Epidemiology 101 HIV/AIDS Case Reporting

1. Epidemiology 101HIV/AIDS Case Reporting March 17, 2009 CHOW Meeting Amy Bauer, MPH Surveillance Epidemiologist

2. How many HIV infected in King Co.? Undiagnosed HIV infection 720- 1,560 Adults reported living w/AIDS 3,506 Diagnosed but not reported 200-800 Reported pediatric HIV/AIDS - 26 Adults reported living w/HIV 2,751

3. What is Surveillance? Disease surveillance is the ongoing and systematic collection, management, analysis, interpretation, dissemination, and evaluation of high quality population-based information about persons with a particular disease.

4. Never In Care Medical Monitoring Exposures Behavioral Surveillance Incidence Surveillance

5. Reporting Requirements • Health care providers are required by law to report HIV/AIDS cases by name to the local health department of the area in which he or she practices • Laboratories are required to report all HIV indicative tests to the Washington State Department of Health(Includes: ALL confirmatory tests, CD4’s and viral load tests)

6. Protection of Case Report Information • State laws and health department security and confidentiality rules protect the identity of persons reported with HIV or AIDS. • Anyone guiltyof violating these confidentiality laws may be found guilty of a gross misdemeanor and may be subject to action for reckless or intentional disclosure up to a fine of $10,000 or actual damages, whichever is greater (RCW 70.24.080, RCW 9A.20.021, RCW 70.24.084).  • Case reports are kept in locked rooms with access limited to authorized personnel who are trained in maintaining confidentiality and security of these records.

7. Surveillance Interests • Date of Birth (Pediatric Exposures) • Date of Initial HIV Diagnosis • Date of Initial AIDS Diagnosis • Date of Death

8. Case Finding • 68% of cases 1st identified by laboratory • (36,000 reports / 20 labs) • 16% reported by physician office • 10% reported by HIV testing clinics • 5% of cases 1st ID thru data linkage • Death / TB / STD registries • Department of Corrections • Medicaid / ADAP • Clinic databases

11. What data is collected? • Demographic Data • Risk Behavior/Exposure Data • Provider/Medical Facility • Laboratory Data • Clinical Data • Antiretroviral Therapy Experience • Past Testing Behavior • Mortality Data

12. Data: the Good, the Bad & the Ugly

13. The Process • Laboratories report all HIV Indicative Tests • Match conducted against Statewide HARS Database • Non Matches generate Investigation Sheet • Providers/Facilities Contacted for Case Report • Data Entered into HARS (HIV/AIDS Reporting System) • New Case information transferred to STD Clinic for PCRS (Partner Counseling & Referral Services)

14. HARS in Washington Washington State Washington State Dept of Health Olympia, WA Seattle-King County Seattle-KingCounty Public Health Seattle & King County Seattle, WA

15. HARS and the CDC • Monthly, the statewide HARS Database is stripped of identifiers and transferred to CDC to form the National Dataset • Semi Annually CDC creates a list of possible Inter-State duplicates • Duplicate lists are sent back to the states, and calls between local surveillance programs are made to resolve residency and case ownership

16. Take Away Message • Security and Confidentiality of Data is Highest Priority • Names are stored ONLY at local and state level • Surveillance data are available for persons who test confidentially or have accessed care • Data on In Migration much more complete than Out Migration • Recently changes in the WAC have mandated comprehensive Laboratory Reporting

17. HIV Mortality Trends • Deaths have declined sharply since 1995 • HIV is no longer a leading cause of death • Survival times after AIDS diagnosis have increase dramatically since 1995 • Age at time of death is increasing • Cause of death among people with HIV is changing

19. Persons living with HIV/AIDS by Gender And Age at Initial HIV Diagnosis (as of 6/30/08) Decreasing % age 30-39

20. Median Age of diagnosed HIV populationKing County residents living with HIV, 1985 - 2005

21. Underlying cause of Death Among King Co. residents with HIV 2000–06, n=610

22. AIDS, HIV, and Deaths by YearKing County, 1987-2007 (as of 6/30/2008) * * * Not adjusted for delays in reporting

23. Reported HIV Prevalence by YearKing County, 1987-2007 (as of 6/30/2008)

24. King County Trends Data as of 6/30/2008 (N=10,680) Chi-square test for trend compares diagnosis with HIV: 1999-01, 2002-04, 2005-07

25. Distribution of New HIV Diagnoses King County sex and race, 1982-2007 *White males *Nonwhite males Nonwhite females White females * indicates significant trend 1999-2007

26. Distribution of New HIV Diagnoses King County mode of transmission, 1982-2007 MSM * MSM/IDU Heterosexual *IDU * indicates significant trend 1999-2007

27. Trends by Place of BirthKing County 1981 - 2007 * Born in U.S. * Born outside U.S. * indicates significant trend 1999-2007

28. HIV Trends by race and place of birth,King County 1981 - 2007

29. Persons Living with HIV/AIDSBy Sex, as of 6/30/2008 Males, 90% Females, 10% Distribution by sex unchanged 1999-2007

30. Persons Living with HIV/AIDSBy Race / Ethnicity, as of 6/30/2008 White, non Hispanic - 68% Native American & Alaskan Native - 1% Black, non Hispanic - 17% Hispanic 9% Asian & Pacific Islanders - 3% Decreasing % Whites, Increasing % API, Hispanic

31. Persons Living with HIV/AIDSBy mode of exposure, as of 6/30/2008 MSM/IDU 8% Heterosexual 10% IDU 5% Other 1% Undetermined 6% MSM, 69% Decreasing % IDU, Increasing % MSM/IDU

32. Persons Living with HIV/AIDSBy Birthplace, as of 6/30/2008 Born in U.S., 81% Unknown birthplace, 4% Foreign-born, 15% Increasing % foreign-born

33. People living with HIV/AIDS Rates by gender & race/ethnicity, King Co. 6/30/08 (N=6283) W B H API NA/AN W B H API NA/AN Males Females

34. Questions? • Jim Kent- Surveillance Coordinator Jim.Kent@kingcounty.gov (206)205-6121 • Amy Bauer- Surveillance Epidemiologist Amy.Bauer@kingcounty.gov (206)205-3407 • Faythe Crosby- Disease Researcher Faythe.Crosby@kingcounty.gov (206)205-9124