case is defined as a person infected with HIV prior to their 13th birthday. Most are diagnosed prior to age 13 but some are diagnosed after that age. These latter cases are deemed pediatric if a cause for the infection can be identified, such as a transfusion, or they were born to a mother known to be infected with HIV but who had not previously been diagnosed.

In the five years (2007-2011) there have been 44 pediatric cases diagnosed with HIV infection in the EMA, approximately 8 each year. Females slightly outnumber males 23 to 19. The majority were Black (29 cases, 66%) followed by Hispanic (5 cases, 11%) and White (3 cases, 7%)

The vast majority were infected perinatally (during pregnancy, child birth or immediately after birth) that accounted for 30 cases or 68%. The remainder did not have an identified or reported mode of infection or a time of transmission.

0

5

10

15

20

25

30

1982

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

Figure 12. Pediatric Cases 1982 -‐ 2011, EMA

Table 15. Pediatric HIV Infection by Race/Ethnicity and Year, 2007 - 2011, EMA2007 2008 2009* 2010 2011*

Total 9 8 8 8 11

GenderMale 5 4 2 2 6Female 4 4 5 6 4

Race/EthnicityBlack 6 4 6 7 6White 0 2 1 0 0Hispanic 2 1 0 1 1

* includes missing gender or race/ethnicity

32 HIV/AIDS in the EMA, NIR and NRR

Table 16. No Identified or No Reported Risk, 2007 - 2011, EMA2007 2008 2009 2010 2011

N % N % N % N % N %NIR 1,067 48 1,149 54 861 44 1,032 56 1,295 65

NRR 311 1 245 11 351 18 224 12 92 5Total* 1,378 49 1,394 65 1,212 63 1,256 68 1,387 70

Male 894 65 937 67 799 66 899 71 1,031 74Female 433 31 426 31 365 30 351 28 351 25

Black 829 60 931 67 728 60 718 57 668 48

White 141 10 123 9 109 9 109 9 75 5

Hispanic 67 5 62 4 55 5 53 4 67 5* NIR+NRR as a percentage of all cases diagnosed each year

A large number of cases diagnosed and reported each year have incomplete information, especially about the possible mode of transmission of HIV. These numbers are broken down into those in whom no trans-mission mode has been identified despite epidemiological investigation (NIR) and those in whom no mode has been reported (NRR). This latter group may have had a mode determined but it had not yet been up-dated on their record. Surveillance staff maintain ongoing investigations to determine the mode of trans-mission in all these cases.

Analysis of NIR/NRR cases finds:

• 65% were male in 2007 increasing to 74% in 2011;

• 31% were female in 2007 decreasing to 25% in 2011;

• 4% had missing gender data in 2007 decreasing to 1% in 2011;

• 60% were Black in 2007 decreasing to 48% in 2011;

• 10% were White in 2007 decreasing to 5% in 2011;

• Hispanics accounted for 5% for each year; and

• the number (and proportion) of NIR/NRR that had missing data on race and/or ethnicity increased from 294 (21%) in 2007 to 549 (39%) in 2011.

The breakdown of NIR/NRR cases resembles the breakdown of reported HIV cases (Tables 5 and 16);

• Males accounted for 81% of HIV cases and 74% of NIR/NRR in 2011;

• Blacks accounted for 58% of HIV cases and 48% of NIR/NRR in 2011;

• Whites accounted for 9% of HIV cases and 5% of NIR/NRR in 2011; and

• Hispanics accounted for 5% of HIV cases and 5% of NIR/NRR in 2011.

33 HIV/AIDS in the EMA, CD4 counts

One of the data elements collected about persons newly diagnosed with HIV on a case report form is the date of the first ever diagnosis of HIV infection and the CD4 count at that time. Compliance with submission of all data elements varies, but over 70% of people with HIV had an initial CD4 count provided. It is noteworthy that CD4 counts at diagnosis have risen over time in all categories suggesting earlier entry into the continuum of HIV care.

In 2007 the median CD4 count at the time of first diagnosis of HIV was 185/mm3 among 83% of infected people having a CD4 test performed and reported. In 2011 the median CD4 count had risen to 332/mm3 among 72% tested:

• the 2007 CD4 count was 185/mm3, 83% of newly diagnosed people;



• the 2010 CD4 count was 313/mm3, 81% of newly diagnosed people; and

• the 2011 CD4 count was 332/mm3, 72% of newly diagnosed people .The CD4 count varies quite markedly depending on transmission category. Over the period 2007 - 2011:

• MSM had the highest median initial CD4 counts of 302/mm3, followed by HET with CD4 counts of 276/mm3, MSM+IDU with counts of 212/mm3 and IDU with counts of 194/mm3 .

CD4 counts also varied by race and ethnicity over the period 2007 - 2011:

• Whites median CD4 counts were 311/mm3, Blacks 281/mm3 and Hispanics 237/mm3 .

0

50

100

150

200

250

300

350

400

2007 2008 2009 2010 2011

Figure 13. CD4 Counts by Race/Ethnicity, EMA Blacks Whites Hispanics All

Table 17. CD4 Counts at Diagnosis by Risk, Year, EMA2007 2008 2009 2010 2011 Median 5 yr

All 185 248 297 313 332 297MSM 230 302 293 319 316 302

IDU 133 184 402 255 194 194MSM+IDU 95 99 218 212 262 212

HET 229 288 304 276 236 276Blacks 178 222 290 307 281 281

Whites 192 336 311 288 343 311Hispanics 142 237 200 254 263 237

0

50

100

150

200

250

300

350

400

450

2007 2008 2009 2010 2011

Figure 14. CD4 Counts by Transmission, EMA

MSM IDU HET All

34 HIV/AIDS in the EMA, Mortality

16.1

3.7 3.3 3.0

20.6

7.2 5.2 5.5 4.9 4.3

27.1

7.4 5.2 6.0 5.2 4.5

0.0

5.0

10.0

15.0

20.0

25.0

30.0

1995 2007 2008 2009 2010 2011

Figure 15. HIV/AIDS Mortality Rates, US, GA, EMA

US GA EMA

The age adjusted mortality rates for people with HIV has declined over the last five years. This has been seen throughout the U.S., Georgia and the Atlanta EMA. In the period 2007 - 2011, the mortality rates in the EMA were up to double that of the U.S. In particular:

• In the U.S. the rate has declined from 3.7 deaths per 100,000 population in 2007 to 3.0 in 2009, the most recent data nationally;

• In Georgia, the rate has declined from 7.2 deaths per 100,000 population in 2007 to 4.3 in 2011;

• In the EMA the rate has declined from 7.4 deaths per 100,000 population in 2007 to 4.5 in 2011.

HIV has not been among the top 15 leading causes of death in the US since 1997. However, in the EMA, HIV/AIDS continues to be a leading cause of death. Statistics show that in the five year period 2007 - 2011 in the EMA, regardless of race or ethnicity:

• HIV was the 7th highest cause of death in all persons aged 20 - 24 years;

• 5th highest in those aged 25 - 34 years;

• 4th highest in those aged 35 - 44 years; and

• 8th highest in those aged 45 - 54 years.

The ranking of cause of death among Blacks in the EMA was far more notable:

• the 4th leading cause of death in those aged 20 - 24 years, 3rd highest in those aged 25 - 34 years;

• the highest cause of death in those aged 35 - 44 years;

• the 3rd highest in those aged 45 - 54 years; and 10th highest in those aged 55 - 64 years.

Among Whites in the EMA HIV was the 5th highest cause of death in those aged 25 - 45 years and did not appear in the top ten causes of death in the age groups 20 - 24 years and 45 and older

Table 18. Top Ten Rankings of HIV/AIDS as Cause of Death, EMA5 year aggregate, 2007 - 2011

All Race/Ethnicity White Black

20-24 yrs 7 425-34 yrs 5 5 335-44 yrs 4 5 145-54 yrs 8 355-64 yrs 10

35

Persons Living

with HIV Disease

(PLWH)

in the Atlanta EMA

2011

36 Persons Living with HIV Disease In The EMA, Overview

At the end of 2007 there were 21,062 persons living with HIV disease (PLWH) in the EMA. Of these:

• 13,428 were living with AIDS (PLWA);

• 7,634 were living with HIV non-AIDS (PLWH non-AIDS).

By the end of 2011 the number of PLWH had increased to 27,355 - an increase of 30% (vital status data were missing in 770). Of these:

• 15,516 were PLWA, an increase of 16% over 2007;

• 11,069 were PLWH non-AIDS, an increase of 45% over 2007. There has been an increasing number of PLWH. The trend over the period 2007 - 2011 is a rapidly increasing number of PLWH non-AIDS and a still steady but lesser increase in the number of PLWA. This is illustrated in Figure 16. The black line is the linear trend line of PLWA and shows a steady increase over the five years. The orange line is the linear trend line of PLWH non-AIDS and is increasing at a steeper or faster rate than the trend line of PLWA. The bars are the number of persons with HIV disease in each year and by stage of disease.

7,000

9,000

11,000

13,000

15,000

2007 2008 2009 2010 2011

Figure 16. PLWH 2007 -‐ 2011, EMA AIDS HIV non-‐AIDS Linear (AIDS) Linear (HIV non-‐AIDS)

Table 19. Numbers of PLWA and PLWH non-AIDS, 2007- 011, EMA2007 2008 2009 2010 2011

AIDS 13,428 14,538 15,548 15,631 14,962HIV non-AIDS 7,634 9,494 10,998 11,255 12,393Total 21,062 24,032 26,546 26,886 27,355

37 HIV/AIDS in the EMA, By Zip Code

Figure 17. PLWH by Zip Code, 2011, EMA

38 PLWH In The EMA, Gender

Since 1981 males have made up 82% of all cases of AIDS and HIV non-AIDS in the EMA. When considering just cases of AIDS in the EMA:

• 80% of all AIDS cases diagnosed each year from 2007 through 2011 were males;

Among reported cases of HIV non-AIDS males still retain a significant majority:

• 72% of newly diagnosed cases in 2007 were males;

• 74% of newly diagnosed cases in 2008;

• 75% of newly diagnsoed cases in 2009 and 2010; and

• 76% of newly diagnosed cases in 2011.

Newly diagnosed cases of AIDS in females have represented 20% of all cases each year 2007 - 2011. As males have increased as a proportion of cases of HIV non-AIDS, so have females decreased:



• 25% of newly diagnosed cases in 2009 and 2010; and

• 24% of newly diagnosed cases in 2011.

At the end of 2011, there were 195 known transgender persons living with HIV disease in the EMA. Characteristics include:

• 52% were Male-to-Female;

• 32% were Hispanic, 25% Black, 16% White and in 18% race/ethnicity was missing;

In the five years 2007 - 2011 there were 96 transgender cases reported with HIV. Their characteristics were similar to the cumulative data:

• 56% were born male;

• 36% were Hispanic, 20% Black and 6% White and in 32% race/ethnicity was missing.

Table 20. Gender of PLWA and PLWH non-AIDS, 2007-2011, EMA2007 2008 2009 2010 2011

AIDS N % N % N % N % N %Males 10,703 80 11,629 80 12,487 80 12,557 80 11,942 80Females 2,725 20 2,909 20 3,061 20 3,074 20 3,020 20

HIV non-AIDSMales 5,473 72 7,005 74 8,259 75 8,435 75 9,476 76Females 2,155 28 2,489 26 2,739 25 2,820 25 2,917 24

TransgenderMale-Female (MtF) 11 8 14 12 9Female-Male (FtM) 8 6 5 11 12

39 PLWH In The EMA, Race/Ethnicity

At the end of 2011, there was a total of 27,355 PLWH in the EMA, an increase of 6,293 (30%) over the total at the end of 2007. Of these, 64% were Black, 20% White, 5% Hispanic, 0.4% Asian and less than 0.1% American Indian, Alaskan Native, Native Hawaiian or Pacific Islander. Almost 3% listed multiracial backgrounds and 7% had unknown racial or ethnic backgrounds. In both males and females, Blacks represented a majority of reported cases, 61% among males and 78% among females.

The proportion who were Black has remained fairly constant among PLWA at 62% over the period 2007 - 2011 while the proportion who were White has declined from 17% to 14%:

• Blacks represented 62% of all PLWH diagnosed in 2007 and a similar proportion through 2011;

• Whites declined from 17% to 14% over the same time frame;

• Hispanics and Other racial groups remained constant; and

• only those of unknown racial or ethnic origin increased.

As can be seen in Table 21, the same proportions have been maintained in PLWH non-AIDS although:

• the proportion of Unknown racial/ethnic origin has increased from 18% of those diagnosed in 2007 to 30% of those diagnosed in 2011.

Table 21. Race/Ethnicity of PLWA and PLWH non-AIDS, 2007-2011, EMAYear Diagnosed 2007 2008 2009 2010 2011All PLWH N % N % N % N % N %Black 1,270 60 1,283 65 1,143 63 1,072 62 1,097 58White 337 16 293 15 220 12 199 11 167 9Hispanic 126 6 100 5 112 6 93 5 103 5Asian 12 <1 8 <1 6 <1 12 <1 15 1Other 2 <1 0 0 0 0 1 <1 3 <1Multiracial 50 2 55 3 34 2 33 2 27 1Unknown 304 14 248 12 293 16 322 19 490 26Subtotal 2,101 1,987 1,808 1,732 1,902PLWABlack 572 63 583 68 471 64 388 62 380 65White 152 17 108 13 87 12 87 14 59 10Hispanic 61 7 53 6 62 8 41 7 38 6Unknown 89 10 69 8 91 12 91 15 93 16PLWH non-AIDSBlack 698 58 700 62 672 63 684 62 717 55White 185 15 185 16 133 12 112 10 108 8Hispanic 65 5 47 4 50 5 52 5 65 5Unknown 215 18 179 16 202 19 231 21 397 30

40 PLWH In The EMA, Ages

The median age of PLWH at the end of 2011 was 44 years. Overall there was little difference in the median ages of males (45 years) or females (44 years).

There was a marked difference in ages when considering PLWH non-AIDS and PLWA where the median age of PLWA (46 yrs) was 15% higher than PLWH non-AIDS (40 yrs).

Among PLWH non-AIDS:

• Blacks (38 yrs) were younger than Whites (44 yrs), Hispanics and Asians (43 yrs);

• Black males (37 yrs) were younger than Whites (46 yrs), Hispanics (44 yrs) and Asians (42 yrs);

• Black females (40 yrs) were older than Whites (26 yrs), Hispanics (36 yrs) but younger than Asians (55 yrs).

Among PLWA:

• Whites (49 yrs) were older than Blacks (45 yrs), Hispanics (48 yrs) and Asians (44 yrs);

• White and Hispanic males (49 yrs) were older than Blacks and Asians (46 yrs each);

• White females were older than Blacks (45 yrs) and Hispanics and Asians (42 yrs each).

Ages of PLWH within the various transmission categories will be discussed in detail within that category following this section. Table 22 has the median ages of the major transmission categories for comparison with gender and stage of disease.

Table 22. Median Ages of PLWA and PLWH non-AIDS, 2011, EMAAll Black White Hispanic Asian Multiracial Unknown

All 44 44 48 41 39 44 38Males 45 43 48 41 39 45 42Females 44 44 45 41 32 43 41

PLWH non-AIDS 40 38 44 43 43 45 41Males 40 37 46 44 42 47 41Females 41 40 26 36 55 39 42

PLWA 46 45 49 48 44 47 43Males 47 46 49 49 46 47 43Females 45 45 46 42 42 46 47

MSM IDU MSM+IDU HET NIR NRR PERIAll 46 46 47 45 45 46 48PLWH non_AIDS 41 39 42 40 39 40 41PLWA 47 47 48 46 45 46 48

41 PLWH, EMA, All Transmissions

The majority of PLWH in the EMA continue to be MSM. At the end of 2011 there were 27,355 PLWH in the EMA. These were categorized as:

• 11,105 in whom the transmission category was MSM;

• 1,746 were HET;

• 1,438 were IDU;

• 914 were MSM+IDU;

• 196 were categorized as PERI;

• 48 had other identified transmission modes; and

• a subtotal of 11,138 had no transmission category identified (NIR) or reported (NRR).

There were 48 PLWH in whom the transmission category was labelled as Other. These included:

• 28 recipients of infected blood or organs; 19 recipients of blood clotting factor; and

• 1 infected child not diagnosed until after turning 13 years.

These proportions must be interpreted cautiously. The proportion at the end of 2011 who were catego-rized as MSM was 42%. However, among those in whom the transmission category was reported, that proportion increased to 72% (see page 28 for methodology). Other examples include:

• in 2007, 36% of all cases were MSM compared to 87% in whom transmission category was known (Table 25).;

• in 2011, 27% of all cases were MSM compared to 89% in whom transmission category was known;

• in 2007, 3% of all cases were HET compared to 7% in whom transmission was known;

• in 2011, 1% of all cases were HET compared to 5% in whom transmission was known.

Table 23. Transmission Categories of All PLWH, 2011, EMAAll Male Female

All PLWH N % % N % % N % %MSM 11,105 42 72 11,105 53 81 0 -- IDU 1,438 5 9 944 5 7 494 9 27MSM+IDU 914 3 6 914 4 7 0 -- HET 1,746 7 11 549 3 4 1,197 21 66NIR/NRR 11,138 41 7,182 34 3,795 67PERI 196 <1 1 83 <1 <1 113 2 6Other 48 <1 <1 30 <1 <1 18 <1 1Total 26,585 20,807 5,617

% - proportion of cases after removing all NIR and NRR

The numbers of PLWH by transmission category does not match the numbers by race/ethnicity or by gender due to incomplete data on transmission categories and/or vital status.

42 PLWH, EMA, All Transmissions

Table 24. Transmission Categories by Race/Ethnicity and Gender of PLWA and PLWH non-AIDS, 2011, EMA

All Male FemaleAll PLWH N % % N % % N % %

ALL PLWH MSM 11,105 42 72 11,105 53 81 0 -- IDU 1,438 5 9 944 5 7 494 9 27MSM+IDU 914 3 6 914 4 7 0 -- HET 1,746 7 11 549 3 4 1,197 21 66NIR/NRR 11,138 41 -- 7,182 34 -- 3,795 67 --PERI 196 <1 <1 83 <1 <1 113 2 6Other 48 <1 <1 30 <1 <1 18 <1 1Total 27,355 21,418 5,937

Black MSM 6,520 38 66 6,520 52 78 0IDU 1,159 7 12 780 6 9 379 9 26MSM+IDU 532 3 5 532 4 6 0HET 1,432 8 15 454 4 5 978 22 67NIR/NRR 7,170 42 -- 4,205 33 -- 2,934 67 --PERI 151 <1 2 63 <1 <1 88 2 6Other 20 <1 <1 7 <1 <1 13 <1 1Total 16,984 12,561 4,392

White MSM 3,453 64 84 3,453 70 88 0IDU 177 3 4 104 2 3 73 16 36MSM+IDU 287 5 7 287 6 7 0HET 156 3 4 39 <1 1 117 25 58NIR/NRR 1,288 24 -- 1,019 21 -- 263 56 --PERI 14 <1 <1 6 <1 <1 6 2 3Other 26 <1 <1 21 <1 <1 21 1 10Total 5,401 4,929 466

Hispanic MSM 618 44 74 618 55 83 0IDU 53 4 6 31 3 4 22 8 25MSM+IDU 44 3 5 44 4 6 0HET 104 7 13 43 4 6 61 23 70NIR/NRR 571 41 -- 388 34 -- 177 67 --PERI 11 <1 1 7 <1 1 4 2 5Other 0 0 0Total 1,401 1,131 264

The numbers of PLWH by transmission category does not match the numbers by race/ethnicity or by gender due to incomplete data

%2 - numbers are the proportion of each category of all cases in which transmission category was reported

43 PLWH In The EMA, MSM

Through December 31, 2011, there were 27,355 PLWH in the EMA. A subtotal of 11,105 were identified as MSM, 42% (compared to 45% of all persons diagnosed with HIV regardless of vital status). When only those in whom a transmission category was reported, 72% of persons living with HIV disease at the end of 2011 were MSM compared to 67% of all people diagnosed with HIV (Table 23). Those in whom the transmission category was MSM+IDU accounted for 914 at the end of 2001 (4%) and 6% of all persons living with HIV disease. Thus, MSM as a potential transmission category (MSM and MSM+IDU), was 46% of all PLWH at the end of 2011 and 78% in whom transmission category was reported .

The number of PLWH who were MSM has declined from 36% of newly diagnosed cases in 2007 to 27% in 2011 (Table 25). However, when only those in whom transmision category was reported are considered, the proportion has increased from 87% of newly diagnosed cases in 2007 to 89% in 2011. As detailed above, if those in whom at least one potential transmission category is MSM are considered, the proportion of newly diagnosed cases (MSM and MSM+IDU) has declined from 37% in 2007 to 27% in 2011. Among those in whom transmission category was reported, the proportion has remained constant at 91%.

MSM accounted for 64% of White PLWH through 2011, 38% of Blacks and 44% of Hispanics (Table 24). As detailed above and when only considering those in whom a transmission category was provided, 84% of Whites were MSM, 66% of Blacks and 74% of Hispanics. When those in whom transmission category was provided and was also MSM+IDU, the proportion of Whites in whom MSM is a potential transmission source increases to 91%, Blacks increase to 72% and Hispanics increase to 79%.

Table 25. Transmission Categories of PLWA and PLWH non-AIDS, by Year of Diagnosis, 2007-2011, EMA

Yr Diagnosed 2007 2008 2009 2010 2011

All PLWH N %1 %2 N %1 %2 N %1 %2 N %1 %2 N %1 %2

MSM 758 36 87 620 31 87 620 34 89 505 29 88 539 27 89IDU 21 1 2 25 1 4 14 <1 2 16 <1 3 18 <1 3MSM+IDU 25 1 3 14 <1 2 17 <1 2 11 <1 2 9 <1 1HET 59 3 7 43 2 6 39 2 6 32 2 6 29 1 5NIR/NRR 1,229 58 1,283 64 1,113 61 1,186 67 1,364 69PERI 5 <1 <1 7 <1 1 5 <1 <1 7 <1 1 6 <1 1Other 4 <1 <1 0 0 -- 2 <1 <1 1 <1 <1 2 <1 <1Total 2,101 1,993 1,810 1,758 1,967The numbers of PLWH by transmission category does not match the numbers by race/ethnicity or by gender due to

incomplete data on transmission categories and/or vital status.%1 - numbers are the proportion of each category of all reported case


44 PLWH In The EMA, IDU & HET

HIV infection has not affected the IDU population in the Atlanta EMA as much as some other EMA’s. Since 1981 there have been 3,804 cases diagnosed among IDU in the EMA through 2011 of whom 1,438 were alive at the end of 2011. The number diagnosed represents 9% of all cases and the number of IDU PLWH represents 5% of all PLWH in the EMA.

In each year between 2007 and 2011 the number of newly diagnosed IDU has remained low, 1% or less of all cases and 2 - 3% of cases in which transmission category was provided.

Although the majority of IDU PLWH were male (944 cases) they represented a smaller proportion of IDU PLWH in males (4.5%) compared to 494 cases in females that represented 9% of all IDU PLWH in females. IDU have represented 7% of Black PLWH (1,159 cases) compared to 3% of Whites (177 cases) and 4% of Hispanics (53 cases).

There were 3,044 cases of HIV diagnosed among those in whom transmission category was HET, representing 7% of all people diagnosed with HIV. Through 2011, 1,746 of these were HET PLWH non-AIDS in the Atlanta EMA, or 7% of all PLWH. As described previously, HET repesented 11% of all persons diagnosed with HIV and PLWH through 2011.

Among Black males, IDU represented 6% of cases (780) compared to 9% (379 cases) in Black females. In comparison, White IDU represented 2% of males (104 cases) and 16% of females (73 cases). A similar discord was seen in Hispanic males where IDU represented 3% (31 cases) and 8% (22 cases) in Hispanic females. Racial differences were more pronounced in HET PLWH cases. Among Black males, HET accounted for 4% of cases compared to 22% among Black females. Among White HET accounted for <1% among males and 25% of females with similar percentages seen in Hispanics .

Table 26. Persons Living with HIV Disease, IDU and HET, 2007-2011, EMAYr Diagnosed 2007 2008 2009 2010 2011

All PLWH N % %2 N % %2 N % %2 N % %2 N % %2

IDU 21 1 2 25 1 4 14 <1 2 16 <1 3 18 <1 3HET 59 3 7 43 2 6 39 2 6 32 2 6 29 1 5

%1 numbers are the proportion of each category of all reported case %2 numbers are the proportion of each category of all cases in which transmission category was reported

M F M F M F M F N % N % N % N % N % N % N % N %

IDU 944 4.5 494 9 780 6 379 9 104 2 73 16 31 3 22 8HET 549 3 1,197 20 454 4 978 22 39 <1 117 25 43 <1 61 25

45 PLWH In The EMA, NIR/NRR

There are large numbers of PLWH in whom no transmission category has been identified or reported (previously known as No Risk Identified or NIR and No Risk Reported or NRR). Although a transmission category may have been identified, in many cases that information has not been entered into a person’s record. This is more common on the statewide surveillance database than on those maintained by providers of care through the Ryan White network.

A total of 11,138 PLWH in the EMA were NIR/NRR, or 41% of all PLWH through 2011. It is not surprising that the number and percentage of cases that fit into this category increases as cases are more recently reported since epidemiological investigation of these incompletely reported cases takes time and resources. At the end of 2007, 58% of cases were NIR/NRR increasing to 69% in 2011. The number declines over time due to follow up investigations that resolve many of these cases.

The number that were NIR/NRR by race/ethnicity varies quite markedly. Among persons living with HIV disease through 2011, 42% of Blacks were NIR/NRR, 24% of Whites and 41% of Hispanics .

Among males, there were 7,182 PLWH catagorized as NIR/NRR through 2011 or 34% of all male PLWH. At the same time there were 3,795 or 67% of all female PLWH in the EMA.

Greater variation was seen by race/ethnicity and gender. Among male PLWH in the NIR/NRR group, Blacks accounted for 33% of all Black male PLWH, White males 21% and Hispanic males 34%. Similarly among female PLWH, Black and Hispanic female NIR/NRR accounted for 67% of all female PLWH compared to White females at 56%.

Table 27. Persons Living with HIV Disease, NIR and NRR, 2007-2011, EMAYr Diagnosed 2007 2008 2009 2010 2011

All PLWH N % N % N % N % N %

NIR/NRR 1,229 58 1,283 64 1,113 61 1,186 67 1,364 69

All Black White Hispanic

M F M F M F M F N % N % N % N % N % N % N % N %

NIR/NRR 7,160 34 3,787 67 4,190 33 2,928 67 1,016 21 263 56 386 34 176 67

46

Ryan White Clients

in the Atlanta EMA

2011

47 Ryan White In The EMA, Facilities

Part A of the Ryan White HIV/AIDS Program funds a range of services and organizations throughout the Atlanta EMA. Services include primary health care, oral health care, medical case management, treatment adherence, mental health services, substance abuse treatment, food services, emergency financial support, psychosocial support, medical transportation services, linguistic services, legal services and child care services. In addition to Part A, the Ryan White Program also provides funding directly to primary care clinics within the Atlanta EMA under Part C. The EMA is also home to one Part D funded site.

Agencies in the Atlanta EMA in 2011 were:

• AID Atlanta;

• AID Gwinnett;

• ANIZ, Inc;

• Altanta Legal Aid Society, Inc;

• Clarke County Board of Health;

• Clayton County Board of Health;

• Cobb and Douglas Public Health;

• DeKalb County Board of Health;

• Emory University Hospital at Midtown;

• Fulton County Department of Health and Wellness;

• Grady Infectious Disease Program;

• Here’s To Life;

• Positive Impact;

• Project Open Hand; and

• Saint Joseph’s Mercy Care Services, Inc.

Clients are eligible to receive any services at Ryan White funded agencies if they are:

• infected with HIV at any stage of infection;

• enrolled in a primary care clinic;

• live within the 20 county Atlanta EMA; and

• have an income that is at or below 300% of the Federal Poverty Level.

Data are collected on each individual and entered by each agency into a centralized database. This database is housed at Fulton County Government using CAREWare software provided and maintained by the HIV/AIDS Bureau of HRSA (HAB). Data are aggregated and duplicates removed prior to any analyses being performed.

48 Ryan White In The EMA, Clients

In 2007 there were 10,764 clients who received services at any Ryan White agency in the EMA. This number steadily increased to 12,685 clients in 2011 (an 18% increase from 2007). The clients in 2011 represented 47% of all known PLWH in the EMA.

While the number of clients at Ryan White agencies increased between 2007 and 2011, the number as a proportion of all PLWH in the EMA decreased from 52% in 2007 to 47% in 2011.

The breakdown of clients attending Ryan White sites indicates that 73% were male, 26% female and 1% were transgender. In comparison, among the general population of the EMA, 49% were male and 51% female. Transgender data are not available for the general population.

Data also indicated that 76% were Black, compared to 32% in the general population, 16% were White compared to 50% in the general population and 5% Hispanic compared to 11% in the general population. Others were Asian (<1% compared to 5% in the general population), multiple races (1%) or unspecified (<1%). American Indian, Alaskan Native,Pacific Islander and Other racial groups made up less than 0.5% compared to the general population where these groups make up about 2%.

10,764 11,650 12,224 12,288 12,685

21,062

24,032 26,546 26,888

27,355

10,000

15,000

20,000

25,000

30,000

2007 2008 2009 2010 2011

Figure 18. Ryan White Clients, 2007-‐2011

RW clients All EMA

Table 28. Ryan White Clients and the General Population, Basic Demographics, 2011, EMA

Male Female Black White Hispanic Other

Ryan White Clients 73% 26% 76% 16% 5% 3%General Population 49% 51% 32% 50% 11% 7%

26%

73%

5%

16%

76%

51%

49%

11%

50%

32%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Female

Male

Hispanic

White

Black

Figure 19. Ryan White Clients, General PopulaIon, 2011, EMA General Pop RW Clients

49 Ryan White In The EMA, Income, Health Insurance

Information about income, household size and health insurance coverage of PLWH is generally not available on the statewide surveillance system. However, all clients seeking services at a Ryan White funded facility have their income, household size and health insurance status recorded in order to ensure eligibility for Ryan White services. Interpretation of these data must be taken with caution since one of the eligibility criteria for receiving care at Ryan White facilities is an income 300% or less of the Federal Poverty Level (FPL).

The average size of households of PLWH in the EMA was 1.5 persons. The FPL for a one person household was $10,890 and for a two person household was $14,710 per year in 2011. Hence, 300% of FPL was $32,670 for a one person household and $44,130 for a two person household. The median household income of Ryan White clients was $6,204 in 2011. A median value means that half of all Ryan White clients had an income less than $6,204 and half had an income above that figure. By comparison the median income of the EMA general population in 2011 was $53,237, see below in Figure 20.

The majority of Ryan White clients, 54%, did not have any health care coverage. An additional 34% had public health coverage with Medicaid, Medicare or through other sources such as the VA or CHAMPUS. Thus, 88% have no or public health coverage. Only 12% had private health insurance. In comparison and in the general population of the EMA, 21% had no health insurance (median level):

• 54% of Ryan White clients have no health insurance;

• 16% of Ryan White clients had Medicaid coverage;

• 16% of Ryan White clients had Medicare coverage;

• 2% of Ryan White clients had other public coverage; and

• 12% of Ryan White clients had private coverage.

54%

21%

0%

10%

20%

30%

40%

50%

60%

No Health Insurance

$6,204

$53,237

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

Median income

Ryan White clients

General popula3on

Figure 20. Median Income and Lack of Health Insurance, Ryan White Clients and the General Population of the EMA, 2011

50 Ryan White In The EMA, Gender, Race/Ethnicity

GenderThe majority of clients attending Ryan White facilities were male and in similar proportions to the total number of persons living with HIV diease in the EMA;

• In 2007, there were 7,791 males or 72% of all clients (80% among all PLWH in the EMA);

• In 2011, there were 9,308 males or 73% of all clients (80% among all PLWH), an increase of 19%;

• In 2007, there were 2,899 females or 27% of all clients (20% among all PLWH in the EMA);

• In 2011 there were 3,256 females or 26% of all clients (20% among all PLWH), an increase of 12%;

• There were 72 transgender clients in 2007 and 120 in 2011 that made up approximately 1% of all clients.

Race/Ethnicity

When stratified by race/ethnicity, the proportion of clients is similar to the breakdown of all PLWH:

• The proportion of clients who were Black was 73% in 2007 and increased to 76% in 2011. In comparison the proportion of all PLWH in the EMA who were Black in 2007 was only 60% and in 2011 was 58%;

• The proportion of clients who were White was 18% in 2007, decreasing to 16% in 2011. In comparison the proportion of all PLWH in the EMA who were White in 2007 was 15% and in 2011 was 9%;

• The proportion of clients that were Hispanic was 6% in 2007 and 5% in 2011. This is identical to the same proportions among PLWH.

72% 73%

27% 25%

0

20

40

60

80

100

120

140

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2007 2011

Figure 21. RW Clients by Gender, 2007, 2011

Female

Male

Transgender

Table 29. Ryan White Clients by Gender, Race/Ethnicity2007 2011

N % PLWH% N % PLWH%Males 7,791 72 80 9,308 73 80Females 2,899 27 20 3,256 26 20Transgender 72 <1 120 1Total 10,762 12,684

Black 7,853 73 60 9,637 76 58White 1,959 18 15 2,006 16 9Hispanic 609 6 6 682 5 5

51 Ryan White In The EMA, Ages

Table 30. Age Distribution, PLWH, Ryan White Clients, 2011, EMARyan White Clients PLWH Cumulative HIV

Median Age 43 44 48N % N % N %

0-12 340 3 86 <1 312 113-19 151 1 202 1 982 320-24 688 5 1,222 5 3,725 1025-29 1,105 9 2,195 8 5,920 1630-34 1,368 11 2,644 10 7,098 1935-39 1,391 11 2,891 11 6,778 1840-44 1,953 15 4,085 15 5,276 1445-49 2,234 18 4,951 19 3,357 950-54 1,713 14 3,781 14 2,013 555-59 1,026 8 2,368 9 1,005 360-64 466 4 1,296 5 515 165-69 156 1 521 2 223 170+ 94 1 338 1 145 <1Total 12,685 26,580 37,349

The median age of all clients receiving services at Ryan White facilities in 2011 was 43 years. Males and females had the same median age of 43 years. Transgender clients were younger at 38 years. Whites were the oldest among racial and ethnic groups at 47 years and Asians were the youngest at 39 years. By comparison, persons with HIV disease:

• had a median age in 2011 of 48 years, compared to 44 years in all PLWH in the EMA and 43 years among Ryan White clients;

• 26% were aged 20 - 29 years compared to 13% among PLWH and 14% of Ryan White clients;



• 10% were aged 50 or more years compared to 31% among PLWH and 28% of Ryan White clients.

0%

5%

10%

15%

20%

25%

30%

35%

40%

0-‐12 13-‐19 20-‐29 30-‐39 40-‐49 50-‐59 60-‐69 70+

Figure 22. Ages, People with HIV, PLWH, RW Clients, 2011, EMA

People with HIV PLWH RW clients

52 Ryan White In The EMA, Transmission Categories

Table 31. Transmission Categories, Ryan White Clients, 2011, EMATransmission All Black White Hispanic

N %1 %2 N %1 %2 N %1 %2 N %1 %2

MSM 6,492 51 87 4,546 47 87 1,439 72 89 343 50 88IDU 401 3 2 310 3 4 69 3 2 14 2 3MSM+IDU 263 2 3 156 2 2 87 4 2 13 2 2HET 4,655 37 7 3,910 41 6 327 16 6 269 39 6NIR/NRR 200 2 151 64 22 1 7 1PERI 399 3 <1 374 4 1 9 1 <1 10 1 1Other 275 2 <1 190 0 -- 53 3 <1 26 4 <1Total 12,685 9,637 2,006 682The numbers of PLWH by transmission category does not match the numbers by race/ethnicity or by gender due to incomplete

data on transmission categories and/or vital status.%1 - numbers are the proportion of each category of all reported case


The largest number of clients by transmission category at Ryan White agencies are MSM (6,492 clients). However, MSM only represent 51% of all clients seen in Ryan White facilities. This is in contrast with the 42% of cases represented by MSM of all PLWH and the 87% of clients in whom a transmission category was reported .

Conversely, clients in whom the transmission category was HET (4,655 clients) represented 37% of all Ryan White clients but only 7% of all PLWH in the EMA and 11% of all PLWH in whom transmission category was reported .

Clients that were IDU, MSM+IDU and PERI had proportions in the Ryan White population, all PLWH and all PLWH in whom transmission category was reported that were more similar.

The proportions of Ryan White clients in the various transmission categories does not appear to be dependent on race or ethnicity. The proportions of each transmission category among Blacks, Whites and Hispanics are very similar and only vary by about 2% (Table 31).

It should be noted that there are far fewer Ryan White clients in whom the transmission category was NIR/NRR than among other PLWH or people with HIV. Since there is such a small number, no statistical extrapolation has been completed.

53 Ryan White In The EMA, Transmission Categories

Table 32. Transmission Categories, Race/Ethnicity, Gender, Ryan White Clients, 2011, EMAAll Male Female

All PLWH N % % N % % N % %MSM 6,492 51 42 6,396 69 53 0 -- IDU 401 3 5 263 3 5 138 4 9MSM+IDU 263 2 3 258 3 4 0 -- HET 4,655 37 7 1,911 20 3 2,730 84 21NIR/NRR 200 2 41 131 1 34 66 2 67PERI 399 3 <1 185 2 <1 214 7 2Other 275 2 <1 164 2 <1 108 3 1Total 12,685 9,308 3,256Black

MSM 4,482 47 38 4,460 66 52 0 --IDU 306 3 7 204 3 6 106 4 9MSM+IDU 156 2 3 152 2 4 0 --HET 3,798 40 8 1,569 23 4 2,329 84 2NIR/NRR 147 2 42 99 1 33 49 2 67PERI 374 4 <1 176 3 <1 198 7 2Other 188 2 <1 102 2 <1 85 3 <1Total 9,451 6,762 2,767White

MSM 1,417 72 64 1,437 82 70 0 --IDU 64 3 3 40 2 2 29 12 16MSM+IDU 86 4 5 86 5 6 0 --HET 311 16 3 134 8 <1 192 80 25NIR/NRR 21 1 24 19 1 21 3 1 56PERI 9 <1 <1 2 <1 <1 7 3 2Other 53 3 <1 44 3 <1 9 4 1Total 1,961 1,762 240

Hispanic

MSM 341 51 44 335 64 55 0 --

IDU 13 2 4 12 2 3 2 1 8

MSM+IDU 12 2 3 13 2 4 0 --

HET 261 39 7 138 26 4 130 87 23

NIR/NRR 7 1 41 5 1 34 2 1 67

PERI 10 1 <1 6 1 <1 4 3 2

Other 25 4 <1 16 3 <1 10 7 <1

Total 669 525 148

% - of all PLWH in the EMA in 2011 to compare with Ryan White clientsThe numbers of PLWH by transmission category does not match the numbers by race/ethnicity/gender due to incomplete data

54 Ryan White Clients In The EMA, Co-Morbidities

A number of infectious diseases are indicative of ongoing high risk activities. These include the sexually transmitted infections of syphilis, gonorrhea, herpes and chlamydia. In addition there are various forms of hepatitis that may be sexually spread or spread through contact with infected blood. Analyses of these diseases in the EMA presents a picture of ongoing risk activities that can assist in targeting preventive programs.

Syphilis

In 2011, 1,911 people in the EMA were diagnosed with syphilis (Table 33, Figure 24). Of these, 1,416 (including 17 missing data) were PLWH in the Ryan White clinics representing 76% of all syphilis cases in the EMA. Among these, males accounted for 92%, Blacks 79% and MSM 81%. The median age of all cases reported with syphilis was 46 years. When viewing the distribution of newly diagnosed syphilis cases in the EMA by the rate of cases per 100,000 persons, the county by county distribution is similar to that of newly diagnosed cases of HIV infection in the same year 2011 (see Figures 23 and 24). Those counties with the highest rates of newly diagnosed HIV infection are also the counties with the highest rates of newly diagnosed syphilis cases. Similarly those counties with the lowest rates in HIV infection (0 - 10 cases per 100,000) are also the lowest in syphilis infection.

Gonorrhea

In 2011, 8,338 people in the EMA were reported with gonorrhea of which 140 were in the Ryan White clinics (Table 33, Figure 25). Males accounted for 93%, 85% were Black, 7% White and 5% Hispanic. MSM accounted for 84% and Heterosexuals 12%. The median age of all PLWH with gonorrhea was 56 years.

Table 33. HIV, Newly Diagnosed Cases of STIs, Ryan White Clients, 2011Male Female Black White Hispanic MSM HET

HIV 1,612 380 1,110 173 105 545 29Syphilis 1,306 93 1,150 173 64 1,146 201Gonorrhea 130 6 115 10 7 73 41Hepatitis B 1,054 212 979 197 58 845 347Hepatitis C 174 43 159 36 11 88 79Chlamydia 155 31 158 19 8 138 40Herpes 93 24 93 11 10 73 41% of cases in each grouping

HIV 78% 21% 64% 20% 5% 42% 7%Syphilis 92% 7% 79% 12% 4% 81% 14%Gonorrhea 93% 4% 85% 7% 5% 84% 12%Hepatitis B 80% 16% 74% 15% 4% 66% 27%Hepatitis C 79% 20% 73% 16% 5% 40% 36%Chlamydia 82% 16% 84% 10% 4% 73% 21%Herpes 77% 22% 77% 9% 8% 60% 34%

55 Ryan White Clients In The EMA, Co-Morbidities

Hepatitis B

There were 1,276 cases of Hepatitis B among PLWHA in 2011 (Table 33). Of these:

• 1,054 were male (80%) and 212 female (16%);

• 979 (74%) were Black, 197 (15%) White and 58 (4%) Hispanic;

• 845 (66%) were MSM, 347 (27%) Heterosexuals, 34 (3%) IDU and 30 (2%) MSM+IDU.

Hepatitis C

There were 219 cases of Hepatitis C reported among PLWHA in the Ryan White clinics in 2011 (Table 33). Ninety-nine of those had co-infection with Hepatitis B. The median age of all was 56 years. Of these 219:

• 174 (79%) were male, 43 (20%) were female and 3 were transgender. Blacks accounted for 159 (73%), Whites 36 (16%) and Hispanics 11 (5%);

• Unlike other transmission categories, MSM accounted for only 88 cases (40%), Heterosexuals 79 (36%), IDU 33 (15%) and MSM+IDU 10 (5%).

Chlamydia

There were 188 cases of chlamydial infection reported among clients of Ryan White clinics in 2011 (Table 33, Figure 26). The median age was 56 years, the same as those with gonorrhea and hepatitis. Among these 192:

• Males accounted for 155 (82%) cases and females 31 (16%);

• There were 158 Blacks (84%) of which 130 were male and 26 female (84% of males and females with chlamydia), 19 Whites (10%) of which 16 were male and 3 female (80% of males and females with chlamydia) and 8 Hispanics (4%);

• MSM accounted for 138 cases (73%) and HET another 40 cases (21%).

Herpes

There were 121 cases of herpes infection reported among PLWHA in the Ryan White clinics in 2011 (Table 33):

• Males accounted for 93 (77%) and females 24 (22%);

• There were 99 Blacks (77%) of which 75 were male and 24 female (81% of males and 86% of females with herpes), 11 Whites (9%) and 10 Hispanics (8%);

• MSM accounted for 73 (60%) cases and heterosexuals 41 cases (34%).

56 Ryan White Clients In The EMA, Co-morbidities

Figure 23. PLWH in Counties of the EMA, 2011

Figure 25. Gonorrhea in Counties of the EMA, 2011

Figure 24. Syphilis in Counties of the EMA, 2011

Figure 26. Chlamydia in Counties of the EMA, 2011

PLWH and newly diagnosed cases of gonorrhea in 2011 (Figures 23, 25): = 0-49; = 50-99; = 100-149; = 150-199; = 200+.

Newly diagnosed cases of syphilis in 2011 (Figure 24): = 0-4.9; = 5-9.9; = 10-14.9; = 15-19.9; = 20+.

Newly diagnosed cases of chlamydia in 2011 (Figure 26): = 0-99.9; = 100-199.9; = 200=299.9; = 300-399.9; = 400+.

All rates refer to cases per 100,000 population

57 HIV Continuum of Care, Cascade

The HIV Continuum of Care, also known as the HIV Treatment Cascade or Cascade, was launched in 2013 to identify issues and opportunities related to improving the delivery of services to PLWH across the entire treatment spectrum. This model has been applied to adult and adolescent Ryan White clients aged 13 years or more and alive at the end of 2011. There are six main stages within the Continuum:

1 . HIV diagnosis by a positive HIV test is the start of the Continuum;

2. getting linked to care is the second stage and is recommended within 3 months of initial diagnosis;

3 . being retained in care is the third stage. This is determined to be met by documented testing of immune and/or viral function within a specific period of time;

4 . engaged in care means more than one of the tests was completed within a nine month period;

5 . accessing antiretroviral therapy; and finally

6 . achieving suppression of the HIV virus as measured by a viral load (VL) less than 200 copies of HIV per ml of bloo d.

There are various stages where a person with HIV may be lost to care such as being diagnosed with HIV and then not being linked to care or being linked to care and not remaining in or being non-compliant with care.

Following are several Figures that examine the HIV Continuum of Care in the EMA in 2011. But there are some definitions needed to understand them:

• diagnosed with HIV: confirmed laboratory result, western blot and/or viral load (VL);

• linked to care: one CD4 or VL lab test performed within 3 months of the initial diagnosis of any stage of HIV infection;

• engaged in care: one or more CD4 or VL tests performed 4-15 months after diagnosis (because of this time line, clients needed to be alive at least 15 months after diagnosis which could be as late as March 2013 if diagnosed in late 2011);

• retained in care: two or more CD4 or VL tests completed during 2011;

• ART: antiretroviral therapy has been prescribed. Since this value is not available, results of the Medical Monitoring Project are used. In the case of the EMA that value is 88% in all, 92% in males and 82% in females.

• viral suppression: VL of less than 200 copies per ml of blood in the last VL measured for that person in 2011.

Although there are no gold standards for each stage, it is reasonable to assume that all PLWH should be linked to and retained in care and that they be prescribed ART to achieve viral suppression. This would limit the impact of HIV disease to that person and further limit spread of HIV to non-infected individuals.

58 HIV Continuum of Care, Ryan White and EMA

71% 67%

47%

31%

57%

78%

50%

63%

Linked Engaged Retained VL<200

Figure 27. Cascade All EMA, Ryan White Clients, 2011

EMA RW clients

Total diagnosed

= 100

Figure 27 below is a graphical representation of the HIV Continuum of Care or Cascade for all adult PLWH in the EMA diagnosed in 2011 and Ryan White clients in 2011. Reading from left to right for the EMA only in grey bars:

• 100 represents the total eligible population of PLWH;

• 71 is the percentage of PLWH who were linked to care;

• 67 is the percentage of PLWH who were engaged in care;

• 47 is the percentage of PLWH who were retained in care; and

• 31 is the percentage of PLWH in whom viral suppression had achieved a figure of less than 200 copies/ml.

By contrast, the Ryan White clients have higher proportions that were engaged and retained in care and double the proportion who had achieved viral suppression:

• 100 represents the total eligible population of Ryan White clients;

• 57 is the percentage who were linked to care;

• 78 is the percentage who were engaged in care;

• 50 is the percentage who were retained in care; and

• 63 is the percentage in whom viral suppression had achieved a figure of less than 200 copies/ml.

Reasons for a lower linkage to care rate includes delays in obtaining appointments with providers, non-compliance with keeping appointments already made and data entry that may not be current. Once in care, engaged and retained, it is apparent that both clients and providers are achieving their goals of viral suppression. Data from the EMA as a whole may not be complete and should therefore be interpreted cautiously.

59 HIV Continuum of Care, Gender

The Continuum methodology was applied to the Ryan White clients and broken down by gender. In all aspects of the Continuum it was evident that females had better outcomes than males:

• 64% of females were linked to care compared to 60% of males;

• 85% of females were engaged in care compared to 81% of males;

• 57% of females were retained in care compared to 53% of males; and

• 68% of females had evidence of viral suppression compared to 63% of males

60%

81%

53% 63% 64%

85%

57%

68%

0%

20%

40%

60%

80%

100%

Total Linked Engaged Retained VL<200

Figure 28. Ryan White Clients by Gender, 2011 Male Female

Total diagnosed = 100

Examination of the Continuum in subpopulations of race/ethnicity reveals some large differences. When comparing Blacks, Whites and Hispanics living with HIV in the EMA (Figure 29, there were too few of Other racial/ethnic groups for meaningful analysis):

• 64% of Blacks are engaged in care compared to 73% of Whites and 70% of Hispanics;

• 44% of Blacks are retained in care compared to 55% of Whites and 58% of Hispanics;

• 26% of Blacks are virally supressed compared to 38% of Whites and 34% of Hispanics .

Again by contrast and among Ryan White clients (Figure 30):

• 81% of Blacks were engaged in care compared to 86% of Whites and 78% of Hispanics;

• 42% of Blacks were retained in care compared to 63% of Whites and 68% of Hispanics;

• 62% of Blacks were virally suppressed compared to 83% of Whites and 84% of Hispanics .

60 HIV Continuum of Care, Race/Ethnicity

74%

64%

44%

26%

76% 73% 55% 38%

84%

70%

58%

34%

0%

20%

40%

60%

80%

100%


Figure 29. Cascade by Race/Ethnicity, EMA,2011

Black White Hisp


60%

81%

42%

62%

66% 86% 63% 83%

66%

78% 68%

84%

0%

20%

40%

60%

80%

100%


Figure 30. Cascade by Race/Ethnicity, RW, 2011

Black

White

Hisp


Data for the Continuum at the EMA level is collected and analyzed by the DPH HAEP based on reported laboratory reports. As previously mentioned some data entry is still not complete and not all reporting is complete and/or timely. Therefore, these data need to be interpreted with caution.

Ryan White providers on the other hand are more inclined to both test, record and report results of testing to their CAREWare database and these data are more likely to be complete.

69%

79%

56%

70%

64% 84% 49% 68%

54%

81%

36%

57%

0%

20%

40%

60%

80%

100%


Figure 31. Ryan White Clients by Age, 2011 Aged 50+ WCA YMSM

Total diagnosed

= 100

When looking at different groups largely by age groups (Figure 31), other disparities are evident. Older Ryan White clients have higher proportions linked (69%) and retained (56%) in care and higher viral suppression rates (70%) than young MSM. Among young MSM, 54% are linked and 36% retained in care and 57% show viral suppression. The combined group of women, children and adolescents (WCA) are mid-way between the other two groups. They showed 64% linkage to care, 49% retention in care and 68% were virally suppressed.

61 HIV Continuum of Care, MSM, HET

A similar picture as was seen with race and ethnicity is also noted when the Continuum is depicted for different transmission categories. In the case of Ryan White clients there were too few in the IDU and Other categories to result in any meaningful analyses; only MSM and HET were analyzed. Among MSM:

• although there were fewer Ryan White MSM linked to care than MSM in the EMA as a whole, there were many more engaged and retained in care (81% and 53% respectively of Ryan White clients versus 65% and 45% of the EMA);

• Ryan White MSM appeared more than twice as likely to have achieved viral suppression (60%) as those in the EMA at large (28%).

Among HET a similar but less dramatic picture appeared:

• a higher proportion of Ryan White HET were linked to care (65%) than in the EMA at large (58%);

• Ryan White HET were more likely to be engaged (82%) and retained in care (55%) than HET in the at large EMA (81% and 53% respectively);

• Ryan White HET were more likely to have achieved viral suppression (70%) than HET in the total EMA (60%).

58%

81%

53% 60%

65%

82%

55%

70%


Figure 33. Cascade, HET, EMA, RW Clients, 2011 EMA RW clients

Total diagnosed

= 100

74% 65%

45%

28%

58%

81%

53% 60%


Figure 32. Cascade, MSM, EMA, RW Clients, 2011

EMA RW clients

Total diagnosed

= 100

62 Behavioral Indicators in the EMA

Behavioral risks in persons living with HIV – Medical Monitoring Project (MMP) The Medical Monitoring Project (MMP) is an ongoing population-based surveillance system that is designed to assess clinical outcomes and behaviors of HIV-infected adults receiving care in the United States. It is currently conducted in 17 states (including Georgia) and 6 cities (including Atlanta) by local and state public health departments in collaboration with the Centers for Disease Control and Prevention (CDC). MMP uses in-person interviews and medical record abstraction to combine behavioral and clinical information on HIV positive individuals, with the goal of describing clinical outcomes, behaviors, and quality of HIV care.

To implement the project, state and local health departments identify HIV care providers in their jurisdictions. A representative sample of these providers is then chosen. The health departments contact all sampled providers; HIV-positive patients are selected from the sampled providers that agree to participate.

Data collection for the Georgia Medical Monitoring Project (GAMMP) began in the summer of 2007 and has continued into 2013. Although data collection is occurring statewide, the majority of participating providers are located within the 20 county Atlanta EMA. There were 319 patients enrolled in the GAMMP in 2009 and 2010. The majority were Black (66%) and male (66%). The following tables show sexual and drug-using behaviors of the patients in the study, along with viral suppression of those sexually active during the study period.

Table 34. Unprotected Sex among MMP Participants, Georgia 2009, 2010No. of partners MSM* (N=102) HET** (N=78) Total (N=180)

N (%) N (%) N (%)One 48 47 67 86 115 64Two or more 54 53 11 14 65 36

Reported unprotected vaginal or anal sex with at least 1 partner in the last 12 monthsMSM (N=86) HET (N=72) Total (N=158)

No 50 58 45 63 95 60Yes 36 42 27 37 63 40

*MSM = Men who have sex with men** = Heterosexual contact with a person with or at high risk for HIV infection (e.g., IDU or, for females, sex with a bisexual male)

Of the 319 patients interviewed, 56% (n=180) reported they were sexually active during the study period. Of these, 57% (n=102) self-identified as men who have sex with men (MSM). Of those who reported unprotected sex (n=158), 57% were among the MSM group and 43% were among the self-identified heterosexual (HET) group. Viral suppression was high, as seen in Table 35, at 80% for those who reported unprotected sex.


Table 35. Viral Suppression among MMP Participants Who Reported Unprotected Sex*, 2009, 2010

Data Source Total VL <200 N %

VL >200 N %

VL Missing N %

MRA** 64 51 80 11 17 2 32013 eHARS*** 64 40 63 19 30 5 8

*Self-reported vaginal or anal sex without a condom with at least 1 partner in the previous 12 months**MRA = medical record abstraction

***eHARS = Enhanced HIV/AIDS Reporting System

Injection drug use (IDU) among GAMMP participants is low, with <1% indicating injecting drugs in the previous 12 months. Non-injection drug use, however, is higher with a quarter of males and 15% of females reporting drug use (Table 36).

Table 36. Recreational Drug Use among MMP Participants, Georgia 2009, 2010Injection drug use in the last 12 months

Male (N=205) N (%)

Female (N=103) N (%)

Total (N=163) N (%)

No 204 99 102 99 306 99Yes 1 <1 1 1 2 <1

Non-injection drug use in the last 12 months*Male (N=204) N (%)

Female (N=103) N (%)

Total (N=308) N (%)

No 153 75 88 85 241 79Yes 51 25 15 15 66 21

Excluding alcoholN refers to the number of participants who responded to a specific question

*Categories are not mutually exclusive

The National HIV Behavioral Survey

The National HIV Behavioral Surveillance (NHBS) system was created by CDC in 2003 to conduct surveillance among persons at high risk for HIV infection. Surveillance is conducted in rotating annual cycles in three different populations: men who have sex with men (MSM), injection drug users (IDUs), and heterosexuals at increased risk for HIV infection (HET). As of 2011, 20 jurisdictions with high AIDS prevalence are funded to conduct NHBS. NHBS activities include assessing and monitoring trends in HIV risk, testing behaviors and access to preventive services among MSMs, IDUs and high-risk heterosexuals (HET).


29%

43%

12%

16%

Figure 34. Condom use among MSM, Georgia 2009, 2010

Did not use condoms

Used condoms en.re .me

Used condoms par.ally

Unknown

The Georgia Department of Public Health collaborated with Emory University to conduct behavioral surveillance within the metropolitan statistical area (MSA) of Atlanta during the first two cycles of data.

Risk Behaviors of MSMs in the Atlanta MSA – NHBS Cycle 2

Data collection for the second MSM cycle was conducted between September and December 2008. Venue based sampling was used in recruit-ing the MSM population. A total of 382 eligible participants completed the survey.

MSM reported their last MSM sex partner was a main sex partner (74%) rather than with a casual (23%) or exchange partner (3%). Of 157 MSM who reported having insertive anal sex during their last sexual encounter, 45 (29%) did not use condoms. Of the 86 (43%) who reported using condoms during insertive anal sex, 19 (22%) did not use a condom the entire time. Of 180 MSM who reported engaging

Table 37. Alcohol Use among MMP Participants, Georgia 2009, 2010Heavy drinking behavior in past 30 days

Male (N=141) N (%)

Female (N=66)N (%)

Total (N=207)N (%)

No 136 96 61 92 197 95Yes 5 4 5 8 10 5

Binge drinking behavior in past 30 daysMale (N=141) Female (N=66) Total (N=207)

No 105 74 53 80 158 76Yes 36 26 13 20 49 24

Drinking before or during sex in the last 12 months*Male (N=141)

N (%)Female (N=66)N (%)

Total (N=207)N (%)

No 80 57 41 62 121 58Yes 60 43 25 38 85 42

Excluding alcoholN refers to the number of participants who responded to a specific question

*Categories are not mutually exclusive


in receptive anal sex at last encounter, 49% (88) did not use a condom or if a condom was initiated, 22% (40) did not continue use during the entire encounter. MSM revealed that 35% (114) met their last sexual partner at a bar/club and 23% (74) met over the internet.

Of the 382 participants in MSM Cycle 2, 335 (88%) reported having an HIV test in their lifetime. Of the 382 tested in the study, 24 (6%) were HIV positive and one was indeterminate. The HIV positive racial/ethnic distribution was 12 Whites, 10 Blacks and 2 Hispanics. Only 3 (1%) of the MSMs tested were unaware of their HIV positive status.

Risk Behaviors of IDUs in the Atlanta MSA – NHBS Cycle 2

Data collection for the second IDU cycle was conducted between September and December 2009. Respondent driven sampling was the methodology used in recruiting the IDU population. A total of 466 IDUs participated in cycle 2 data collection.

The IDU population reported injecting heroin (60%), combining heroin and powdered cocaine (16%), crack cocaine (15%) and crystal meth (8%). Other issues such as injection paraphernalia sharing was still present among this population, 156 (33%) reported sharing syringes and 373 (80%) reported sharing other paraphernalia such as cotton, water, and cooker at last use. Over two-thirds (69%) reported not knowing their injecting partner’s HIV status, about one-third (32%) stated their last injecting partner was MSM. 377 (81%) reported not knowing their injecting partner’s Hepatitis C status. There were 87 (19%) HIV infected participants in this cycle.

Of the 87 IDUs that were positive for HIV, 43 (49%) were aware of being HIV positive at the time of their test. 145 (31%) of the total IDU participants reported ever being told by a physician that they had hepatitis. 46 (32%) reported having Hepatitis B and 110 (76%) reported Hepatitis C. 275 (59%) of all participants reported being tested for HCV. Ninety percent of those aware of their HCV status reported knowing it for a year or longer and 125 (86%) of them reported not being given medicine to treat HCV.

Table 38. HIV & HCV Prevalence among IDUs by Race/Ethnicity†

Race/Ethnicity HIV+N %

HCV +N %

*Black 63 72 69 66

*White 21 31 21 20

Hispanic 4 5 4 4*Multi-racial 3 3 7 7

†HIV and HCV Positive Diagnoses only among population *Non-HispanicOf the 87 IDUs that were positive for HIV, 49% (43) were aware of being HIV positive at time of test. Thirty-one percent (145) reported ever being told by a

physician that they had hepatitis, of these 32% (46) reported having Hepatitis B and 76% (110) reported Hepatitis C. Fifty-nine percent (275) reported being tested for HCV. Ninety percent of those aware of their HCV status reported knowing it for a year or longer and 86% (125) of them reported not being given

medicine to treat HCV.

66

APPENDICES

67

Appendix A. Population of the EMA by Race/Ethnicity, 2011

White Black Asian Other Race Hispanic

Barrow 51,720 8,116 2,371 1,340 6,365Bartow 79,426 10,419 812 1,820 7,944Carroll 80,634 20,312 882 2,193 7,138Cherokee 175,942 13,001 3,754 3,924 21,665Clayton 40,478 167,731 12,852 5,108 35,363Cobb 390,507 173,068 32,061 14,440 87,477Coweta 93,567 22,599 2,020 2,376 9,067DeKalb 210,513 371,907 36,120 12,595 68,758Douglas 65,175 51,914 2,091 2,723 11,452Fayette 72,418 21,930 4,311 2,074 7,051Forsyth 144,197 5,495 12,026 2,616 17,506Fulton 388,403 412,942 53,992 17,570 76,692Gwinnett 357,414 193,377 87,977 16,927 169,246Henry 107,654 76,362 6,367 4,476 12,501Newton 52,355 40,769 998 1,876 4,816Paulding 106,958 24,737 1,367 2,896 7,584Pickens 27,609 435 128 392 851Rockdale 34,946 39,113 1,593 1,591 8,522Spalding 38,809 21,035 595 1,055 2,539Walton 65,711 13,460 1,020 1,301 3,088

EMA 2,584,436 1,688,722 263,337 99,293 565,625

68

Appendix B. Median Ages in Years by County, EMA, 2011All Male Female White Black

Barrow 34.0 33.0 35 .1 35 .3 32.9Bartow 36 .6 35 .8 37 .5 38 .1 31 .8Carroll 33 .8 32.9 34 .8 36 .5 27.4

Cherokee 36 .7 36.0 37 .5 37 .8 31 .6Clayton 31.7 30.0 33.2 43.2 30.5

Cobb 35 .7 34 .5 36 .8 39 .7 30.8Coweta 37.0 36 .1 37 .8 38 .6 32.6DeKalb 34 .5 33 .1 36.0 39 .3 33 .1

Douglas 35 .4 34 .1 36 .5 40.3 31.0Fayette 43.1 42.0 44.1 45.2 38.5Forsyth 37 .3 36 .8 37 .8 38 .4 33.2Fulton 34 .3 33 .3 35.2 38 .4 32.3

Gwinnett 34.0 32.7 35 .1 38 .8 30.4Henry 35 .7 34 .4 36 .7 38 .8 32.3

Newton 35.2 33 .4 36 .6 39.0 31 .5Paulding 34 .3 33 .4 35.2 35.1 31 .3

Pickens 43.0 42.1 43 .9 42.6 36.2Rockdale 37 .4 35 .6 38 .7 45.8 32.5Spalding 37 .5 35 .8 39.0 41 .4 30.9

Walton 38.0 37.0 38 .8 39 .1 31 .9

EMA 35.7 34.5 36.8 38.9 31.9

69

Appendix C. Proportions of Age by County in the EMA, 2011

Age in Years <13 13-19 20-29 30-39 40-49 50-59 60+Barrow 21% 9% 13% 15% 14% 12% 14%Bartow 19% 10% 13% 13% 15% 13% 16%Carroll 18% 11% 16% 13% 13% 12% 16%Cherokee 20% 10% 11% 15% 16% 13% 15%Clayton 21% 11% 15% 15% 15% 12% 11%Cobb 18% 10% 14% 15% 16% 13% 14%Coweta 19% 10% 12% 14% 16% 13% 17%DeKalb 18% 9% 16% 16% 15% 13% 14%Douglas 20% 11% 12% 15% 16% 13% 14%Fayette 16% 12% 8% 9% 17% 17% 21%Forsyth 22% 10% 8% 14% 19% 12% 14%Fulton 17% 10% 16% 16% 15% 12% 14%Gwinnett 21% 11% 13% 15% 16% 13% 11%Henry 20% 12% 11% 14% 17% 13% 14%Newton 20% 11% 12% 14% 15% 12% 16%Paulding 21% 11% 12% 16% 17% 12% 12%Pickens 16% 8% 10% 12% 14% 15% 25%Rockdale 18% 11% 12% 13% 15% 14% 17%Spalding 18% 9% 13% 13% 13% 13% 20%Walton 19% 10% 11% 13% 15% 13 % 18%

Median 19% 10% 12% 14% 15% 13% 14%

70

Appendix D. Household/Per Capita Income by County, General and Ryan WhitePopulations, 2011

Household Gen $1

Household RW $2

Per Capita Gen $3

Uninsured Rate HIV Cases

Barrow 50,604 13,956 20,740 23% 119Bartow 49,060 12,270 22,324 21% 262Carroll 45,752 12,542 20,739 21% 311

Cherokee 66,717 11,148 29,968 17% 358Clayton 42,936 10,124 18,835 23% 2,364

Cobb 65,423 9,600 33,514 20% 2,820Coweta 61,015 14,033 26,117 17% 260DeKalb 51,712 8,424 28,843 23% 10,365

Douglas 54,763 10,075 24,547 20% 296Fayette 81,498 15,834 35,405 10% 213Forsyth 88,262 9,234 35,277 13% 111Fulton 88,262 8,088 35,277 23% 20,694

Gwinnett 63,076 11,554 26,712 23% 2,061Henry 64,251 9,256 25,949 16% 295

Newton 51,691 11,420 21,246 21% 244Paulding 51,691 7,878 21,246 16% 92

Pickens 50,582 4 26,206 20% 26Rockdale 55,819 9,936 24,606 21% 182Spalding 41,163 10,938 19,547 22% 32

Walton 51,347 9,264 22,993 20% 112

Median 53,238 10,124 25,278 21%1 Household income in the general population 2 Household income in Ryan White Clients

3 Per capita income in the general population 4 too few clients to analyze

71Abbreviations Used In This Profile

Abbreviations Used In This Profile

AIDS . . . . . . . . . . . . . . . . . Acquired Immuno-Deficiency Syndrome (Stage III HIV infection)

ART . . . . . . . . . . . . . . . . . . Anti Retroviral Therapy

CAREWare . . . . . . .Software from HRSA/HAB, distributed at no charge by HAB within HRSA

CDC . . . . . . . . . . . . . . . . . .Centers for Disease Control and Prevention

DHHS . . . . . . . . . . . . . . . Department of Health and Human Services

DPH . . . . . . . . . . . . . . . . . . Department of Public Health

eHARS . . . . . . . . . . . . . . Electronic HIV AIDS Reporting System

ELR . . . . . . . . . . . . . . . . . . . Electronic Lab Reporting

EMA . . . . . . . . . . . . . . . . . Atlanta Eligible Metropolitan Area

FPL . . . . . . . . . . . . . . . . . . . Federal Poverty Level

HAB . . . . . . . . . . . . . . . . . . HIV/AIDS Bureau

HAEP . . . . . . . . . . . . . . . . HIV/AIDS Epidemiology Program

HET . . . . . . . . . . . . . . . . . . Heterosexual

HIV non-AIDS . . . HIV infection without the diagnosis of AIDS (Stage I and II HIV infection)

HRSA . . . . . . . . . . . . . . . . Health Resources and Services Administration

IDU . . . . . . . . . . . . . . . . . . . Injecting Drug User

MSA . . . . . . . . . . . . . . . . . Metropolitan Statistical Area

MMP . . . . . . . . . . . . . . . . Medical Monitoring Project

MSM . . . . . . . . . . . . . . . . Men who have Sex with Men

NIR . . . . . . . . . . . . . . . . . . . No Identified Risk

NRR . . . . . . . . . . . . . . . . . . No Reported Risk

PERI . . . . . . . . . . . . . . . . . Perinatal

Period . . . . . . . . . . . . . . The period of time January 1, 2007 through December 31, 2011

PWH . . . . . . . . . . . . . . . . People with HIV

PLWHA . . . . . . . . . . . . . People Living With HIV and/or AIDS

PWHA . . . . . . . . . . . . . . People With HIV and/or AIDS

TGA . . . . . . . . . . . . . . . . . . Transitional Grant Area

an epidemiological profile of hiv/aids in the atlanta ema...

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