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Home My WebLink Abouthiv-report-2013-2015-archiveHIV Epidemiology & Surveillance Unit Alameda County Public Health Department HIV in Alameda County, 2013-2015 HIV in Alameda County, 2013-2015 February 2017 HIV Epidemiology and Surveillance Unit HIV STD Section Division of Communicable Disease Control and Prevention Alameda County Public Health Department HIV in Alameda County, 2013-2015 ii Alameda County Public Health Department Director & Health Oﬃcer Muntu Davis, MD, MPH Division of Communicable Disease Control and Prevention Director Erica Pan, MD, MPH HIV STD Section Director Nicholas J. Moss, MD, MPH HIV Epidemiology and Surveillance Unit Director Neena Murgai, PhD, MPH Epidemiologists Richard J. Lechtenberg, MPH, CPH Janet Tang, PhD, MPH Surveillance Clerk Danielle Coggins Public Health Investigators Jesus Altamirano George Banks, MD Oliver Heitkamp Maria Hernandez Alameda County Public Health Department HIV Epidemiology and Surveillance Unit 1000 Broadway, Suite 310 Oakland, CA 94607 Phone: (510) 268-2372 Fax: (510) 208-1278 Email: Neena.Murgai@acgov.org HIV in Alameda County, 2013-2015 iii Acknowledgements This report was produced by the HIV Epidemiology and Surveillance Unit. Richard Lechtenberg, MPH, CPH conducted data analysis and compiled ﬁndings. Overall guidance on analysis and content as well as editorial review were provided Neena Murgai, Ph.D., MPH. Review and comments were provided by Janet Tang, Ph.D., MPH. Case investigation, data collection, and data management were conducted by the HIV Surveillance Team: Jesus Altamirano, George Banks, Oliver Heitkamp, Maria Hernandez, and Danielle Coggins. Cover Photo: “Dusk in the Oakland Hills” by Joe Parks is licensed under CC BY 2.0, https://commons.wikimedia.org/w/index.php?curid=26550998. This report is available online at http://www.acphd.org/data-reports/reports-by-topic/hivaids.aspx. Suggested citation for this report: Alameda County Public Health Department. HIV in Alameda County, 2013-2015. http://www.acphd.org/data-reports/reports-by-topic/hivaids.aspx. Published February 2017. Accessed [date]. HIV in Alameda County, 2013-2015 iv Contents 1 Background 1 Overview of this Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Deﬁnitions Used in this Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Other Conventions Used . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 2 New Diagnoses 5 Characteristics of New Diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Diagnosis Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Timeliness of Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 3 People Living with HIV 27 Characteristics of PLHIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Prevalence Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Deaths Among PLHIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 4 The Continuum of HIV Care 39 The Overall Continuum of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 Linkage to Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 Retention in Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 Virologic Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 Appendix A: Technical Notes 66 Data Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Statistical Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Data Suppression Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66 Death Ascertainment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 Appendix B: Reporting Requirements 68 Health Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 Appendix C: HIV Surveillance in Alameda County 71 Security and Conﬁdentiality of Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 Bibliography 74 HIV in Alameda County, 2013-2015 v List of Figures 1.1 Regions of Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 1.2 Neighborhoods in the City of Oakland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 2.1 New Diagnoses by Sex, Alameda County, 2006-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 2.2 New Diagnoses by Sex and Mode of Transmission, Alameda County, 2013-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 2.3 New Diagnoses by Race/Ethnicity, Alameda County, 2013-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 2.4 Age of New Diagnoses, Alameda County, 2013-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 2.5 Geographic Distribution of New HIV Cases by Residence at HIV Diagnosis, Alameda County, 2013-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 2.6 Residence at HIV Diagnosis, Oakland and Surrounding Area, 2013-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 2.7 Rates of New Diagnoses by Sex, Alameda County, 2013-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 2.8 Trends in Rates of New Diagnoses by Sex, Alameda County, 2006-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 2.9 Rates of New Diagnoses by Race/Ethnicity, Alameda County, 2013-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 2.10 Trends in Rates of New Diagnoses by Race/Ethnicity, Alameda County, 2006-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 2.11 Trends in Rates of New Diagnoses by Race/Ethnicity and Sex, Alameda County, 2006-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 2.12 Rates of New Diagnoses by Age, Alameda County, 2013-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 2.13 Trends in Rates of New Diagnoses by Age, Alameda County, 2006-2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 2.14 Late Diagnosis by Race/Ethnicity, Alameda County, 2012-2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 2.15 Late Diagnosis by Sex, Alameda County, 2012-2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 vi 2.16 Late Diagnosis by Age, Alameda County, 2012-2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 2.17 First CD4 Count at Diagnosis by Race/Ethnicity, Alameda County, 2012-2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 2.18 First CD4 Count at Diagnosis by Sex, Alameda County, 2012-2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 2.19 First CD4 Count at Diagnosis by Age, Alameda County, 2012-2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 3.1 PLHIV by Sex, Alameda County, year-end 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 3.2 PLHIV by Race/Ethnicity, Alameda County, year-end 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 3.3 Age of PLHIV, Alameda County, year-end 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 3.4 Prevalence of HIV by Sex, Alameda County, year-end 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 3.5 Prevalence of HIV by Race/Ethnicity, Alameda County, year-end 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 3.6 Prevalence of HIV by Age, Alameda County, year-end 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 3.7 Prevalence of HIV by Census Tract of Residence, Alameda County, year-end 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 3.8 Prevalence of HIV by Census Tract of Residence, Oakland and Surrounding Area, year-end 2015 . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 3.9 Death Rate among Alameda County Residents Ever Diagnosed with AIDS, 1985-2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 4.1 The Continuum of HIV Care in Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . .40 4.2 Days Between Diagnosis and First CD4 or Viral Load, Alameda County, 2012-2014 . . . . . . . .41 4.3 Linkage to HIV Care within 90 Days of Diagnosis by Sex, Alameda County, 2012-2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 4.4 Linkage to HIV Care within 90 Days of Diagnosis by Race/Ethnicity, Alameda County, 2012-2014 42 4.5 Linkage to HIV Care within 90 Days of Diagnosis by Age, Alameda County, 2012-2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 4.6 Number of HIV Care Visits per PLHIV in 2014, Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 4.7 Retention in HIV Care by Sex, Alameda County, 2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 4.8 Retention in HIV Care by Race/Ethnicity, Alameda County, 2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 4.9 Retention in HIV Care by Age, Alameda County, 2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 4.10 Virologic Status by Sex, Alameda County, 2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 HIV in Alameda County, 2013-2015 vii 4.11 Virologic Status by Race/Ethnicity, Alameda County, 2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 4.12 Virologic Status by Age, Alameda County, 2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45 A.1 Timeline of Mandated HIV Reporting in California . . . . . . . . . . . . . . . . . . . . . . . . .72 A.2 The HIV Surveillance System in Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . .73 HIV in Alameda County, 2013-2015 viii List of Tables 2.1 New HIV Diagnoses, Alameda County, 2013-2015 . . . . . . . . . . . . . . . . . . . . . . . . . .16 2.2 HIV Diagnosis Rates by Sex and Age, Alameda County, 2013-2015 . . . . . . . . . . . . . . . . .18 2.3 HIV Diagnosis Rates by Sex and Race/Ethnicity, Alameda County, 2013-2015 . . . . . . . . . . .19 2.4 HIV Diagnosis Rates by Race/Ethnicity and Age, Alameda County, 2013-2015 . . . . . . . . . . .20 2.5 Late Diagnosis by Sex and Age, Alameda County, 2012-2014 . . . . . . . . . . . . . . . . . . . . .23 2.6 Late Diagnosis by Sex and Race/Ethnicity, Alameda County, 2012-2014 . . . . . . . . . . . . . . .24 2.7 Late Diagnosis by Race/Ethnicity and Age, Alameda County, 2012-2014 . . . . . . . . . . . . . .25 3.1 People Living with HIV Disease and Prevalence Rates, Alameda County, Year-End 2015 . . . . . .33 3.2 HIV Prevalence by Sex and Age, Alameda County, Year-End 2015 . . . . . . . . . . . . . . . . . .35 3.3 HIV Prevalence by Sex and Race/Ethnicity, Alameda County, Year-End 2015 . . . . . . . . . . .36 3.4 HIV Prevalence by Race/Ethnicity and Age, Alameda County, Year-End 2015 . . . . . . . . . . .37 4.1 Timely Linkage to HIV Care Among New Diagnoses by Sex and Age, Alameda County, 2012-2014 46 4.2 Timely Linkage to HIV Care Among New Diagnoses by Sex and Race/Ethnicity, Alameda County, 2012-2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 4.3 Timely Linkage to HIV Care Among New Diagnoses by Race/Ethnicity and Age, Alameda County, 2012-2014 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 4.4 Engagement in HIV Care in 2014 Among PLHIV at Year-End 2013 by Sex and Age, Alameda County 50 4.5 Engagement in HIV Care in 2014 Among PLHIV at Year-End 2013 by Sex and Race/Ethnicity, Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 4.6 Engagement in HIV Care in 2014 Among PLHIV at Year-End 2013 by Race/Ethnicity and Age, Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 4.7 Retention in Continuous HIV Care in 2014 Among PLHIV at Year-End 2013 by Sex and Age, Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 4.8 Retention in Continuous HIV Care in 2014 Among PLHIV at Year-End 2013 by Sex and Race/Ethnicity, Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56 4.9 Retention in Continuous HIV Care in 2014 Among PLHIV at Year-End 2013 by Race/Ethnicity and Age, Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 4.10 Viral Suppression in 2014 Among PLHIV at Year-End 2013 by Sex and Age, Alameda County . .60 4.11 Viral Suppression in 2014 Among PLHIV at Year-End 2013 by Sex and Race/Ethnicity, Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 4.12 Viral Suppression in 2014 Among PLHIV at Year-End 2013 by Race/Ethnicity and Age, Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62 ix 4.13 Viral Suppression in 2014 Among PLHIV at Year-End 2013 and in Care in 2014 by Sex, Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64 4.14 Viral Suppression in 2014 Among PLHIV at Year-End 2013 and in Care in 2014 by Race/Ethnicity, Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 4.15 Viral Suppression in 2014 Among PLHIV at Year-End 2013 and in Care in 2014 by Age, Alameda County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 HIV in Alameda County, 2013-2015 x Background 1 Background Overview of this Report This report is based on human immunodeﬁciency virus (HIV) case surveillance in Alameda County. It summarizes data on HIV in three chapters as described below. 1.New Diagnoses: This chapter describes patterns of HIV diagnosis in Alameda County, characterizing those who were recently diagnosed according to demographic factors, risk factors and stage of disease. 2.People Living with HIV: The second chapter of the report describes the characteristics of all people known to be living with HIV disease (PLHIV) in Alameda County. This chapter describes the total burden of HIV disease in the county and how it varies by demographic factors as well as by geography. It also describes changes in mortality rates (deaths) over time among those ever diagnosed with Acquired Immune Deﬁciency Syndrome (AIDS). 3.The Continuum of HIV Care: The ﬁnal chapter of this report presents the continuum of HIV care in Alameda County. Modern medical treatments for HIV can halt the progression of the disease and prevent its spread, but not all persons living with HIV receive eﬀective treatment. The continuum of HIV care (also known as the “HIV care cascade”) is a framework that presents diﬀerent indicators of engagement in HIV care among PLHIV, including linkage to care, retention in care, and viral suppression. HIV/AIDS HIV attacks the immune system, weakening it over time such that HIV-infected persons become increasingly susceptible to opportunistic infections and other medical conditions. The most advanced stage of infection, when the immune system is weakest, is called AIDS. Medical treatments can inhibit HIV’s ability to replicate and greatly temper its eﬀect, but the human body cannot clear HIV. HIV primarily is transmitted through unprotected sex, needle-sharing, or spread from mother to fetus during pregnancy. Deﬁnitions Used in this Report Stages of HIV Infection For surveillance purposes, HIV disease progression is classiﬁed into 4 stages from acute infection (Stage 0) to AIDS (Stage 3). In this report, we use “HIV” to refer to HIV disease at any stage (including Stage 3/AIDS) and AIDS to refer speciﬁcally to Stage 3 HIV disease. We use the acronym “PLHIV” to refer to all people living with HIV disease, regardless of stage. HIV in Alameda County, 2013-2015 1 Background Case Deﬁnition All reported HIV cases must meet the Centers for Disease Control and Prevention (CDC) case deﬁnition based on laboratory or clinical criteria. [3] Clinical criteria include a medical provider diagnosis and evidence of HIV treatment, unexplained low CD4 count, or opportunistic infection. The full criteria may be found at http: //www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm. Transmission Category For surveillance purposes, each reported HIV case must be classiﬁed according to their risk factors for acquiring HIV. Cases with multiple risk factors are assigned a transmission category, the risk factor most likely to have re- sulted in HIV transmission according to a hierarchy developed by the CDC. In this context, “heterosexual contact” refers to sexual contact with a partner of the opposite sex with a known risk factor for HIV. In some cases, part- ners’ risk factors are unknown, leaving some heterosexual cases without known HIV risk factors. Such cases are assigned to the “unknown” transmission category. The only exception is when a case’s sex at birth is female and she reported sex with males, in which case she is presumed to have been infected through heterosexual contact in accordance with CDC-accepted guidance set by the Council of State and Territorial Epidemiologists. [6] Demographics Demographic data in this report are based on investigations of medical records. Although the transgender commu- nity is highly impacted by HIV, data on current gender identity are not reliably captured in medical records. For this reason, all analyses are presented by sex assigned at birth, for which we use “sex” as shorthand. Data from racial/ethnic groups in which there were very small numbers were combined for these analyses. Asians and Paciﬁc Islanders are combined into a single category. American Indians, Alaskan Natives, and those identifying with multiple races are combined along with those of unknown race into another group (“Other/Unk”). In tables and charts, the category “Asians and Paciﬁc Islanders” is abbreviated “API” and “African American” is abbreviated “AfrAmer”. Geographic Area Residential addresses are geocoded to census tract and city/Census-designated place. Region and neighborhood boundaries established by the Alameda County Community Assessment, Planning, and Evaluation (CAPE) unit based on census tract aggregates are used. These geographic areas are shown in Figures 1.1 and 1.2. HIV in Alameda County, 2013-2015 2 Background Figure 1.1: Regions of Alameda County Figure 1.2: Neighborhoods in the City of Oakland HIV in Alameda County, 2013-2015 3 Background Other Conventions Used Indicators that are broken out by subgroup (e.g., race/ethnicity) are presented along with the overall group total (e.g., all races) for comparison. Where rates are presented, they are often accompanied by error bars to convey their degree of statistical variability. These error bars depict 95% conﬁdence intervals (a “margin of error”) for the estimates. (In the case of trends, error bands formed by connecting the ends of these margins of error are shown.) Conﬁdence intervals are displayed in select subgroup analyses of indicators. Conﬁdence intervals that do not overlap are considered “statistically signiﬁcant” and generally represent true diﬀerences that are not attributed to chance alone, though it is still possible. Details regarding how these conﬁdence intervals are calculated can be found in the technical notes (see “Calculation of Conﬁdence Intervals” on page 66). Tables showing breakdowns of populations (e.g., new diagnoses, people living with HIV) for indicators (e.g., diag- nosis rates, viral suppression) by demographic or other subgroup are included at the end of each chapter. Note that in each table the length of the green bar is proportional to the fraction of the total population in that subgroup. Ad- ditionally, estimates of each indicator and lines depicting 95% conﬁdence intervals for the estimate are also shown for absolute comparisons between subgroups. Relative comparisons of subgroups (e.g., “Late diagnosis is three times as common in group A as it is in group B”) may be made by comparing estimates, when shown. Unreliable estimates are not shown in tables, although their conﬁdence intervals may be. Details on data suppression can be found in the technical notes (see “Data Suppression Rules” 4 on page 66). Lastly, in order to protect privacy, case counts less than ﬁve are not presented in this report. HIV in Alameda County, 2013-2015 4 New Diagnoses 2 New Diagnoses Estimating the incidence of new HIV infections is complex due to the variable time interval between when a person becomes infected and when their infection is diagnosed. However, due to reporting requirements, surveillance data reliably describe new HIV diagnoses. In 2015, there were an estimated 39,513 new diagnoses of HIV infection in the US for an overall diagnosis rate of 12.3 per 100,000 persons. Rates were highest among men as compared to women (24.4 vs. 5.4 diagnoses per 100,000), those aged 20-24 or 25-29 (31.2 and 33.4 per 100,000, respectively), African Americans and Latinos (44.3 and 16.4 per 100,000), and in the South and Northeast (16.8 and 11.6 per 100,000). Men who have sex with men (MSM), including those that inject drugs, accounted for 70% of all infections, heterosexual contact accounted for 24%, and other modes of transmission accounted for the remaining 6%. [4] In California, there were an estimated 5,002 new diagnoses for an overall statewide rate of 13.0 diagnoses per 100,000 in 2014. The epidemiology of HIV in Alameda County largely mirrored that in the nation, with the exception that heterosexual contact was believed to account for only about 18% of all new diagnoses among Alameda County residents. [1] The sections below describe HIV in Alameda County by examining characteristics of new diagnoses, new diagnosis rates, and the timeliness of diagnoses by demographic characteristics. Data presented in this chapter are also sum- marized in Table 2.1. Detailed stratiﬁcation of newly diagnosed cases in 2013-2015 by sex, age and race/ethnicity are provided in Tables 2.2 - 2.7 at the end of this chapter. HIV in Alameda County, 2013-2015 5 New Diagnoses Characteristics of New Diagnoses Since HIV became reportable by name in California in 2006, between 200 and 300 new cases of HIV disease have been reported each year among Alameda County residents. In Alameda County, those newly diagnosed with HIV disease were overwhelmingly male. The proportion of new diagnoses among males increased steadily from 77.1% in 2006 to 87.6% in 2012 before decreasing over the subsequent 2 years to 83.1% in 2015. Figure 2.1: New Diagnoses by Sex, Alameda County, 2006-2015 20% 40% 60% 80% 100% 2006 (N=284) 2007 (N=307) 2008 (N=235) 2009 (N=273) 2010 (N=234) 2011 (N=212) 2012 (N=234) 2013 (N=213) 2014 (N=204) 2015 (N=261) Male Female NOTE: “Sex” here refers to sex assigned at birth. Among the 575 men diagnosed with HIV from 2013 to 2015, the overwhelming majority were men who have sex with men (MSM). Nearly eight in ten newly diagnosed women were reported to or presumed to have become infected by a heterosexual sex partner who had a documented HIV risk factor; nearly all the remaining women were through injection drug use (IDU). Figure 2.2: New Diagnoses by Sex and Mode of Transmission, Alameda County, 2013-2015 Female (N=103) Male (N=575) 0%10%20%30%40%50%60%70%80%90%100% MSM MSM & IDU IDU Heterosexual Contact Presumed Heterosexual Contact Unknown NOTES: “Sex” here refers to sex assigned at birth. HIV in Alameda County, 2013-2015 6 New Diagnoses From 2013 to 2015, the largest proportion of new HIV diagnoses was among African Americans, who comprised about 40% of new diagnoses. Whites and Latinos each comprised nearly a quarter and Asians and Paciﬁc Islanders 11% of new diagnoses. Figure 2.3: New Diagnoses by Race/Ethnicity, Alameda County, 2013-2015 23% 2.8% 10.9% 38.3% 24.9% Other/Unk API Latino White AfrAmer 0 100 200 300 Number of Cases NOTE: “Other/Unk” includes American Indians, Alaskan Natives, and those identifying with multiple racial categories as well as those for whom race/ethnicity could not be identiﬁed. The median age among Alameda County residents diagnosed with HIV disease from 2013 to 2015 was 35 years. Most diagnoses were among those in their twenties to forties. Figure 2.4: Age of New Diagnoses, Alameda County, 2013-2015 27.0 35.0 47.0 0 20 40 60 80 0 20 40 60 80 Age in years at first HIV diagnosis Nu m b e r o f C a s e s NOTE: The dashed lines indicate the 25th, 50th, and 75th percentile values for age among the new diagnoses. HIV in Alameda County, 2013-2015 7 New Diagnoses New diagnoses of HIV were most concentrated in the Oakland area and in the central county region (as deﬁned in 1.1 on page 3). Figure 2.5: Geographic Distribution of New HIV Cases by Residence at HIV Diagnosis, Alameda County, 2013-2015 Contra Costa San Joaquin San Mateo Santa Clara Fremont Sunol Oakland Hayward Livermore Dublin Pleasanton Union City Newark Berkeley San Leandro Alameda Castro Valley Fairview Alameda Albany San Lorenzo Ashland Piedmont Emeryville Cherryland 0 5 102.5 Miles± San Francisco Bay NOTE: N=628; an additional 22 diagnoses (3.38% of all) are not repre- sented due to incomplete street address. Within the Oakland area, new diagnoses were less concentrated in the Oakland hills (Northwest Hills, Southeast Hills, and Lower Hills neighborhoods) than the rest of the city. Figure 2.6: Residence at HIV Diagnosis, Oakland and Surrounding Area, 2013-2015 San Francisco Oakland Berkeley San Leandro Alameda Castro Valley Alameda Albany Piedmont Emeryville Elmhurst Lower HillsWest Oakland Fruitvale Central East Oakland San Antonio Southeast Hills Northwest Hills North Oakland Downtown and Chinatown Contra Costa San Francisco Bay 0 1.5 30.75 Miles ±Oaklandneighborhoods Cities HIV in Alameda County, 2013-2015 8 New Diagnoses Diagnosis Rates This section examines trends in HIV diagnosis rates. Diagnosis rates do not necessarily mean HIV incidence. Trends in diagnosis rates may reﬂect changes over time in HIV incidence, but may also reﬂect changes in HIV testing practices. For example, HIV incidence could decrease while HIV diagnosis rates increase if more HIV- unaware persons are tested and diagnosed. Due to small numbers of diagnoses occurring in Alameda County in any given year, annual diagnosis rates may be statistically unstable. We performed statistical analyses to identify trends that are least likely to reﬂect random year-to-year variability and indicated signiﬁcance in captions;apparent trends do not indicate statistical signiﬁcance unless speciﬁed. From 2013 to 2015, there were 678 new HIV diagnoses with an annual rate of 14.4 per 100,000 residents in Alameda County. New diagnosis rates were nearly six times higher among males than among females during 2013-2015. Figure 2.7: Rates of New Diagnoses by Sex, Alameda County, 2013-2015 14.4 24.9 4.3 Female (N=103) Male (N=575) All (N=678) 0 10 20 30 Annual Diagnosis Rate per 100,000 NOTE: “Sex” here refers to sex assigned at birth. HIV diagnosis rates declined steadily between 2006 and 2015, decreasing by an average 3.6% annually overall, 2.4% annually among males, and 9.2% annually among females. Rates have consistently been higher in men. Figure 2.8: Trends in Rates of New Diagnoses by Sex, Alameda County, 2006-2015 0 10 20 30 40 20 0 6 − 0 8 20 0 7 − 0 9 20 0 8 − 1 0 20 0 9 − 1 1 20 1 0 − 1 2 20 1 1 − 1 3 20 1 2 − 1 4 20 1 3 − 1 5 An n u a l D i a g n o s i s R a t e pe r 1 0 0 , 0 0 0 All Male Female NOTE: “Sex” here refers to sex assigned at birth. HIV in Alameda County, 2013-2015 9 New Diagnoses From 2013 to 2015, the highest diagnosis rate was among African Americans, which was more than three times higher than the second most impacted group, Latinos. The lowest diagnosis rate was seen among Asians and Paciﬁc Islanders. Figure 2.9: Rates of New Diagnoses by Race/Ethnicity, Alameda County, 2013-2015 14.4 49.1 10.9 14.4 5.6 API (N=74) Latino (N=156) White (N=169) AfrAmer (N=260) All races (N=678) 0 10 20 30 40 50 60 Annual Diagnosis Rate per 100,000 Diagnosis rates were relatively constant since 2006 in most racial/ethnic groups. The apparent increase in recent years was not a statistically signiﬁcant trend. However, the average annual decline in diagnosis rate of 4.9% among African Americans was statistically signiﬁcant. Figure 2.10: Trends in Rates of New Diagnoses by Race/Ethnicity, Alameda County, 2006-2015 0 25 50 75 100 20 0 6 − 0 8 20 0 7 − 0 9 20 0 8 − 1 0 20 0 9 − 1 1 20 1 0 − 1 2 20 1 1 − 1 3 20 1 2 − 1 4 20 1 3 − 1 5 An n u a l D i a g n o s i s R a t e pe r 1 0 0 , 0 0 0 All races AfrAmer White Latino API HIV in Alameda County, 2013-2015 10 New Diagnoses The overall decline in the county-wide diagnosis rate was driven largely by decreases in diagnoses among African Americans, and in particular, African American women, where rates decreased by 9.6% per year on average. Whereas there were 42.8 new diagnoses per 100,000 African American women in 2006-2008, that rate was more than halved by 2012-2014 to 18.2 new diagnoses per 100,000. Rates also declined among Latino women, by an average 7.8% per year. Among all males, the only signiﬁcant trend was a decline among African Americans of 3.2% per year on average. Figure 2.11: Trends in Rates of New Diagnoses by Race/Ethnicity and Sex, Alameda County, 2006-2015 Male Female 0 30 60 90 120 0 30 60 90 120 20 0 6 − 0 8 20 0 7 − 0 9 20 0 8 − 1 0 20 0 9 − 1 1 20 1 0 − 1 2 20 1 1 − 1 3 20 1 2 − 1 4 20 1 3 − 1 5 20 0 6 − 0 8 20 0 7 − 0 9 20 0 8 − 1 0 20 0 9 − 1 1 20 1 0 − 1 2 20 1 1 − 1 3 20 1 2 − 1 4 20 1 3 − 1 5 An n u a l D i a g n o s i s R a t e pe r 1 0 0 , 0 0 0 All races AfrAmer White Latino API NOTE: “Sex” refers to sex assigned at birth. From 2013 to 2015, new HIV diagnoses were most common among those in their tweinties, thirties, and forties, with an average 33.3, 23.2, and 21.2 diagnoses per 100,000 respectively. New HIV diagnoses were somewhat less common among those in their ﬁfties and least common among those at the extremes of the age spectrum (i.e., teens and those aged 60 & over). Figure 2.12: Rates of New Diagnoses by Age, Alameda County, 2013-2015 14.4 4.3 33.3 23.2 21.2 14.4 4.760 & over (N=40) 50−59 (N=93) 40−49 (N=143) 30−39 (N=159) 20−29 (N=225) 13−19 (N=18) All ages (N=678) 0 10 20 30 40 50 Annual Diagnosis Rate per 100,000 HIV in Alameda County, 2013-2015 11 New Diagnoses Figure 2.13: Trends in Rates of New Diagnoses by Age, Alameda County, 2006-2015 0 10 20 30 40 50 20 0 6 − 0 8 20 0 7 − 0 9 20 0 8 − 1 0 20 0 9 − 1 1 20 1 0 − 1 2 20 1 1 − 1 3 20 1 2 − 1 4 20 1 3 − 1 5 An n u a l D i a g n o s i s R a t e pe r 1 0 0 , 0 0 0 All ages 13−19 20−29 30−39 40−49 50−59 60 & over By age, diagnosis rates have decreased by an average of 5.9% per year among those 30-39 and 5.4% per year among those 40-49. While rates among those 60 & over decreased by an average of 17.1% per year through 2012, they have held steady since then. Rates in younger age groups appear to have largely held steady for the past decade. By age and race, the only signiﬁcant trends in diagnosis rates that were identiﬁed were among African Americans: 6.7% annual decline among those aged 30-39 and 50 & over and a 9.2% decline among those aged 40-49. Stratiﬁed diagnosis rates by sex, age and race/ethnicity are provided in tables at the end of this chapter. The disparity in diagnosis rates between African Americans and whites was more pronounced among females compared to males. While African American males had 4.1 times the diagnosis rates compared to whites diagnosed in 2013- 2015, African American females had 8.5 times the diagnosis rates of whites (Table 2.3). Timeliness of Diagnosis Diagnosis of HIV early in the course of infection is an important component of eﬀective HIV prevention and control as it reduces both the risk of transmission to others and, with treatment, the impact of HIV infection on a person’s health. Late Diagnosis A commonly-used indicator of late HIV diagnosis is the time to progression to AIDS (stage 3 infection). A diagnosis is considered to be late if AIDS is diagnosed at the same time as a person’s initial HIV diagnosis or if the person progresses to AIDS within one year of the initial HIV diagnosis. The analyses presented in this section are for 2012-2014 to allow a full year of follow-up from initial HIV diagnosis. Stratiﬁed analyses of late diagnosis by sex, HIV in Alameda County, 2013-2015 12 New Diagnoses age, and race/ethnicity is provided in tables at the end of this chapter. Apparent diﬀerences should be interpreted with caution due to the small numbers of diagnoses seen in some subgroups, resulting in statistical instability. In Alameda County, 35.9% of new diagnoses between 2012 and 2014 were late. Although whites and Asians and Paciﬁc Islanders appear to have the lowest rate and Latinos the highest, diﬀerences by race were not statistically signiﬁcant. Figure 2.14: Late Diagnosis by Race/Ethnicity, Alameda County, 2012-2014 31.9% 40.1% 32.9% 34.8% 35.9% API (N=72) Latino (N=152) White (N=152) AfrAmer (N=253) All races (N=651) 0%10%20%30%40%50% Percent with a late diagnosis There was no statistical diﬀerence in late diagnosis by sex. Figure 2.15: Late Diagnosis by Sex, Alameda County, 2012-2014 30.7% 36.8% 35.9% Female (N=88) Male (N=563) All (N=651) 0%10%20%30%40%50% Percent with a late diagnosis NOTE: “Sex” refers to sex assigned at birth. HIV in Alameda County, 2013-2015 13 New Diagnoses The proportion of late diagnoses generally increased with age: over half of HIV diagnoses among those aged 60 and over were late. Late diagnosis was less common among those aged 20 to 29—fewer than 3 in 10 were diagnosed late in this age group. Diﬀerences by age group and the trend of increasing rate of late diagnosis as age increased, were statistically signiﬁcant. Figure 2.16: Late Diagnosis by Age, Alameda County, 2012-2014 51.7% 40.2% 43.6% 34.2% 27.7% 30.4% 35.9% 60 & over (N=29) 50−59 (N=82) 40−49 (N=165) 30−39 (N=149) 20−29 (N=202) 13−19 (N=23) All ages (N=651) 0%20%40%60% Percent with a late diagnosis First CD4 Count CD4 cell count at the time of diagnosis is another indicator of the timeliness of HIV diagnosis. CD4+ T-cells, an important component of the human immune system, are infected and killed by the HIV virus. Anti-retroviral therapy (ART) allows the body to increase the CD4 count, but the longer a person goes without taking ART, which controls the level of HIV in their body, the lower their CD4 count will be and the more susceptible the person will be to opportunistic infections. Once a person’s CD4 count falls below 200cells/mm3, the person is considered to have AIDS.1 Among those diagnosed with HIV disease in 2012-2014 and for whom a CD4 count was conducted within 90 days, the median CD4 count at the time of diagnosis was 370.5 cells/mm3. Whites had the highest median CD4 count at diagnosis among all racial/ethnic groups and Asian Paciﬁc Islanders and Latinos the lowest. Figure 2.17: First CD4 Count at Diagnosis by Race/Ethnicity, Alameda County, 2012-2014 301.0 324.0 444.0 386.0 370.5 API (N=59) Latino (N=127) White (N=121) AfrAmer (N=192) All races (N=516) 0 100 200 300 400 500 Median CD4 1Note that the analyses presented in this section exclude 135 cases (20.7% of all diagnoses) with a ﬁrst CD4 count more than 90 days after diagnosis. HIV in Alameda County, 2013-2015 14 New Diagnoses Median CD4 within 90 days of diagnosis was comparable between males and females. This is consistent with the lack of diﬀerence in late diagnosis by sex. Figure 2.18: First CD4 Count at Diagnosis by Sex, Alameda County, 2012-2014 371.0 370.0 370.5 Female (N=73) Male (N=443) All (N=516) 0 100 200 300 400 500 Median CD4 NOTE: “Sex” refers to sex assigned at birth. Those aged 20-29 had a substantially higher median CD4 count at diagnosis than any other age group. Median CD4 count was generally lower in successively older age groups, with the possible exception of those aged 50-59. Those 60 and older had the lowest median CD4 count at diagnosis. However, data for this group and those aged 13-19 should be interpreted with caution due to small numbers. Figure 2.19: First CD4 Count at Diagnosis by Age, Alameda County, 2012-2014 258.0 350.5 301.0 370.5 427.0 430.0 370.5 60 & over (N=21) 50−59 (N=66) 40−49 (N=130) 30−39 (N=110) 20−29 (N=167) 13−19 (N=21) All ages (N=516) 0 100 200 300 400 500 Median CD4 HIV in Alameda County, 2013-2015 15 New Diagnoses Ta b l e 2 . 1 : N e w H I V D i a g n o s e s , A l a m e d a C o u n t y , 2 0 1 3 - 2 0 1 5 NO T E : Th i s ta b l e sp a n s mu l t i p l e pa g e s . Ch a r a c t e r i s t i c Ca t e g o r y Av e r a g e An n u a l Co u n t Pe r c e n t Av e r a g e A n n u a l Di a g n o s i s R a t e pe r 1 0 0 , 0 0 0 95 % Co n f i d e n c e In t e r v a l Al l D i a g n o s e s -- 22 6 . 0 10 0 . 0 % 14 . 4 12 . 5 - 1 6 . 3 Se x a Ma l e 19 1 . 7 84 . 8 % 24 . 9 21 . 4 - 2 8 . 4 Fe m a l e 34 . 3 15 . 2 % 4. 3 2. 9 - 5 . 7 Ra c e / E t h n i c i t y b Af r A m e r 86 . 7 38 . 3 % 49 . 1 38 . 8 - 5 9 . 5 Wh i t e 56 . 3 24 . 9 % 10 . 9 8. 0 - 1 3 . 7 La t i n o 52 . 0 23 . 0 % 14 . 4 10 . 5 - 1 8 . 3 AP I 24 . 7 10 . 9 % 5. 6 4. 4 - 7 . 1 Ot h e r / U n k 6. 3 2. 8 % -- -- Ag e ( y e a r s ) c 0- 1 2 0. 0 0. 0 % ** ** 13 - 1 9 6. 0 2. 7 % 4. 3 2. 6 - 6 . 9 20 - 2 9 75 . 0 33 . 2 % 33 . 3 25 . 7 - 4 0 . 8 30 - 3 9 53 . 0 23 . 5 % 23 . 2 16 . 9 - 2 9 . 4 40 - 4 9 47 . 7 21 . 1 % 21 . 2 15 . 2 - 2 7 . 2 50 - 5 9 31 . 0 13 . 7 % 14 . 4 11 . 6 - 1 7 . 6 60 & o v e r 13 . 3 5. 9 % 4. 7 3. 4 - 6 . 5 HIV in Alameda County, 2013-2015 16 New Diagnoses Ta b l e 2 . 1 : N e w H I V D i a g n o s e s , A l a m e d a C o u n t y , 2 0 1 3 - 2 0 1 5 ( c o n t i n u e d ) NO T E : Th i s ta b l e sp a n s mu l t i p l e pa g e s . Ch a r a c t e r i s t i c Ca t e g o r y Av e r a g e An n u a l Co u n t Pe r c e n t Av e r a g e A n n u a l Di a g n o s i s R a t e pe r 1 0 0 , 0 0 0 95 % Co n f i d e n c e In t e r v a l Re s i d e n c e No r t h C o u n t y 20 . 3 9. 0 % 15 . 1 11 . 5 - 1 9 . 3 Oa k l a n d A r e a 13 1 . 0 58 . 0 % 26 . 2 21 . 7 - 3 0 . 7 Ce n t r a l C o u n t y 43 . 0 19 . 0 % 11 . 6 8. 1 - 1 5 . 0 So u t h C o u n t y 18 . 3 8. 1 % 5. 4 4. 1 - 7 . 0 Tr i - V a l l e y 12 . 3 5. 5 % 5. 8 4. 1 - 8 . 0 Re m a i n d e r o f c o u n t y * * * * Un k n o w n * * -- -- So u r c e : Al a m e d a Co u n t y eH A R S , 20 1 6 Q2 [a] Re f e r s to se x as s i g n e d at bi r t h [b] 'O t h e r / U n k ' = Am e r i c a n In d i a n s an d Ala s k a n Na t i v e s , mu l t i p l e ra c e , un k n o w n ra c e [c] Ag e at di a g n o s i s [*] So m e ce l l s su p p r e s s e d to pr o t e c t co n f i d e n t i a l i t y . [** ] Un s t a b l e es t i m a t e s no t sh o w n . [-- ] Ra t e no t ca l c u l a b l e fo r la c k of a de n o m i n a t o r . HIV in Alameda County, 2013-2015 17 New Diagnoses Table 2.2: HIV Diagnosis Rates by Sex and Age, Alameda County, 2013-2015 Sexa Age Average Annual Count Percent Average Annual Diagnosis Rate per 100,000 95% Confidence Interval All All ages 226.0 100.0%14.4 12.5 - 16.3 0-4 0.0 0.0%**** 5-12 0.0 0.0%**** 13-19 6.0 2.7%4.3 2.6 - 6.9 20-24 32.3 14.3%28.3 23.0 - 34.6 25-29 42.7 18.9%38.3 26.8 - 49.9 30-39 53.0 23.5%23.2 16.9 - 29.4 40-49 47.7 21.1%21.2 15.2 - 27.2 50 & over 44.3 19.6%8.9 6.3 - 11.6 Male All ages 191.7 84.8%24.9 21.4 - 28.4 0-4 **** 5-12 0.0 0.0%**** 13-19 **** 20-24 29.0 12.8%50.1 40.1 - 61.8 25-29 39.7 17.6%70.9 48.8 - 92.9 30-39 45.3 20.1%40.3 28.6 - 52.1 40-49 40.0 17.7%35.9 24.8 - 47.0 50 & over 33.0 14.6%14.3 11.6 - 17.4 Female All ages 34.3 15.2%4.3 2.9 - 5.7 0-4 **** 5-12 0.0 0.0%**** 13-19 **** 20-24 3.3 1.5%**** 25-29 3.0 1.3%**** 30-39 7.7 3.4%6.6 4.2 - 9.9 40-49 7.7 3.4%6.7 4.3 - 10.1 50 & over 11.3 5.0%4.3 3.0 - 6.0 Source:Alameda County eHARS,2016 Q2 [a]Refersto sex assigned at birth [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 18 New Diagnoses Table 2.3: HIV Diagnosis Rates by Sex and Race/Ethnicity, Alameda County, 2013-2015 Sexa Race/ Ethnicityb Average Annual Count Percent Average Annual Diagnosis Rate per 100,000 95% Confidence Interval All All races 226.0 100.0%14.4 12.5 - 16.3 AfrAmer 86.7 38.3%49.1 38.8 - 59.5 White 56.3 24.9%10.9 8.0 - 13.7 Latino 52.0 23.0%14.4 10.5 - 18.3 API 24.7 10.9%5.6 4.4 - 7.1 Other/Unk 6.3 2.8%---- Male All races 191.7 84.8%24.9 21.4 - 28.4 AfrAmer 66.0 29.2%79.8 60.6 - 99.1 White 49.7 22.0%19.3 13.9 - 24.7 Latino 48.0 21.2%26.0 18.7 - 33.4 API **** Other/Unk **---- Female All races 34.3 15.2%4.3 2.9 - 5.7 AfrAmer 20.7 9.1%22.1 16.9 - 28.3 White 6.7 2.9%2.6 1.6 - 4.0 Latino 4.0 1.8%2.3 1.2 - 3.9 API **** Other/Unk **---- Source:Alameda County eHARS,2016 Q2 [a]Refersto sex assigned at birth [b]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [*]Some cells suppressed to protect confidentiality. [--]Rate not calculable forlack of a denominator. HIV in Alameda County, 2013-2015 19 New Diagnoses Table 2.4: HIV Diagnosis Rates by Race/Ethnicity and Age, Alameda County, 2013-2015 NOTE:This table spans multiple pages. Race/ Ethnicitya Age Average Annual Count Percent Average Annual Diagnosis Rate per 100,000 95% Confidence Interval All races All ages 226.0 100.0%14.4 12.5 - 16.3 0-4 0.0 0.0%**** 5-12 0.0 0.0%**** 13-19 6.0 2.7%4.3 2.6 - 6.9 20-24 32.3 14.3%28.3 23.0 - 34.6 25-29 42.7 18.9%38.3 26.8 - 49.9 30-39 53.0 23.5%23.2 16.9 - 29.4 40-49 47.7 21.1%21.2 15.2 - 27.2 50 & over 44.3 19.6%8.9 6.3 - 11.6 AfrAmer All ages 86.7 38.3%49.1 38.8 - 59.5 0-4 0.0 0.0%**** 5-12 0.0 0.0%**** 13-19 4.0 1.8%23.5 12.1 - 41.0 20-24 15.3 6.8%123.4 90.3 - 164.6 25-29 16.7 7.4%147.4 109.4 - 194.4 30-39 18.7 8.3%80.7 60.9 - 104.7 40-49 13.3 5.9%51.7 36.9 - 70.4 50 & over 18.7 8.3%31.1 23.5 - 40.4 White All ages 56.3 24.9%10.9 8.0 - 13.7 0-4 **** 5-12 0.0 0.0%**** 13-19 **** 20-24 5.3 2.4%17.1 9.8 - 27.8 25-29 9.0 4.0%28.2 18.6 - 41.0 30-39 11.3 5.0%17.8 12.3 - 24.9 40-49 15.7 6.9%20.2 14.9 - 26.9 50 & over 14.7 6.5%6.5 4.7 - 8.7 HIV in Alameda County, 2013-2015 20 New Diagnoses Table 2.4: HIV Diagnosis Rates by Race/Ethnicity and Age, Alameda County, 2013-2015 (continued) NOTE:This table spans multiple pages. Race/ Ethnicitya Age Average Annual Count Percent Average Annual Diagnosis Rate per 100,000 95% Confidence Interval Latino All ages 52.0 23.0%14.4 10.5 - 18.3 0-4 **** 5-12 0.0 0.0%**** 13-19 **** 20-24 6.7 2.9%20.5 12.5 - 31.7 25-29 12.3 5.5%38.3 27.0 - 52.8 30-39 13.0 5.8%21.1 15.0 - 28.8 40-49 12.7 5.6%27.1 19.2 - 37.2 50 & over 6.0 2.7%9.6 5.7 - 15.2 API All ages 24.7 10.9%5.6 4.4 - 7.1 0-4 0.0 0.0%**** 5-12 0.0 0.0%**** 13-19 **** 20-24 **** 25-29 **** 30-39 **** 40-49 **** 50 & over 3.0 1.3%**** HIV in Alameda County, 2013-2015 21 New Diagnoses Table 2.4: HIV Diagnosis Rates by Race/Ethnicity and Age, Alameda County, 2013-2015 (continued) NOTE:This table spans multiple pages. Race/ Ethnicitya Age Average Annual Count Percent Average Annual Diagnosis Rate per 100,000 95% Confidence Interval Other/Unk All ages 6.3 2.8%---- 0-4 0.0 0.0%---- 5-12 0.0 0.0%---- 13-19 0.0 0.0%---- 20-24 **---- 25-29 **---- 30-39 **---- 40-49 **---- 50 & over 2.0 0.9%---- Source:Alameda County eHARS,2016 Q2 [a]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. [--]Rate not calculable for lack of a denominator. HIV in Alameda County, 2013-2015 22 New Diagnoses Table 2.5: Late Diagnosis by Sex and Age, Alameda County, 2012-2014 All Diagnoses late_dx Sexa Age at Diagnosis Average Annual Count Column Percent Average Annual Count Row Percent All All ages 217.0 100.0%78.0 35.9% 5-12 **0.0 * 13-19 **2.3 * 20-24 31.3 14.4%7.3 23.4% 25-29 36.0 16.6%11.3 31.5% 30-39 49.7 22.9%17.0 34.2% 40-49 55.0 25.3%24.0 43.6% 50 & over 37.0 17.1%16.0 43.2% Male All ages 187.7 86.5%69.0 36.8% 5-12 **0.0 * 13-19 **2.0 * 20-24 29.7 13.7%7.0 23.6% 25-29 32.3 14.9%10.3 32.0% 30-39 43.3 20.0%15.3 35.4% 40-49 47.7 22.0%21.0 44.1% 50 & over 28.7 13.2%13.3 ** Female All ages 29.3 13.5%9.0 30.7% 5-12 0.0 0.0%0.0 ** 13-19 2.0 0.9%0.3 ** 20-24 1.7 0.8%0.3 ** 25-29 3.7 1.7%1.0 ** 30-39 6.3 2.9%1.7 ** 40-49 7.3 3.4%3.0 ** 50 & over 8.3 3.8%2.7 ** Source:Alameda County eHARS,2016 Q2 [a]Refers to sex assigned at birth [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 23 New Diagnoses Table 2.6: Late Diagnosis by Sex and Race/Ethnicity, Alameda County, 2012-2014 All Diagnoses late_dx Sexa Race/ Ethnicityb Average Annual Count Column Percent Average Annual Count Row Percent All All races 217.0 100.0%78.0 35.9% AfrAmer 84.3 38.9%29.3 34.8% White 50.7 23.3%16.7 32.9% Latino 50.7 23.3%20.3 40.1% API 24.0 11.1%7.7 ** Other/Unk 7.3 3.4%4.0 ** Male All races 187.7 86.5%69.0 36.8% AfrAmer 66.7 30.7%24.0 36.0% White 45.7 21.0%15.3 33.6% Latino 46.7 21.5%19.0 40.7% API **7.7 * Other/Unk **3.0 * Female All races 29.3 13.5%9.0 30.7% AfrAmer 17.7 8.1%5.3 ** White 5.0 2.3%1.3 ** Latino 4.0 1.8%1.3 ** API **0.0 * Other/Unk **1.0 * Source:Alameda County eHARS,2016 Q2 [a]Refers to sex assigned at birth [b]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 24 New Diagnoses Table 2.7: Late Diagnosis by Race/Ethnicity and Age, Alameda County, 2012-2014 NOTE:This table spans multiple pages. All Diagnoses late_dx Race/ Ethnicitya Age at Diagnosis Average Annual Count Column Percent Average Annual Count Row Percent All races All ages 217.0 100.0%78.0 35.9% 5-12 **0.0 * 13-19 **2.3 * 20-24 31.3 14.4%7.3 23.4% 25-29 36.0 16.6%11.3 31.5% 30-39 49.7 22.9%17.0 34.2% 40-49 55.0 25.3%24.0 43.6% 50 & over 37.0 17.1%16.0 43.2% AfrAmer All ages 84.3 38.9%29.3 34.8% 5-12 **0.0 * 13-19 **1.0 * 20-24 14.3 6.6%3.0 ** 25-29 14.0 6.5%4.7 ** 30-39 18.7 8.6%5.3 ** 40-49 17.7 8.1%9.7 ** 50 & over 15.0 6.9%5.7 ** White All ages 50.7 23.3%16.7 32.9% 5-12 **0.0 * 13-19 **0.0 * 20-24 4.7 2.2%1.0 ** 25-29 6.7 3.1%1.0 ** 30-39 9.0 4.1%4.0 ** 40-49 16.7 7.7%5.3 ** 50 & over 13.3 6.1%5.3 ** HIV in Alameda County, 2013-2015 25 New Diagnoses Table 2.7: Late Diagnosis by Race/Ethnicity and Age, Alameda County, 2012-2014 (continued) NOTE:This table spans multiple pages. All Diagnoses late_dx Race/ Ethnicitya Age at Diagnosis Average Annual Count Column Percent Average Annual Count Row Percent Latino All ages 50.7 23.3%20.3 40.1% 5-12 0.0 0.0%0.0 ** 13-19 2.0 0.9%0.7 ** 20-24 6.7 3.1%2.0 ** 25-29 11.0 5.1%3.7 ** 30-39 12.7 5.8%4.0 ** 40-49 13.0 6.0%6.7 ** 50 & over 5.3 2.5%3.3 ** API All ages 24.0 11.1%7.7 ** 5-12 0.0 0.0%0.0 ** 13-19 **0.3 * 20-24 **1.0 * 25-29 **1.3 * 30-39 7.3 3.4%2.7 ** 40-49 **1.7 * 50 & over 1.7 0.8%0.7 ** Other/Unk All ages 7.3 3.4%4.0 ** 5-12 0.0 0.0%0.0 ** 13-19 **0.3 * 20-24 **0.3 * 25-29 **0.7 * 30-39 2.0 0.9%1.0 ** 40-49 **0.7 * 50 & over 1.7 0.8%1.0 ** Source:Alameda County eHARS,2016 Q2 [a]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 26 People Living with HIV 3 People Living with HIV In the United States, there were an estimated 955,081 PLHIV at the end of 2014. Prevalence was highest among men as compared to women (555.3 vs. 169.2 PLHIV per 100,000 population), those aged 45-49 and 50-54 (729.6 and 748.8 per 100,000 respectively), African Americans and Latinos (1,025.2 and 358.3 per 100,000 respectively), and in the northeast and south (419.5 and 352.5 per 100,000 respectively). That same year, California had an estimated 126,241 PLHIV for an overall prevalence of 327.5 per 100,000 population. HIV prevalence in women in California (77.3 per 100,000) was half that of women nationally. [4] This chapter examines prevalence, or the proportion of people in Alameda County with HIV infection, reﬂecting the overall burden of HIV in the population. Data presented do not include those with undiagnosed infection but include all diagnosed PLHIV, regardless of the stage of their infection, and include newly diagnosed cases.1 First, characteristics of PLHIV in the county are presented. Then the prevalence of HIV disease in diﬀerent subpopulations is described. Finally, mortality (deaths) among PLHIV ever diagnosed with AIDS is described. Table 3.1 summarizes data presented in this chapter. Stratiﬁed prevalence rates by sex, age and race/ethnicity are provided in tables at the end of this chapter. 1PLHIV counts exclude those that only moved to Alameda County after their diagnosis and have never seen an HIV healthcare provider in Alameda County. The latter limitation is due to the criteria the California Department of Public Health (CDPH) uses to determine the subset of the statewide HIV database to which local health departments have access ( [1] resided in the county at ﬁrst HIV diagnosis or at progression to Stage 3 infection (AIDS), or [2] have ever had an HIV-related laboratory result ordered by a healthcare provider in the county). So, for example, the 5,801 persons we know of and believe to have been living with HIV in Alameda County at year-end 2014 are not all but rather 94.7% of the 6,125 PLHIV CDPH knows of and believes to have been living here at that time (based on data reported to them through December 31, 2015). The discrepancy in overall PLHIV counts may be oﬀset by the fact that some of the persons believed to have been living in the county may actually have moved out of the county as surveillance data do not reﬂect a person’s residence at all times with perfect accuracy. HIV in Alameda County, 2013-2015 27 People Living with HIV Characteristics of PLHIV At the end of 2015, there were an estimated 5,897 PLHIV in Alameda County. Similar to the distribution of sex among new diagnoses of HIV, those living with HIV in Alameda County at year-end 2015 were predominantly male (82.4%). Figure 3.1: PLHIV by Sex, Alameda County, year-end 2015 17.6% 82.4% Female Male 0 1,000 2,000 3,000 4,000 5,000 6,000 Number of Cases NOTE: “Sex” refers to sex assigned at birth. Approximately 41% of PLHIV in Alameda County were African American and 32.5% were white. Latinos and Asians and Paciﬁc Islanders each comprised a smaller proportion of PLHIV. Figure 3.2: PLHIV by Race/Ethnicity, Alameda County, year-end 2015 2.2% 6.4% 18.1% 32.5% 40.9% Other/Unk API Latino White AfrAmer 0 1,000 2,000 3,000 Number of Cases NOTE: “Other/Unk” includes American Indians, Alaskan Natives, mul- tiracial, and unknown categories. HIV in Alameda County, 2013-2015 28 People Living with HIV Half of PLHIV were in their ﬁfties or older. Only about a quarter were in their thirties or younger at year-end 2015. Figure 3.3: Age of PLHIV, Alameda County, year-end 2015 41.0 50.0 58.0 0 250 500 750 1000 0 25 50 75 100 Age at year−end 2015 Nu m b e r o f C a s e s NOTE: The dashed lines indicate the 25th, 50th, and 75th percentile values for age among PLHIV. Race/ethnic disparities in numbers of PLHIV were more apparent among women compared to men—while there were approximately equal proportions of African Americans and whites among males, there were nearly four times as many African American women compared to white women (Table 3.3). Prevalence Rates At the end of 2015 there were 5,897 people living with HIV in Alameda County for a prevalence rate of 372.5 per 100,000 or 0.4% of residents. HIV prevalence was about ﬁve times higher among males as compared to females at year-end 2015. Figure 3.4: Prevalence of HIV by Sex, Alameda County, year-end 2015 372.5 625.0 128.6 Female (N=1,036) Male (N=4,861) All (N=5,897) 0 200 400 600 800 Rate per 100,000 NOTE: “Sex” refers to sex assigned at birth. HIV in Alameda County, 2013-2015 29 People Living with HIV African Americans carried over 3.5 times the burden of HIV compared to the next most impacted group in Alameda County—whites. The burden of HIV was lowest among Asians and Paciﬁc Islanders. Figure 3.5: Prevalence of HIV by Race/Ethnicity, Alameda County, year-end 2015 372.5 1,382.2 374.0 286.9 83.1API (N=376) Latino (N=1,066) White (N=1,915) AfrAmer (N=2,411) All races (N=5,897) 0 500 1,000 1,500 Rate per 100,000 HIV prevalence was higher in each successive age group ranging from 18.7 per 100,000 youth aged 13-19 to a high of 871.7 per 100,000 people ages 50-59. The number of children aged 0-12 living with HIV was too low to estimate a statistically reliable prevalence rate. Prevalence among those aged 60 and over diﬀered only slightly from those in their thirties. This ﬁnding is consistent with the improved survival of PLHIV in the ART era. Figure 3.6: Prevalence of HIV by Age, Alameda County, year-end 2015 372.5 18.7 201.1 374.8 639.4 871.7 408.660 & over (N=1,189) 50−59 (N=1,932) 40−49 (N=1,437) 30−39 (N=851) 20−29 (N=455) 13−19 (N=26) All ages (N=5,897) 0 250 500 750 1,000 Rate per 100,000 The disparity in prevalence rates by race was more pronounced among females compared to males. While preva- lence was about 3 times higher among African American males compared to white males, it was more than 10 times higher among African American females compared to white females (see Table 3.3). Additionally, although HIV prevalence was higher among white males than Latino males, this was not the case among females. HIV in Alameda County, 2013-2015 30 People Living with HIV Oakland had the highest HIV prevalence within Alameda County followed by the central county region. Figure 3.7: Prevalence of HIV by Census Tract of Residence, Alameda County, year-end 2015 Countywide prevalence: 372.5 per 100,000 Contra Costa San Joaquin San Mateo Santa Clara Fremont Sunol Oakland Hayward Livermore Dublin Pleasanton Union City Newark Berkeley San Leandro Alameda Castro Valley Fairview Alameda Albany San Lorenzo Ashland Piedmont Emeryville Cherryland 0 5 102.5 Miles± San Francisco Bay Prevalence (per 100,000) < 10 cases 139.8 - 360.0 360.1 - 570.0 570.1 - 840.0 840.1 - 1260.0 1260.1 - 2285.0 NOTE: N=4,990; an additional 761 PLHIV (13.23% of all) are not repre- sented due to incomplete street address. THe North and West Oakland, Downtown, Chinatown, and San Antonio neighborhoods had the highest HIV prevalence rate, ranging from 1-2% of residents. Figure 3.8: Prevalence of HIV by Census Tract of Residence, Oakland and Surrounding Area, year-end 2015 Contra Costa Oakland Berkeley San Leandro Alameda Castro Valley Alameda Albany Ashland Piedmont Emeryville Elmhurst Lower Hills Southeast Hills West Oakland Fruitvale Central East Oakland North Oakland San Antonio Northwest Hills Downtownand Chinatown San Francisco 0 1.5 30.75 Miles ±Prevalence (per 100,000) < 10 cases 139.8 - 360.0 360.1 - 570.0 570.1 - 840.0 840.1 - 1260.0 1260.1 - 2285.0 Oaklandneighborhoods Cities HIV in Alameda County, 2013-2015 31 People Living with HIV Deaths Among Alameda County Residents Ever Diagnosed with AIDS Although HIV without AIDS has only been reportable by name in California since 2006, AIDS has been a re- portable disease since the early 1980s allowing examination of long-term trends in death rates among the subset of PLHIV ever diagnosed with AIDS. In 1985, there were 38.7 deaths (from any cause, whether HIV-related or not) per 100 Alameda County residents ever diagnosed with AIDS. This rate dropped to 7.5 deaths per 100 by 1997 and has declined slowly, but steadily since then. In 2013, there were 57 deaths among the 3,755 residents ever diagnosed with AIDS for a rate of 1.47 deaths per 100 residents. Figure 3.9: Death Rate among Alameda County Residents Ever Diagnosed with AIDS, 1985-2013 10 20 30 40 50 1985 1990 1995 2000 2005 2010 2015 De a t h s p e r 1 0 0 NOTE: Death rates calculated among persons ever diagnosed with AIDS while a resident of Alameda County, regardless of county of residence at death. Deaths in PLHIV without AIDS are not reported here. HIV in Alameda County, 2013-2015 32 People Living with HIV Ta b l e 3 . 1 : P e o p l e L i v i n g w i t h H I V D i s e a s e a n d P r e v a l e n c e R a t e s , A l a m e d a C o u n t y , Y e a r - E n d 2 0 1 5 NO T E : Th i s ta b l e sp a n s mu l t i p l e pa g e s . Ch a r a c t e r i s t i c Ca t e g o r y Co u n t Pe r c e n t Pr e v a l e n c e p e r 10 0 , 0 0 0 95 % Co n f i d e n c e In t e r v a l Al l P L H I V -- 5, 8 9 7 10 0 . 0 % 37 2 . 5 36 3 . 0 - 3 8 2 . 0 Se x a Ma l e 4, 8 6 1 82 . 4 % 62 5 . 0 60 7 . 5 - 6 4 2 . 6 Fe m a l e 1, 0 3 6 17 . 6 % 12 8 . 6 12 0 . 8 - 1 3 6 . 5 Ra c e / E t h n i c i t y b Af r A m e r 2, 4 1 1 40 . 9 % 1, 3 8 2 . 2 1, 3 2 7 . 0 - 1 , 4 3 7 . 4 Wh i t e 1, 9 1 5 32 . 5 % 37 4 . 0 35 7 . 3 - 3 9 0 . 8 La t i n o 1, 0 6 6 18 . 1 % 28 6 . 9 26 9 . 7 - 3 0 4 . 1 AP I 37 6 6. 4 % 83 . 1 74 . 7 - 9 1 . 5 Ot h e r / U n k 12 9 2. 2 % -- -- Ag e ( y e a r s ) c 0- 1 2 7 0. 1 % ** ** 13 - 1 9 26 0. 4 % 18 . 7 12 . 2 - 2 7 . 4 20 - 2 9 45 5 7. 7 % 20 1 . 1 18 2 . 6 - 2 1 9 . 6 30 - 3 9 85 1 14 . 4 % 37 4 . 8 34 9 . 6 - 3 9 9 . 9 40 - 4 9 1, 4 3 7 24 . 4 % 63 9 . 4 60 6 . 4 - 6 7 2 . 5 50 - 5 9 1, 9 3 2 32 . 8 % 87 1 . 7 83 2 . 9 - 9 1 0 . 6 60 & o v e r 1, 1 8 9 20 . 2 % 40 8 . 6 38 5 . 4 - 4 3 1 . 8 HIV in Alameda County, 2013-2015 33 People Living with HIV Ta b l e 3 . 1 : P e o p l e L i v i n g w i t h H I V D i s e a s e a n d P r e v a l e n c e R a t e s , A l a m e d a C o u n t y , Y e a r - E n d 2 0 1 5 ( c o n t i n u e d ) NO T E : Th i s ta b l e sp a n s mu l t i p l e pa g e s . Ch a r a c t e r i s t i c Ca t e g o r y Co u n t Pe r c e n t Pr e v a l e n c e p e r 10 0 , 0 0 0 95 % Co n f i d e n c e In t e r v a l Re s i d e n c e No r t h C o u n t y 49 7 8. 4 % 36 3 . 9 33 1 . 9 - 3 9 5 . 9 Oa k l a n d A r e a 3, 6 5 3 61 . 9 % 72 3 . 6 70 0 . 2 - 7 4 7 . 1 Ce n t r a l C o u n t y 1, 0 8 5 18 . 4 % 28 8 . 6 27 1 . 4 - 3 0 5 . 8 So u t h C o u n t y 40 5 6. 9 % 11 8 . 4 10 6 . 9 - 1 3 0 . 0 Tr i - V a l l e y 23 8 4. 0 % 11 0 . 9 96 . 8 - 1 2 5 . 0 Re m a i n d e r o f c o u n t y 14 0. 2 % 15 6 . 7 85 . 7 - 2 6 2 . 9 Un k n o w n 5 0. 1 % ** ** So u r c e : Al a m e d a Co u n t y eH A R S , 20 1 6 Q2 [a] Re f e r s to se x as s i g n e d at bi r t h [b] 'O t h e r / U n k ' = Am e r i c a n In d i a n s an d Ala s k a n Na t i v e s , mu l t i p l e ra c e , un k n o w n ra c e [c] Ag e at ye a r - e n d 20 1 5 [** ] Un s t a b l e es t i m a t e s no t sh o w n . [-- ] Ra t e no t ca l c u l a b l e fo r la c k of a de n o m i n a t o r . HIV in Alameda County, 2013-2015 34 People Living with HIV Table 3.2: HIV Prevalence by Sex and Age, Alameda County, Year-End 2015 Sexa Age Count Percent Prevalence per 100,000 95% Confidence Interval All All ages 5,897 100.0%372.5 363.0 - 382.0 0-12 7 0.1%**** 13-19 26 0.4%18.7 12.2 - 27.4 20-29 455 7.7%201.1 182.6 - 219.6 30-39 851 14.4%374.8 349.6 - 399.9 40-49 1,437 24.4%639.4 606.4 - 672.5 50-59 1,932 32.8%871.7 832.9 - 910.6 60 & over 1,189 20.2%408.6 385.4 - 431.8 Male All ages 4,861 82.4%625.0 607.5 - 642.6 0-12 **** 13-19 **** 20-29 400 6.8%349.8 315.5 - 384.0 30-39 695 11.8%623.9 577.5 - 670.3 40-49 1,149 19.5%1,031.2 971.6 - 1,090.8 50-59 1,617 27.4%1,489.7 1,417.1 - 1,562.3 60 & over 978 16.6%746.9 700.1 - 793.8 Female All ages 1,036 17.6%128.6 120.8 - 136.5 0-12 **** 13-19 **** 20-29 55 0.9%49.1 37.0 - 64.0 30-39 156 2.6%134.9 113.7 - 156.0 40-49 288 4.9%254.2 224.8 - 283.5 50-59 315 5.3%278.6 247.8 - 309.3 60 & over 211 3.6%131.8 114.0 - 149.6 Source:Alameda County eHARS,2016 Q2 [a]Refersto sex assigned at birth [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 35 People Living with HIV Table 3.3: HIV Prevalence by Sex and Race/Ethnicity, Alameda County, Year-End 2015 Sexa Race/ Ethnicityb Count Percent Prevalence per 100,000 95% Confidence Interval All All races 5,897 100.0%372.5 363.0 - 382.0 AfrAmer 2,411 40.9%1,382.2 1,327.0 - 1,437.4 White 1,915 32.5%374.0 357.3 - 390.8 Latino 1,066 18.1%286.9 269.7 - 304.1 API 376 6.4%83.1 74.7 - 91.5 Other/Unk 129 2.2%---- Male All races 4,861 82.4%625.0 607.5 - 642.6 AfrAmer 1,763 29.9%2,151.4 2,051.0 - 2,251.8 White 1,746 29.6%685.2 653.1 - 717.4 Latino 926 15.7%489.7 458.2 - 521.2 API 316 5.4%146.0 129.9 - 162.1 Other/Unk 110 1.9%---- Female All races 1,036 17.6%128.6 120.8 - 136.5 AfrAmer 648 11.0%700.7 646.7 - 754.6 White 169 2.9%65.7 55.8 - 75.6 Latino 140 2.4%76.7 64.0 - 89.4 API 60 1.0%25.4 19.4 - 32.7 Other/Unk 19 0.3%---- Source:Alameda County eHARS,2016 Q2 [a]Refersto sex assigned at birth [b]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [--]Rate not calculable forlack of a denominator. HIV in Alameda County, 2013-2015 36 People Living with HIV Table 3.4: HIV Prevalence by Race/Ethnicity and Age, Alameda County, Year-End 2015 NOTE:This table spans multiple pages. Race/ Ethnicitya Age Count Percent Prevalence per 100,000 95% Confidence Interval All races All ages 5,897 100.0%372.5 363.0 - 382.0 0-12 7 0.1%**** 13-19 26 0.4%18.7 12.2 - 27.4 20-29 455 7.7%201.1 182.6 - 219.6 30-39 851 14.4%374.8 349.6 - 399.9 40-49 1,437 24.4%639.4 606.4 - 672.5 50-59 1,932 32.8%871.7 832.9 - 910.6 60 & over 1,189 20.2%408.6 385.4 - 431.8 AfrAmer All ages 2,411 40.9%1,382.2 1,327.0 - 1,437.4 0-12 5 0.1%**** 13-19 17 0.3%101.3 59.0 - 162.1 20-29 203 3.4%863.4 744.6 - 982.1 30-39 346 5.9%1,562.6 1,398.0 - 1,727.3 40-49 554 9.4%2,202.1 2,018.7 - 2,385.5 50-59 795 13.5%2,934.4 2,730.4 - 3,138.4 60 & over 491 8.3%1,420.3 1,294.6 - 1,545.9 White All ages 1,915 32.5%374.0 357.3 - 390.8 0-12 **** 13-19 **** 20-29 83 1.4%132.1 105.2 - 163.8 30-39 184 3.1%304.8 260.8 - 348.9 40-49 396 6.7%530.5 478.2 - 582.7 50-59 750 12.7%806.8 749.0 - 864.5 60 & over 498 8.4%360.4 328.8 - 392.1 HIV in Alameda County, 2013-2015 37 People Living with HIV Table 3.4: HIV Prevalence by Race/Ethnicity and Age, Alameda County, Year-End 2015 (continued) NOTE:This table spans multiple pages. Race/ Ethnicitya Age Count Percent Prevalence per 100,000 95% Confidence Interval Latino All ages 1,066 18.1%286.9 269.7 - 304.1 0-12 **** 13-19 **** 20-29 116 2.0%177.2 145.0 - 209.5 30-39 215 3.6%340.0 294.5 - 385.4 40-49 330 5.6%681.3 607.8 - 754.9 50-59 267 4.5%818.3 720.2 - 916.5 60 & over 132 2.2%405.9 336.6 - 475.1 API All ages 376 6.4%83.1 74.7 - 91.5 0-12 **** 13-19 **** 20-29 36 0.6%57.2 40.1 - 79.2 30-39 83 1.4%114.3 91.0 - 141.7 40-49 116 2.0%168.2 137.6 - 198.8 50-59 90 1.5%143.8 115.6 - 176.8 60 & over 50 0.8%63.2 46.9 - 83.3 Other/Unk All ages 129 2.2%---- 0-12 0 0.0%---- 13-19 0 0.0%---- 20-29 17 0.3%---- 30-39 23 0.4%---- 40-49 41 0.7%---- 50-59 30 0.5%---- 60 & over 18 0.3%---- Source:Alameda County eHARS,2016 Q2 [a]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. [--]Rate not calculable for lack of a denominator. HIV in Alameda County, 2013-2015 38 The Continuum of HIV Care 4 The Continuum of HIV Care Anti-retroviral therapy (ART), when taken regularly, can suppress HIV, limiting the damage done by the virus to the immune system as well as lowering the likelihood of ongoing transmission. ART thus beneﬁts both PLHIV as well as the larger community. In order to maximize these beneﬁts, it is crucial that PLHIV be diagnosed, linked to and retained in regular HIV care, and be prescribed and take ART. These steps—diagnosis, linkage, retention, and prescription to and adherence to ART—are all pre-requisites for achieving virologic suppression. Together, these steps comprise the continuum of HIV care, also called the HIV care cascade or the stages of HIV care. The continuum has gained enormous popularity as a framework for conceptualizing HIV care and prevention eﬀorts. In the United States, the CDC estimated that 84.0% of persons diagnosed in 2014 linked to care within 3 months.1 Additionally, CDC estimated that, at the end of 2013, 87.0% of all PLHIV had been diagnosed and that, among those still alive and who had been diagnosed by the end of the previous year, 70.9% received any HIV care, 56.5% were retained in continuous care, and 54.7% were virally suppressed. In California, 81.8% of those diagnosed in 2014 were estimated to have linked to care within 3 months. By the end of 2013, 90.3% of PLHIV were believed to have been diagnosed and, among those still alive and who had been diagnosed by the end of the previous year, 71.1% of were estimated to have received any HIV care in 2013, 55.9% were estimated to have been retained in continuous care, and 55.6% were estimated to have been virally suppressed at last test.2 [5] 1Among those aged 13 or older at diagnosis in the 33 jurisdictions with complete laboratory reporting. 2Data on receipt of HIV medical care and viral suppression are based on data for PLHIV aged 13 or older, diagnosed by year-end 2012, alive at year-end 2013, and residing in the 33 jurisdictions with complete laboratory reporting. CD4 or viral load tests ordered in 2013 were used as markers of HIV care. Retention in continuous care is deﬁned 2 or more CD4 or viral load tests at least 3 months apart and viral suppression is deﬁned as last viral load in 2013 <200 copies/mL. HIV in Alameda County, 2013-2015 39 The Continuum of HIV Care The Overall Continuum of Care In Alameda County, between 75.1% and 85.2% of new diagnoses between 2012 and 2014 were linked to care within 3 months, depending on whether HIV-related labs ordered on the date of diagnosis were included as a marker of linkage. Approximately 59.6% of PLHIV in Alameda County for the entirety of 2014 had 2 or more visits 90 or more days apart that year and so were considered retained in care. Viral suppression was estimated to be 4.6% higher (64.2%) that same year. Figure 4.1: The Continuum of HIV Care in Alameda CountyThe Continuum of HIV Care in Alameda County Among N=634 new diagnoses in 2012‐2014* Among N=, PLHIV in Alameda Co. for the entirety of 2014** 100% Incl. labs at dx 1+ visit Excl. labs at dx 2+ visits 90+ days apart 64.2% 85.2% 75.9%75.1% 60% 80% 59. 20% 40% 0% Linked Retained Virally Suppressed *Of 651 total diagnoses, 17 died within 90 days and are excluded from analysis **Of 5,662 PLHIV at year‐end 2013, 62 are known to have died and an additional 227 to have moved out of Alameda County in 2014 1) Linkage defined as having a reported CD4 or VL ordered within 90 days or less of diagnosis; 2) Retention calculated using labs ordered in 2013; 3) Viral suppression defined as most recent VL in 2013 < 200 copies/mL * Of 651 total diagnoses, 17 died within 90 days and were excluded from analysis ** Of 5,662 PLHIV at year-end 2013, 62 were known to have died and an additional 227 to have moved out of Alameda County in 2014 This chapter presents data on select measures along the continuum of HIV including estimates stratiﬁed by demo- graphics. Data on ART use were not available for analysis. Stratiﬁed analysis of measures along the continuum (linkage, retention, and virologic status) are presented in Tables 4.1-4.15 at the end of this chapter. Note that ap- parent diﬀerences should be interpreted with caution due to the small numbers in some subgroups and resulting statistical instability. Linkage to Care Here we present linkage to care estimates for Alameda County. It should be noted that receipt of a CD4 count or viral load test is not always a deﬁnitive indicator of linkage to care. For example, a health care provider may order these tests concurrently with a conﬁrmatory test or a patient may not return for the test results. Labs ordered after the date of diagnosis provide an alternative method for estimating linkage to care. We present both estimates HIV in Alameda County, 2013-2015 40 The Continuum of HIV Care of linkage—one that includes labs done on the date of diagnosis and another that excludes them—providing what might be considered upper and lower bounds on the proportion linked. Patients who died within 90 days of diagnosis were not included (N=17). The median time from diagnosis to ﬁrst CD4 or viral load among Alameda County residents diagnosed in 2012-2014 was 5.5 days. Excluding labs ordered on the date of diagnosis, the median time from diagnosis was 13.5 days. Figure 4.2: Days Between Diagnosis and First CD4 or Viral Load, Alameda County, 2012-2014 90−day target for timely linkage 0% 20% 40% 60% 80% 100% 0 30 60 90 120 150 180 210 240 270 300 330 360 Days post−diagnosis Cu m u l a t i v e p e r c e n t l i n k e d Excl. labs at dx Incl. labs at dx Overall, just over 85% of those diagnosed with HIV in Alameda County from 2012 to 2014 were linked to HIV care within 90 days of their diagnosis. Excluding labs ordered on date of diagnosis, about 75% of newly diagnosed cases were linked. Diﬀerences by sex assigned at birth were not statistically signiﬁcant. Figure 4.3: Linkage to HIV Care within 90 Days of Diagnosis by Sex, Alameda County, 2012-2014 87.4% 82.8% 84.8% 73.9% 85.2% 75.1% Female (N=87) Male (N=547) All (N=634) 0%25%50%75%100% Percent linked in 90 days or less Excl. labs at dx Incl. labs at dx NOTE: “Sex” refers to sex assigned at birth. HIV in Alameda County, 2013-2015 41 The Continuum of HIV Care Timely linkage to HIV care by race/ethnicity was highest among Asians and Paciﬁc Islanders and lowest among African Americans. Diﬀerences by race/ethnicity were not statistically signiﬁcant. Figure 4.4: Linkage to HIV Care within 90 Days of Diagnosis by Race/Ethnicity, Alameda County, 2012-2014 88.9% 80.6% 87.8% 76.4% 85.8% 75.7% 82.7% 72.3% 85.2% 75.1% API (N=72) Latino (N=148) White (N=148) AfrAmer (N=249) All races (N=634) 0%25%50%75%100% Percent linked in 90 days or less Excl. labs at dx Incl. labs at dx Linkage was generally higher at the extremes of the age spectrum and lower among those in their thirties and forties. Diﬀerences by age group were not statistically sig- niﬁcant. Figure 4.5: Linkage to HIV Care within 90 Days of Diagnosis by Age, Alameda County, 2012-2014 87.5% 79.2% 87.3% 75.9% 83.8% 71.9% 81.6% 74.8% 86.6% 75.1% 95.5% 90.9% 85.2% 75.1% 60 & over (N=24) 50−59 (N=79) 40−49 (N=160) 30−39 (N=147) 20−29 (N=201) 13−19 (N=22) All ages (N=634) 0%25%50%75%100% Percent linked in 90 days or less Excl. labs at dx Incl. labs at dx HIV in Alameda County, 2013-2015 42 The Continuum of HIV Care Retention in Care In 2014, 75.9% of PLHIV1 had one or more visits to an HIV care provider. About 15% of all PLHIV had only a single visit; however, it is possible that some had additional visits, but no lab tests were ordered. Figure 4.6: Number of HIV Care Visits per PLHIV in 2014, Alameda County 2.4% 3.7% 12.0% 22.3% 22.7% 12.8% 24.1% 6+ 5 4 3 2 1 None 0 500 1,000 1,500 Number of PLHIV Nu m b e r o f v i s i t s In 2014, 59.6% of PLHIV had two or more visits 90 days or more apart. Diﬀerences by sex were not statistically signiﬁcant. Figure 4.7: Retention in HIV Care by Sex, Alameda County, 2014 58.8% 59.8% 59.6% Female (N=957) Male (N=4,416) All (N=5,373) 0%20%40%60%80% Percent with 2+ visits 90+ days apart in 2014 NOTE: “Sex” refers to sex assigned at birth. 1PLHIV that died or moved in 2014 were excluded from all analysis of retention in care. HIV in Alameda County, 2013-2015 43 The Continuum of HIV Care Asian and Paciﬁc Islander PLHIV had the highest rates of retention in HIV care in 2014, followed by whites. Only about 55% of Latino PLHIV were retained in care. Figure 4.8: Retention in HIV Care by Race/Ethnicity, Alameda County, 2014 64.8% 55.1% 61.0% 59.4% 59.6% API (N=318) Latino (N=940) White (N=1,771) AfrAmer (N=2,221) All races (N=5,373) 0%20%40%60%80% Percent with 2+ visits 90+ days apart in 2014 PLHIV aged 30-39 at year-end 2014 had the lowest rates of reten- tion in care; successively younger and successively older age groups had higher rates. Retention was highest among those ages 13-19 and 60 and over; however the number of PLHIV aged 13-19 was small. The general trend of higher retention in older age groups was statisticaly signiﬁcant. Figure 4.9: Retention in HIV Care by Age, Alameda County, 2014 64.6% 64.3% 57.4% 50.1% 54.2% 77.8% 59.6% 60 & over (N=950) 50−59 (N=1,674) 40−49 (N=1,550) 30−39 (N=776) 20−29 (N=395) 13−19 (N=18) All ages (N=5,373) 0%25%50%75%100% Percent with 2+ visits 90+ days apart in 2014 Virologic Status The ﬁnal measure along the care continuum is virologic suppression, deﬁned as a viral load under 200 copies per ml. For the purposes of these analyses, an undetectable viral load is deﬁned as 75 copies per ml or less. PLHIV that died or moved in 2014 were excluded. Disparities in virologic suppression among PLHIV in care can suggest potential diﬀerences in ART use or eﬀectiveness. HIV in Alameda County, 2013-2015 44 The Continuum of HIV Care Approximately 64% of PLHIV were virally suppressed at their most recent test in 2014, with the majority being undetectable. Virologic suppression was about 3% lower among female PLHIV compared to male PLHIV, but this diﬀerence was not statistically signiﬁcant. Among those in care, viral suppression was higher among males than females (Table 4.13). Figure 4.10: Virologic Status by Sex, Alameda County, 2014 Female (N=957) Male (N=4,416) All (N=5,373) 0%10%20%30%40%50%60%70%80%90%100% Undetectable Suppressed Unsuppressed Only CD4 reported No CD4s or VLs reported NOTE: “Sex” refers to sex assigned at birth. In 2014, almost 70% of white and Asian and Paciﬁc Islander PLHIV were virally suppressed. Viral suppression was about 10% lower in all other racial/ethnic groups. Similar disparities were seen among those in care (Table 4.14). Figure 4.11: Virologic Status by Race/Ethnicity, Alameda County, 2014 API (N=318) Latino (N=940) White (N=1,771) AfrAmer (N=2,221) All races (N=5,373) 0%10%20%30%40%50%60%70%80%90%100% Undetectable Suppressed Unsuppressed Only CD4 reported No CD4s or VLs reported Viral suppression rates generally increased as age increased, ranging from about 54% among those ages 20-29 to 70% among those ages 60 and over. A similar pattern was seen among those in care (Table 4.15). Figure 4.12: Virologic Status by Age, Alameda County, 2014 60 & over (N=950) 50−59 (N=1,674) 40−49 (N=1,550) 30−39 (N=776) 20−29 (N=395) 13−19 (N=18) All ages (N=5,373) 0%10%20%30%40%50%60%70%80%90%100% Undetectable Suppressed Unsuppressed Only CD4 reported No CD4s or VLs reported HIV in Alameda County, 2013-2015 45 The Continuum of HIV Care Table 4.1: Timely Linkage to HIV Care Among New Diagnoses by Sex and Age, Alameda County, 2012-2014 All Diagnoses linked90_inclDxDt Sexa Age at Diagnosis Average Annual Count Column Percent Average Annual Count Row Percent All All ages 211.3 100.0%180.0 85.2% 5-12 **0.3 * 13-19 **7.0 * 20-24 31.3 14.8%28.0 ** 25-29 35.7 16.9%30.0 84.1% 30-39 49.0 23.2%40.0 81.6% 40-49 53.3 25.2%44.7 83.8% 50 & over 34.3 16.2%30.0 87.4% Male All ages 182.3 86.3%154.7 84.8% 5-12 **0.3 * 13-19 **5.3 * 20-24 29.7 14.0%26.3 ** 25-29 32.0 15.1%26.7 83.3% 30-39 42.7 20.2%35.0 82.0% 40-49 46.0 21.8%39.0 84.8% 50 & over 26.3 12.5%22.0 83.5% Female All ages 29.0 13.7%25.3 87.4% 5-12 0.0 0.0%0.0 ** 13-19 2.0 0.9%1.7 ** 20-24 1.7 0.8%1.7 100.0% 25-29 3.7 1.7%3.3 ** 30-39 6.3 3.0%5.0 ** 40-49 7.3 3.5%5.7 ** 50 & over 8.0 3.8%8.0 100.0% Source:Alameda County eHARS,2016 Q2 NOTE:Excludes N=17 persons who died within 90 days of diagnosis. [a]Refers to sex assigned at birth [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 46 The Continuum of HIV Care Table 4.2: Timely Linkage to HIV Care Among New Diagnoses by Sex and Race/Ethnicity, Alameda County, 2012-2014 All Diagnoses linked90_inclDxDt Sexa Race/ Ethnicityb Average Annual Count Column Percent Average Annual Count Row Percent All All races 211.3 100.0%180.0 85.2% AfrAmer 83.0 39.3%68.7 82.7% White 49.3 23.3%42.3 85.8% Latino 49.3 23.3%43.3 87.8% API 24.0 11.4%21.3 ** Other/Unk 5.7 2.7%4.3 ** Male All races 182.3 86.3%154.7 84.8% AfrAmer 65.3 30.9%53.3 81.6% White 44.3 21.0%37.7 85.0% Latino 45.3 21.5%40.0 88.2% API **20.0 * Other/Unk **3.7 * Female All races 29.0 13.7%25.3 87.4% AfrAmer 17.7 8.4%15.3 ** White 5.0 2.4%4.7 ** Latino 4.0 1.9%3.3 ** API **1.3 * Other/Unk **0.7 * Source:Alameda County eHARS,2016 Q2 NOTE:Excludes N=17 persons who died within 90 days of diagnosis. [a]Refers to sex assigned at birth [b]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 47 The Continuum of HIV Care Table 4.3: Timely Linkage to HIV Care Among New Diagnoses by Race/Ethnicity and Age, Alameda County, 2012-2014 NOTE:This table spans multiple pages. All Diagnoses linked90_inclDxDt Race/ Ethnicitya Age at Diagnosis Average Annual Count Column Percent Average Annual Count Row Percent All races All ages 211.3 100.0%180.0 85.2% 5-12 **0.3 * 13-19 **7.0 * 20-24 31.3 14.8%28.0 ** 25-29 35.7 16.9%30.0 84.1% 30-39 49.0 23.2%40.0 81.6% 40-49 53.3 25.2%44.7 83.8% 50 & over 34.3 16.2%30.0 87.4% AfrAmer All ages 83.0 39.3%68.7 82.7% 5-12 **0.3 * 13-19 **4.0 * 20-24 14.3 6.8%12.3 ** 25-29 14.0 6.6%11.7 ** 30-39 18.3 8.7%14.0 ** 40-49 17.7 8.4%15.0 ** 50 & over 14.0 6.6%11.3 ** White All ages 49.3 23.3%42.3 85.8% 5-12 **0.0 * 13-19 **0.3 * 20-24 4.7 2.2%4.7 100.0% 25-29 6.7 3.2%6.3 ** 30-39 9.0 4.3%6.3 ** 40-49 16.0 7.6%13.3 ** 50 & over 12.7 6.0%11.3 ** HIV in Alameda County, 2013-2015 48 The Continuum of HIV Care Table 4.3: Timely Linkage to HIV Care Among New Diagnoses by Race/Ethnicity and Age, Alameda County, 2012-2014 (continued) NOTE:This table spans multiple pages. All Diagnoses linked90_inclDxDt Race/ Ethnicitya Age at Diagnosis Average Annual Count Column Percent Average Annual Count Row Percent Latino All ages 49.3 23.3%43.3 87.8% 5-12 0.0 0.0%0.0 ** 13-19 2.0 0.9%2.0 100.0% 20-24 6.7 3.2%6.0 ** 25-29 10.7 5.0%8.0 ** 30-39 12.7 6.0%11.7 ** 40-49 12.3 5.8%10.7 ** 50 & over 5.0 2.4%5.0 100.0% API All ages 24.0 11.4%21.3 ** 5-12 0.0 0.0%0.0 ** 13-19 **0.7 * 20-24 **4.0 * 25-29 **3.3 * 30-39 7.3 3.5%6.3 ** 40-49 **5.3 * 50 & over **1.7 * Other/Unk All ages 5.7 2.7%4.3 ** 5-12 0.0 0.0%0.0 ** 13-19 0.0 0.0%0.0 ** 20-24 **1.0 * 25-29 **0.7 * 30-39 1.7 0.8%1.7 100.0% 40-49 **0.3 * 50 & over **0.7 * Source:Alameda County eHARS,2016 Q2 NOTE:Excludes N=17 persons who died within 90 days of diagnosis. [a]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 49 The Continuum of HIV Care Table 4.4: Engagement in HIV Care in 2014 Among PLHIV at Year-End 2013 by Sex and Age, Alameda County All PLHIV 1+ Visits in 2014b Sexa Age at Year-End 2013 Count Column Percent Count Row Percent All All ages 5,373 100.0%4,079 75.9% 0-12 10 0.2%8 ** 13-19 18 0.3%16 ** 20-29 395 7.4%304 77.0% 30-39 776 14.4%560 72.2% 40-49 1,550 28.8%1,165 75.2% 50-59 1,674 31.2%1,306 78.0% 60 & over 950 17.7%720 75.8% Male All ages 4,416 82.2%3,345 75.7% 0-12 **5 * 13-19 **6 * 20-29 342 6.4%263 76.9% 30-39 603 11.2%437 72.5% 40-49 1,255 23.4%933 74.3% 50-59 1,416 26.4%1,101 77.8% 60 & over 787 14.6%600 76.2% Female All ages 957 17.8%734 76.7% 0-12 **3 * 13-19 **10 * 20-29 53 1.0%41 ** 30-39 173 3.2%123 71.1% 40-49 295 5.5%232 78.6% 50-59 258 4.8%205 79.5% 60 & over 163 3.0%120 73.6% Source:Alameda County eHARS,2016 Q2 NOTE:Excludes PLHIV at year-end 2013 who died (N=62)or moved out of the county (N=227)in 2014. [a]Refers to sex assigned at birth [b]Reported HIV viral load and CD4 laboratory tests results taken as markers of HIV medical care visits. [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 50 The Continuum of HIV Care Table 4.5: Engagement in HIV Care in 2014 Among PLHIV at Year-End 2013 by Sex and Race/Ethnicity, Alameda County All PLHIV 1+ Visits in 2014c Sexa Race/ Ethnicityb Count Column Percent Count Row Percent All All races 5,373 100.0%4,079 75.9% AfrAmer 2,221 41.3%1,678 75.6% White 1,771 33.0%1,364 77.0% Latino 940 17.5%687 73.1% API 318 5.9%245 77.0% Other/Unk 123 2.3%105 85.4% Male All races 4,416 82.2%3,345 75.7% AfrAmer 1,616 30.1%1,218 75.4% White 1,618 30.1%1,241 76.7% Latino 814 15.1%598 73.5% API 263 4.9%198 75.3% Other/Unk 105 2.0%90 85.7% Female All races 957 17.8%734 76.7% AfrAmer 605 11.3%460 76.0% White 153 2.8%123 80.4% Latino 126 2.3%89 70.6% API 55 1.0%47 ** Other/Unk 18 0.3%15 ** Source:Alameda County eHARS,2016 Q2 NOTE:Excludes PLHIV at year-end 2013 who died (N=62)or moved out of the county (N=227)in 2014. [a]Refers to sex assigned at birth [b]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [c]Reported HIV viral load and CD4 laboratorytests results taken as markers of HIV medical care visits. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 51 The Continuum of HIV Care Table 4.6: Engagement in HIV Care in 2014 Among PLHIV at Year-End 2013 by Race/Ethnicity and Age, Alameda County NOTE:This table spans multiple pages. All PLHIV 1+ Visits in 2014b Race/ Ethnicitya Age at Year-End 2013 Count Column Percent Count Row Percent All races All ages 5,373 100.0%4,079 75.9% 0-12 10 0.2%8 ** 13-19 18 0.3%16 ** 20-29 395 7.4%304 77.0% 30-39 776 14.4%560 72.2% 40-49 1,550 28.8%1,165 75.2% 50-59 1,674 31.2%1,306 78.0% 60 & over 950 17.7%720 75.8% AfrAmer All ages 2,221 41.3%1,678 75.6% 0-12 7 0.1%6 ** 13-19 11 0.2%9 ** 20-29 186 3.5%151 81.2% 30-39 327 6.1%236 72.2% 40-49 604 11.2%456 75.5% 50-59 683 12.7%531 77.7% 60 & over 403 7.5%289 71.7% White All ages 1,771 33.0%1,364 77.0% 0-12 **1 * 13-19 **2 * 20-29 58 1.1%45 ** 30-39 155 2.9%109 70.3% 40-49 474 8.8%359 75.7% 50-59 678 12.6%534 78.8% 60 & over 402 7.5%314 78.1% HIV in Alameda County, 2013-2015 52 The Continuum of HIV Care Table 4.6: Engagement in HIV Care in 2014 Among PLHIV at Year-End 2013 by Race/Ethnicity and Age, Alameda County (continued) NOTE:This table spans multiple pages. All PLHIV 1+ Visits in 2014b Race/ Ethnicitya Age at Year-End 2013 Count Column Percent Count Row Percent Latino All ages 940 17.5%687 73.1% 0-12 **1 * 13-19 **4 * 20-29 103 1.9%75 72.8% 30-39 201 3.7%139 69.2% 40-49 316 5.9%226 71.5% 50-59 225 4.2%172 76.4% 60 & over 90 1.7%70 77.8% API All ages 318 5.9%245 77.0% 0-12 **0 * 13-19 **1 * 20-29 31 0.6%19 ** 30-39 63 1.2%52 82.5% 40-49 122 2.3%93 76.2% 50-59 62 1.2%48 ** 60 & over 39 0.7%32 ** HIV in Alameda County, 2013-2015 53 The Continuum of HIV Care Table 4.6: Engagement in HIV Care in 2014 Among PLHIV at Year-End 2013 by Race/Ethnicity and Age, Alameda County (continued) NOTE:This table spans multiple pages. All PLHIV 1+ Visits in 2014b Race/ Ethnicitya Age at Year-End 2013 Count Column Percent Count Row Percent Other/Unk All ages 123 2.3%105 85.4% 0-12 0 0.0%0 ** 13-19 0 0.0%0 ** 20-29 17 0.3%14 ** 30-39 30 0.6%24 ** 40-49 34 0.6%31 ** 50-59 26 0.5%21 ** 60 & over 16 0.3%15 ** Source:Alameda County eHARS,2016 Q2 NOTE:Excludes PLHIV at year-end2013 who died (N=62)or moved out of the county (N=227)in 2014. [a]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [b]Reported HIV viral load and CD4 laboratory tests results taken as markers of HIV medical care visits. [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 54 The Continuum of HIV Care Table 4.7: Retention in Continuous HIV Care in 2014 Among PLHIV at Year-End 2013 by Sex and Age, Alameda County All PLHIV 2+ Visits 90+ Days Apart in 2014b Sexa Age at Year-End 2013 Count Column Percent Count Row Percent All All ages 5,373 100.0%3,204 59.6% 0-12 10 0.2%8 ** 13-19 18 0.3%14 ** 20-29 395 7.4%214 54.2% 30-39 776 14.4%389 50.1% 40-49 1,550 28.8%889 57.4% 50-59 1,674 31.2%1,076 64.3% 60 & over 950 17.7%614 64.6% Male All ages 4,416 82.2%2,641 59.8% 0-12 **5 * 13-19 **5 * 20-29 342 6.4%187 54.7% 30-39 603 11.2%302 50.1% 40-49 1,255 23.4%715 57.0% 50-59 1,416 26.4%910 64.3% 60 & over 787 14.6%517 65.7% Female All ages 957 17.8%563 58.8% 0-12 **3 * 13-19 **9 * 20-29 53 1.0%27 ** 30-39 173 3.2%87 50.3% 40-49 295 5.5%174 59.0% 50-59 258 4.8%166 64.3% 60 & over 163 3.0%97 59.5% Source:Alameda County eHARS,2016 Q2 NOTE:Excludes PLHIV at year-end 2013 who died (N=62)or moved out of the county (N=227)in 2014. [a]Refers to sex assigned at birth [b]Reported HIV viral load and CD4 laboratory tests results taken as markers of HIV medical care visits. [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 55 The Continuum of HIV Care Table 4.8: Retention in Continuous HIV Care in 2014 Among PLHIV at Year-End 2013 by Sex and Race/Ethnicity, Alameda County All PLHIV 2+ Visits 90+ Days Apart in 2014c Sexa Race/ Ethnicityb Count Column Percent Count Row Percent All All races 5,373 100.0%3,204 59.6% AfrAmer 2,221 41.3%1,320 59.4% White 1,771 33.0%1,080 61.0% Latino 940 17.5%518 55.1% API 318 5.9%206 64.8% Other/Unk 123 2.3%80 65.0% Male All races 4,416 82.2%2,641 59.8% AfrAmer 1,616 30.1%964 59.7% White 1,618 30.1%987 61.0% Latino 814 15.1%451 55.4% API 263 4.9%168 63.9% Other/Unk 105 2.0%71 67.6% Female All races 957 17.8%563 58.8% AfrAmer 605 11.3%356 58.8% White 153 2.8%93 60.8% Latino 126 2.3%67 53.2% API 55 1.0%38 ** Other/Unk 18 0.3%9 ** Source:Alameda County eHARS,2016 Q2 NOTE:Excludes PLHIV at year-end 2013 who died (N=62)or moved out of the county (N=227)in 2014. [a]Refers to sex assigned at birth [b]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [c]Reported HIV viral load and CD4 laboratorytests results taken as markers of HIV medical care visits. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 56 The Continuum of HIV Care Table 4.9: Retention in Continuous HIV Care in 2014 Among PLHIV at Year-End 2013 by Race/Ethnicity and Age, Alameda County NOTE:This table spans multiple pages. All PLHIV 2+ Visits 90+ Days Apart in 2014b Race/ Ethnicitya Age at Year-End 2013 Count Column Percent Count Row Percent All races All ages 5,373 100.0%3,204 59.6% 0-12 10 0.2%8 ** 13-19 18 0.3%14 ** 20-29 395 7.4%214 54.2% 30-39 776 14.4%389 50.1% 40-49 1,550 28.8%889 57.4% 50-59 1,674 31.2%1,076 64.3% 60 & over 950 17.7%614 64.6% AfrAmer All ages 2,221 41.3%1,320 59.4% 0-12 7 0.1%6 ** 13-19 11 0.2%7 ** 20-29 186 3.5%104 55.9% 30-39 327 6.1%172 52.6% 40-49 604 11.2%351 58.1% 50-59 683 12.7%442 64.7% 60 & over 403 7.5%238 59.1% White All ages 1,771 33.0%1,080 61.0% 0-12 **1 * 13-19 **2 * 20-29 58 1.1%31 ** 30-39 155 2.9%69 44.5% 40-49 474 8.8%275 58.0% 50-59 678 12.6%429 63.3% 60 & over 402 7.5%273 67.9% HIV in Alameda County, 2013-2015 57 The Continuum of HIV Care Table 4.9: Retention in Continuous HIV Care in 2014 Among PLHIV at Year-End 2013 by Race/Ethnicity and Age, Alameda County (continued) NOTE:This table spans multiple pages. All PLHIV 2+ Visits 90+ Days Apart in 2014b Race/ Ethnicitya Age at Year-End 2013 Count Column Percent Count Row Percent Latino All ages 940 17.5%518 55.1% 0-12 **1 * 13-19 **4 * 20-29 103 1.9%54 52.4% 30-39 201 3.7%92 45.8% 40-49 316 5.9%167 52.8% 50-59 225 4.2%143 63.6% 60 & over 90 1.7%57 63.3% API All ages 318 5.9%206 64.8% 0-12 **0 * 13-19 **1 * 20-29 31 0.6%16 ** 30-39 63 1.2%41 ** 40-49 122 2.3%71 58.2% 50-59 62 1.2%45 ** 60 & over 39 0.7%32 ** HIV in Alameda County, 2013-2015 58 The Continuum of HIV Care Table 4.9: Retention in Continuous HIV Care in 2014 Among PLHIV at Year-End 2013 by Race/Ethnicity and Age, Alameda County (continued) NOTE:This table spans multiple pages. All PLHIV 2+ Visits 90+ Days Apart in 2014b Race/ Ethnicitya Age at Year-End 2013 Count Column Percent Count Row Percent Other/Unk All ages 123 2.3%80 65.0% 0-12 0 0.0%0 ** 13-19 0 0.0%0 ** 20-29 17 0.3%9 ** 30-39 30 0.6%15 ** 40-49 34 0.6%25 ** 50-59 26 0.5%17 ** 60 & over 16 0.3%14 ** Source:Alameda County eHARS,2016 Q2 NOTE:Excludes PLHIV at year-end2013 who died (N=62)or moved out of the county (N=227)in 2014. [a]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [b]Reported HIV viral load and CD4 laboratory tests results taken as markers of HIV medical care visits. [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 59 The Continuum of HIV Care Table 4.10: Viral Suppression in 2014 Among PLHIV at Year-End 2013 by Sex and Age, Alameda County All PLHIV Suppressed at Last Viral Load in 2014b Sexa Age at Year-End 2013 Count Column Percent Count Row Percent All All ages 5,373 100.0%3,449 64.2% 0-12 10 0.2%7 ** 13-19 18 0.3%11 ** 20-29 395 7.4%215 54.4% 30-39 776 14.4%435 56.1% 40-49 1,550 28.8%975 62.9% 50-59 1,674 31.2%1,138 68.0% 60 & over 950 17.7%668 70.3% Male All ages 4,416 82.2%2,856 64.7% 0-12 **5 * 13-19 **4 * 20-29 342 6.4%192 56.1% 30-39 603 11.2%341 56.6% 40-49 1,255 23.4%793 63.2% 50-59 1,416 26.4%963 68.0% 60 & over 787 14.6%558 70.9% Female All ages 957 17.8%593 62.0% 0-12 **2 * 13-19 **7 * 20-29 53 1.0%23 ** 30-39 173 3.2%94 54.3% 40-49 295 5.5%182 61.7% 50-59 258 4.8%175 67.8% 60 & over 163 3.0%110 67.5% Source:Alameda County eHARS,2016 Q2 NOTE:Excludes PLHIV at year-end 2013 who died (N=62)or moved out of the county (N=227)in 2014. [a]Refers to sex assigned at birth [b]Viral load categories are defined as follows:Suppressed =76-199 copies/ml,Unsuppressed =200+ copies/ml [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 60 The Continuum of HIV Care Table 4.11: Viral Suppression in 2014 Among PLHIV at Year-End 2013 by Sex and Race/Ethnicity, Alameda County All PLHIV Suppressed at Last Viral Load in 2014c Sexa Race/ Ethnicityb Count Column Percent Count Row Percent All All races 5,373 100.0%3,449 64.2% AfrAmer 2,221 41.3%1,338 60.2% White 1,771 33.0%1,235 69.7% Latino 940 17.5%582 61.9% API 318 5.9%213 67.0% Other/Unk 123 2.3%81 65.9% Male All races 4,416 82.2%2,856 64.7% AfrAmer 1,616 30.1%968 59.9% White 1,618 30.1%1,131 69.9% Latino 814 15.1%507 62.3% API 263 4.9%178 67.7% Other/Unk 105 2.0%72 68.6% Female All races 957 17.8%593 62.0% AfrAmer 605 11.3%370 61.2% White 153 2.8%104 68.0% Latino 126 2.3%75 59.5% API 55 1.0%35 ** Other/Unk 18 0.3%9 ** Source:Alameda County eHARS,2016 Q2 NOTE:Excludes PLHIV at year-end 2013 who died (N=62)or moved out of the county (N=227)in 2014. [a]Refers to sex assigned at birth [b]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [c]Viral load categories are defined as follows:Suppressed =76-199 copies/ml,Unsuppressed =200+ copies/ml [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 61 The Continuum of HIV Care Table 4.12: Viral Suppression in 2014 Among PLHIV at Year-End 2013 by Race/Ethnicity and Age, Alameda County NOTE:This table spans multiple pages. All PLHIV Suppressed at Last Viral Load in 2014b Race/ Ethnicitya Age at Year-End 2013 Count Column Percent Count Row Percent All races All ages 5,373 100.0%3,449 64.2% 0-12 10 0.2%7 ** 13-19 18 0.3%11 ** 20-29 395 7.4%215 54.4% 30-39 776 14.4%435 56.1% 40-49 1,550 28.8%975 62.9% 50-59 1,674 31.2%1,138 68.0% 60 & over 950 17.7%668 70.3% AfrAmer All ages 2,221 41.3%1,338 60.2% 0-12 7 0.1%6 ** 13-19 11 0.2%5 ** 20-29 186 3.5%98 52.7% 30-39 327 6.1%171 52.3% 40-49 604 11.2%361 59.8% 50-59 683 12.7%440 64.4% 60 & over 403 7.5%257 63.8% White All ages 1,771 33.0%1,235 69.7% 0-12 **1 * 13-19 **2 * 20-29 58 1.1%35 ** 30-39 155 2.9%94 60.6% 40-49 474 8.8%313 66.0% 50-59 678 12.6%487 71.8% 60 & over 402 7.5%303 75.4% HIV in Alameda County, 2013-2015 62 The Continuum of HIV Care Table 4.12: Viral Suppression in 2014 Among PLHIV at Year-End 2013 by Race/Ethnicity and Age, Alameda County (continued) NOTE:This table spans multiple pages. All PLHIV Suppressed at Last Viral Load in 2014b Race/ Ethnicitya Age at Year-End 2013 Count Column Percent Count Row Percent Latino All ages 940 17.5%582 61.9% 0-12 **0 * 13-19 **3 * 20-29 103 1.9%62 60.2% 30-39 201 3.7%109 54.2% 40-49 316 5.9%196 62.0% 50-59 225 4.2%148 65.8% 60 & over 90 1.7%64 71.1% API All ages 318 5.9%213 67.0% 0-12 **0 * 13-19 **1 * 20-29 31 0.6%10 ** 30-39 63 1.2%42 ** 40-49 122 2.3%83 68.0% 50-59 62 1.2%46 ** 60 & over 39 0.7%31 ** HIV in Alameda County, 2013-2015 63 The Continuum of HIV Care Table 4.12: Viral Suppression in 2014 Among PLHIV at Year-End 2013 by Race/Ethnicity and Age, Alameda County (continued) NOTE:This table spans multiple pages. All PLHIV Suppressed at Last Viral Load in 2014b Race/ Ethnicitya Age at Year-End 2013 Count Column Percent Count Row Percent Other/Unk All ages 123 2.3%81 65.9% 0-12 0 0.0%0 ** 13-19 0 0.0%0 ** 20-29 17 0.3%10 ** 30-39 30 0.6%19 ** 40-49 34 0.6%22 ** 50-59 26 0.5%17 ** 60 & over 16 0.3%13 ** Source:Alameda County eHARS,2016 Q2 NOTE:Excludes PLHIV at year-end2013 who died (N=62)or moved out of the county (N=227)in 2014. [a]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [b]Viral load categories are defined as follows:Suppressed =76-199 copies/ml,Unsuppressed =200+copies/ml [*]Some cells suppressed to protect confidentiality. [**]Unstable estimates not shown. Table 4.13: Viral Suppression in 2014 Among PLHIV at Year-End 2013 and in Care in 2014 by Sex, Alameda County All PLHIV Suppressed at Last Viral Load in 2014b Sexa Count Column Percent Count Row Percent All 4,079 100.0%3,449 84.6% Male 3,345 82.0%2,856 85.4% Female 734 18.0%593 80.8% Source:Alameda County eHARS,2016 Q2 NOTE:Excludes PLHIV at year-end 2013 who died (N=62),moved out of the county (N=227),or did not have any HIV labs reported (N=1294)in 2014. [a]Refers to sex assigned at birth [b]Viral load categories are defined as follows:Suppressed =76-199 copies/ml, Unsuppressed =200+copies/ml HIV in Alameda County, 2013-2015 64 The Continuum of HIV Care Table 4.14: Viral Suppression in 2014 Among PLHIV at Year-End 2013 and in Care in 2014 by Race/Ethnicity, Alameda County All PLHIV Suppressed at Last Viral Load in 2014b Race/ Ethnicitya Count Column Percent Count Row Percent All races 4,079 100.0%3,449 84.6% AfrAmer 1,678 41.1%1,338 79.7% White 1,364 33.4%1,235 90.5% Latino 687 16.8%582 84.7% API 245 6.0%213 86.9% Other/Unk 105 2.6%81 77.1% Source:Alameda County eHARS,2016 Q2 NOTE:Excludes PLHIV at year-end 2013 who died (N=62),moved out of the county (N=227), or did not have any HIV labs reported (N=1294)in 2014. [a]'Other/Unk'=American Indians and Alaskan Natives,multiple race,unknown race [b]Viral load categories are defined as follows:Suppressed =76-199 copies/ml, Unsuppressed =200+copies/ml [**]Unstable estimates not shown. Table 4.15: Viral Suppression in 2014 Among PLHIV at Year-End 2013 and in Care in 2014 by Age, Alameda County All PLHIV Suppressed at Last Viral Load in 2014a Age at Year-End 2013 Count Column Percent Count Row Percent All ages 4,079 100.0%3,449 84.6% 0-12 8 0.2%7 ** 13-19 16 0.4%11 ** 20-29 304 7.5%215 70.7% 30-39 560 13.7%435 77.7% 40-49 1,165 28.6%975 83.7% 50-59 1,306 32.0%1,138 87.1% 60 & over 720 17.7%668 92.8% Source:Alameda County eHARS,2016 Q2 NOTE:Excludes PLHIV at year-end 2013 who died (N=62),moved out of the county (N=227), or did not have any HIV labs reported (N=1294)in 2014. [a]Viral load categories are defined as follows:Suppressed =76-199 copies/ml, Unsuppressed =200+copies/ml [**]Unstable estimates not shown. HIV in Alameda County, 2013-2015 65 Technical Notes Appendix A: Technical Notes Data Sources All counts and proportions in this report were calculated using data from the Enhanced HIV/AIDS Reporting System (eHARS). Numerators of rates were also obtained from eHARS; denominators were derived using data from the United States Census (2000 and 2010) and Environmental Systems Research Institute (2012 and later). Mid-year population estimates for intercensal years prior to 2012 as well as all year-end estimates were obtained through linear interpolation. Statistical Analysis Calculation of Conﬁdence Intervals All conﬁdence intervals (CI) depicted in the report are at the 95% conﬁdence level. CIs for proportions are calculated on the log odds (“logit”) scale and then antilogit-transformed in order to preclude lower limits less than 0% and upper limits greater than 100%. Conﬁdence limits for rates are calculated using a Poisson distribution for counts less than 100 and a binomial distribution for counts of 100 or greater. Signiﬁcance Testing and Statistical Modeling The statistical signiﬁcance of associations between categorical variables was tested by Pearson’s chi square test or Fisher’s exact test, as appropriate. Diﬀerences in CD4 count at diagnosis were assessed using ANOVA unless Levene’s Test for Homogeneity of Variances yielded a signiﬁcant result (at alpha = 0.05), in which case Welch’s ANOVA was used. Trend analyses were performed using Join Point [2] to model crude rates as a log-linear function of year separately for each stratum of the categorical variable(s); errors were assumed to have Poisson variance and to be independent. Grid search and the modiﬁed Bayesian Information Criterion were used to select the best ﬁtting model from among those with zero to four join points at least 2 years apart between 2007 and 2014 (the second and second-to-last years examined). Data Suppression Rules Proportions In accordance with draft guidelines released by the National Center for Health Statistics [8], proportions are considered to be statistically unreliable and are not presented if they meet either of the following criteria: HIV in Alameda County, 2013-2015 66 Technical Notes 1.The absolute CI width exceeds 20%. 2.The absolute CI width does not exceed 20%, but the relative CI width (the absolute CI width divided by the lesser of the proportion and its complement) exceeds 120%. Rates Rates for subpopulations with fewer than 12 cases are considered to be statistically unreliable and were not pre- sented. In these instances, the relative standard error of the rate exceeds 30%. Death Ascertainment Alameda County HIV surveillance oﬃcials are notiﬁed by the local Oﬃce of Vital Registration whenever HIV is documented on a death certiﬁcate ﬁled in Alameda County. Additionally, the California Oﬃce of AIDS pe- riodically matches state HIV registry data to national death databases such as the National Death Index and the Social Security Administration’s Death Master File. PLHIV who died outside of Alameda County and were ever associated with Alameda County or whose HIV was not documented on their death certiﬁcate are thus generally captured through this process with some delay. HIV in Alameda County, 2013-2015 67 Appendix B: Reporting Requirements The representativeness and accuracy of HIV surveillance data depend on the reliable, complete, and timely reporting of data by health care providers and laboratories in accordance with California law. The Adult HIV/AIDS Case Report Form, which is used to report data on cases of HIV infection, is available at http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph8641a.pdf. Help completing it in Alameda County can be obtained by calling (510) 268-2372. Health Care Providers Title 17, Section 2643.5, “HIV Reporting by Health Care Providers,” requires health care providers to report cases of HIV disease (at any stage) to the local health department in the jurisdiction of their practice: (a)Each health care provider that orders a laboratory test used to identify HIV, a component of HIV, or antibodies to or antigens of HIV shall submit to the laboratory performing the test a pre-printed laboratory requisition form which includes all documentation as speciﬁed in 42 CFR 493.1105 (57 FR 7162, Feb. 28, 1992, as amended at 58 FR 5229, Jan. 19, 1993) and adopted in Business and Professions Code, Section 1220. (b)The person authorized to order the laboratory test shall include the following when submitting information to the laboratory: (1)Complete name of patient; and (2)Patient date of birth (2-digit month, 2-digit day, 4-digit year); and (3)Patient gender (male, female, transgender male-to-female, or transgender female-to-male); and (4)Date biological specimen was collected; and (5)Name, address, telephone number of the health care provider and the facility where services were ren- dered, if diﬀerent. (c)Each health care provider shall, within seven calendar days of receipt from a laboratory of a patient’s conﬁrmed HIV test or determination by the health care provider of a patient’s conﬁrmed HIV test, report the conﬁrmed HIV test to the local Health Oﬃcer for the jurisdiction where the health care provider facility is located. The report shall consist of a completed copy of the HIV/AIDS Case Report form. (1)All reports containing personal information, including HIV/AIDS Case Reports, shall be sent to the local Health Oﬃcer or his or her designee by: 68 Technical Notes (A)courier service, U.S. Postal Service Express or Registered mail, or other traceable mail; or (B)person-to-person transfer with the local Health Oﬃcer or his or her designee. (2)The health care provider shall not submit reports containing personal information to the local Health Oﬃcer or his or her designee by electronic facsimile transmission or by electronic mail or by non- traceable mail. (d)HIV reporting by name to the local Health Oﬃcer, via submission of the HIV/AIDS Case Report, shall not supplant the reporting requirements in Article 1 of this Subchapter when a patient’s medical condition progresses from HIV infection to an Acquired Immunodeﬁciency Syndrome (AIDS) diagnosis. (e)A health care provider who receives notiﬁcation from an out-of-state laboratory of a conﬁrmed HIV test for a California patient shall report the ﬁndings to the local Health Oﬃcer for the jurisdiction where the health care provider facility is located. (f)When a health care provider orders multiple HIV-related viral load tests for a patient, or receives multiple laboratory reports of a conﬁrmed HIV test, the health care provider shall be required to submit only one HIV/AIDS Case Report, per patient, to the local Health Oﬃcer. (g)Nothing in this Subchapter shall prohibit the local health department from assisting health care providers to report HIV cases. (h)Information reported pursuant to this Article is acquired in conﬁdence and shall not be disclosed by the health care provider except as authorized by this Article, other state or federal law, or with the written consent of the individual to whom the information pertains or the legal representative of that individual. Note: Authority cited: Sections 120125, 120130, 120140, 121022, 131080 and 131200, Health and Safety Code. Reference: Sections 1202.5, 1206, 1206.5, 1220, 1241, 1265 and 1281, Business and Professions Code; and Sections 1603.1, 101160, 120175, 120250, 120775, 120885-120895, 120917, 120975, 120980, 121015, 121022, 121025, 121035, 121085, 131051, 131052, 131056 and 131080, Health and Safety Code. Laboratories Title 17, Section 2643.10, “HIV Reporting by Laboratories,” requires laboratories to report all HIV-related labora- tory tests to the local health department in the jurisdiction of the ordering provider: (a)The laboratory director or authorized designee shall, within seven calendar days of determining a conﬁrmed HIV test, report the conﬁrmed HIV test to the Health Oﬃcer for the local health jurisdiction where the health care provider facility is located. The report shall include the (1)Complete name of patient; and (2)Patient date of birth (2-digit month, 2-digit day, 4-digit year); and (3)Patient gender (male, female, transgender male-to-female, or transgender female-to-male); and (4)Name, address, and telephone number of the health care provider and the facility that submitted the biological specimen to the laboratory, if diﬀerent; and (5)Name, address, and telephone number of the laboratory; and (6)Laboratory report number as assigned by the laboratory; and HIV in Alameda County, 2013-2015 69 Technical Notes (7)Laboratory results of the test performed; and (8)Date the biological specimen was tested in the laboratory; and (9)Laboratory Clinical Laboratory Improvement Amendments (CLIA) number. (b) (1)All reports containing personal information, including laboratory reports, shall be sent to the local Health Oﬃcer or his or her designee by: (A)courier service, U.S. Postal Service Express or Registered mail, or other traceable mail; or (B)person-to-person transfer with the local Health Oﬃcer or his or her designee. (2)The laboratory shall not submit reports containing personal information to the local Health Oﬃcer or his or her designee by electronic facsimile transmission or by electronic mail or by non-traceable mail. (c)A laboratory that receives incomplete patient data from a health care provider for a biological specimen with a conﬁrmed HIV test, shall contact the submitting health care provider to obtain the information required pursuant to Section 2643.5(b)(1)-(5), prior to reporting the conﬁrmed HIV test to the local Health Oﬃcer. (d)If a laboratory transfers a biological specimen to another laboratory for testing, the laboratory that ﬁrst receives the biological specimen from the health care provider shall report conﬁrmed HIV tests to the local Health Oﬃcer. (e)Laboratories shall not submit reports to the local health department for conﬁrmed HIV tests for patients of an Alternative Testing Site or other anonymous HIV testing program, a blood bank, a plasma center, or for participants of a blinded and/or unlinked seroprevalence study. (f)When a California laboratory receives a biological specimen for testing from an out-of-state laboratory or health care provider, the California director of the laboratory shall ensure that a conﬁrmed HIV test is reported to the state health department in the state where the biological specimen originated. (g)When a California laboratory receives a report from an out of state laboratory that indicates evidence of a conﬁrmed HIV test for a California patient, the California laboratory shall notify the local Health Oﬃcer and health care provider in the same manner as if the ﬁndings had been made by the California laboratory. (h)Information reported pursuant to this Article is acquired in conﬁdence and shall not be disclosed by the laboratory except as authorized by this Article, other state or federal law, or with the written consent of the individual to whom the information pertains or the legal representative of the individual. Note: Authority cited: Section 1224, Business and Professions Code; and Sections 120125, 120130, 120140, 121022, 131080 and 131200, Health and Safety Code. Reference: Sections 1206, 1206.5, 1209, 1220, 1241, 1265, 1281 and 1288, Business and Professions Code; and Sections 101150, 120175, 120775, 120885-120895, 120975, 120980, 121022, 121025, 121035, 131051, 131052, 131056 and 131080, Health and Safety Code. HIV in Alameda County, 2013-2015 70 Appendix C: HIV Surveillance in Alameda County California Code of Regulations (CCR) Title 17, Section 2643.5 requires all health care providers (HCP) to report all cases of HIV disease they encounter in their clinical practice to the county/local health jurisdiction in which the encounter occurs. Additionally, CCR Title 17, Section 2643.10 requires all commercial laboratories to report all HIV-related laboratory tests they conduct to the local health jurisdiction of the HCP who ordered the test, providing an additional means by which local health departments may learn of a case of HIV disease. In November 2015, California adopted the Electronic Laboratory Reporting (ELR) system for laboratories per- forming HIV testing. [7] HIV test results delivered through ELR meet the statutory and regulatory reporting requirements for HIV test results. HIV-related laboratory results are submitted to the California Department of Public Health (CDPH) and routed to Alameda County for investigation. Establishment of ELR resulted in major changes in the local processing and management of laboratory results for HIV surveillance. Figure A.2 illustrates the steps involved in processing lab results, including ELR, for HIV surveillance in Alameda County. As shown in the ﬁgure, reported labs are checked against a local database to identify cases not previously re- ported. Potential new cases are investigated by trained ﬁeld staﬀ, who visit the oﬃce of the HCP that or- dered the laboratory tests(s) or submitted the report and complete a standardized case report form (available at http://www.cdph.ca.gov/pubsforms/forms/CtrldForms/cdph8641a.pdf) using information abstracted from the patient’s medical record and obtained from the HCP. Forms are then transmitted to CDPH, which in turn routinely submits de-identiﬁed data to CDC. When cases reported by diﬀerent states appear to be the same person, CDC notiﬁes the appropriate states to contact each other directly and determine whether the cases are duplicates. Security and Conﬁdentiality of Data In accordance with the county’s data use and disclosure agreement with CDPH, all data collected in the course of conducting HIV surveillance are used solely for public health purposes. Additionally, administrative, technical, and physical safeguards are in place to ensure the security and conﬁdentiality of these data. All paper records are stored in locked ﬁle cabinets in an oﬃce with restricted access. Electronic data transmissions are encrypted and occur over a secure ﬁle transfer network. All electronic data are stored in a restricted access directory on a protected server. Limitations of Surveillance Data and of County Analysis A major strength of HIV surveillance data is that it captures and reﬂects the entire population of HIV diagnosed individuals. HIV surveillance data are not without their limitations however, which limit the analyses that can be done. These limitations include, but are not limited to: 71 Technical Notes •Data quality:Public health investigators extract required information from medical records for HIV report- ing. Some information, such as risk factors or identiﬁcation as transgender may not have been available in the medical record, elicited from the patient by the HCP, or adequately described. •Data quantity:In small subpopulations, the number of new diagnoses or PLHIV was not large enough to allow certain analyses. Statistical analyses based on small numbers may result in unstable estimates which can be misleading. •Timeliness of reporting:Surveillance data are the product of a long process triggered by a visit to a HCP by an HIV-infected individual and culminating in the entry of case data into the statewide HIV surveillance database at the California Department of Public Health. Intermediate steps include, but are not limited to, laboratory testing, submission of case reports and lab results to the local health department, and investigation of each report. Data preparation, analysis and interpretation take additional time. For these reasons, there can be a 6-12 month delay in estimating numbers of diagnoses or PLHIV and in estimating any measures dependent on laboratory test results. •History of reporting laws:The laws mandating the reporting of HIV-related laboratory test results and of cases of HIV disease at its diﬀerent stages have changed over time, and this impacts our ability to characterize the epidemic at diﬀerent points in the past. Although AIDS has been reportable since 1983, HIV disease at its earlier stages was not reportable until mid-2002 and even then only by a non-name code. More reliable, name-based data on HIV non-AIDS cases became mandated in 2006, and HIV-related labs became reportable in California in 2009. Consequently, most of analyses are limited to 2006 and later, and analyses relying on laboratory reporting are limited to 2010 and later. Figure A.1: Timeline of Mandated HIV Reporting in California 1983 2002 2006 2009HIV−related laboratory results reportable HIV non−AIDS reportable by name HIV non−AIDS reportable by non−name code Stage 3 HIV infection (AIDS) reportable 1990 2000 2010 Year HIV in Alameda County, 2013-2015 72 Technical Notes Figure A.2: The HIV Surveillance System in Alameda County HIV in Alameda County, 2013-2015 73 Technical Notes HIV in Alameda County, 2013-2015 74 Bibliography [1]California hiv surveillance report —2014, October 2016. URL http://www.cdph.ca.gov/programs/ aids/Documents/California%20HIV%20Surveillance%20Report%20-%202014.pdf. [2]Joinpoint regression program, version 4.3.1.0, April 2016. URL https://surveillance.cancer.gov/joinpoint/. [3]Centers for Disease Control and Prevention. Revised surveillance case deﬁnition for hiv infection —united states, 2014, April 2014. URL http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6303a1.htm. [4]Centers for Disease Control and Prevention. Diagnoses of hiv infection in the united states and dependent areas, 2015, November 2016. URL https://www.cdc.gov/hiv/pdf/library/reports/surveillance/ cdc-hiv-surveillance-report-2015-vol-27.pdf. [5]Centers for Disease Control and Prevention. Monitoring selected national hiv prevention and care objectives by using hiv surveillance data—united states and 6 dependent areas—2014, July 2016. URL https://www.cdc.gov/hiv/pdf/library/reports/surveillance/ cdc-hiv-surveillance-supplemental-report-vol-21-4.pdf. [6]Eve Mokotoﬀ, Lucia V. Torian, Monica Olkowski, James T. Murphy, Dena Bensen, Maree Kay Parisi, and Jennifer Chase. Positions statements 2007: Heterosexual hiv transmission classiﬁcation, 2007. URL www.cste.org/resource/resmgr/PS/07-ID-09.pdf. [7]California Department of Public Health. Establishment of state electronic laboratory reporting system for hiv, November 2015. URL https://www.cdph.ca.gov/programs/aids/Documents/HIVELRLaunchLetter.doc.pdf. [8]Jennifer Parker. Draft suppression/presentation guidelines guidelines for proportions, January 2015. URL https://www.cdc.gov/nchs/data/bsc/bscpres_parker_january2015.pdf. HIV in Alameda County, 2013-2015 75 Alameda County Public Health Department 1000 Broadway, Suite 310 Oakland, CA 94607