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Baltimore-Towson Metropolitan Statistical Area (MSA)HIV/AIDS Epidemiological ProfileFourth Quarter 2011Data reported through December 31, 2011Center for HIV Surveillance, Epidemiology and EvaluationInfectious Disease BureauPrevention and Health Promotion AdministrationMaryland Department of Health and Mental -800-358-9001PercentageEstimated Number and Percentage of HIV Infected AdultsEngaged in Selected Stages of the Continuum of Care,Baltimore MSA, Maryland, ked to Retained inDiagnosed HIV Care HIV CareEngagement in CareOn ARTSuppressedVLEngagement in the Continuum of HIV CareIn their 2011 article in Clinical Infectious Diseases, Gardner et al. utilize a continuum of care “cascade” to illustratenational estimates of the number of persons living with HIV who belong to each of the stages of engagement in HIV care.Nationally, it was estimated that among persons living with HIV in the United States, only 19% have achieved viralsuppression. The Maryland Engagement in HIV Care Cascade (above) uses the national estimate of the number ofundiagnosed persons (20%) to generate an estimated total number of HIV infected persons in Maryland, and then useslocal data to describe the number and percentage of persons living with HIV in Maryland who belong to each of the stagesof engagement in HIV care. In the Baltimore-Towson MSA, 68% of HIV diagnosed persons are linked to care. Half (50%)of HIV diagnosed persons are retained in care. Fewer still, 35% are on antiretroviral therapy, and 20% have achievedviral suppression.Gardner et al, “The Spectrum of Engagement in HIV Care and its Relevance to Test‐and‐Treat Strategies for Prevention of HIVInfection.” Clin Infect Dis. 2011; 52 (6): 793‐800.
TABLE OF CONTENTSSection I – Background Information . 3Section II – Trends 1985-2010 . 6Figure 1 – Trends in Reported HIV and AIDS Diagnoses and Deaths, 1985-2010. 6Figure 2 – Trends in Living HIV Cases, 1985-2010 . 7Figure 3 – Trends in Adult/Adolescent Reported HIV Diagnoses by Sex at Birth, 1985-2010 . 8Figure 4 – Trends in Adult/Adolescent Reported HIV Diagnoses by Race/Ethnicity, 1985-2010 . 9Figure 5 – Trends in Adult/Adolescent Reported HIV Diagnoses by Age at Diagnosis, 1985-2010 . 10Figure 6 – Trends in Adult/Adolescent Reported HIV Diagnoses by Exposure Category, 1985-2010. 11Section III – Adult/Adolescent Cases by Jurisdiction . 12Table 1 – Adult/Adolescent HIV Cases by Jurisdiction, Diagnoses during 2010 . 12Table 2 – Adult/Adolescent AIDS Cases by Jurisdiction, Diagnoses during 2010 . 12Table 3 – Adult/Adolescent HIV Cases by Jurisdiction, Alive on 12/31/2010 . 13Table 4 – CD4 Testing for Adult/Adolescent HIV Cases by Jurisdiction, Alive on 12/31/2010 . 14Table 5 – HIV Viral Load Testing for Adult/Adolescent HIV Cases by Jurisdiction, Alive on 12/31/2010 . 14Section IV – Cases by Age . 15Table 6 – HIV Cases by Age at Diagnosis, Diagnoses during 2010. 15Table 7 – AIDS Cases by Age at Diagnosis, Diagnoses during 2010 . 15Table 8 – HIV Cases by Current Age, Alive on 12/31/2010 . 16Table 9 – CD4 Testing for Adult/Adolescent HIV Cases by Current Age, Alive on 12/31/2010 . 17Table 10 – HIV Viral Load Testing for Adult/Adolescent HIV Cases by Current Age, Alive on 12/31/2010 . 17Section V – Adult/Adolescent Cases by Demographics . 18Table 11 – Adult/Adolescent HIV Cases by Demographics, Diagnoses during 2010 . 18Table 12 – Adult/Adolescent AIDS Cases by Demographics, Diagnoses during 2010 . 19Table 13 – Adult/Adolescent HIV Cases by Demographics, Alive on 12/31/2010 . 20Table 14 – CD4 Testing for Adult/Adolescent HIV Cases by Demographics, Alive on 12/31/2010 . 21Table 15 – HIV Viral Load Testing for Adult/Adolescent HIV Cases by Demographics, Alive on 12/31/2010 . 22Section VI – HIV Cases by Expanded Demographics, Alive on 12/31/2010 . 23Table 16 – Male HIV Cases by Current Age and Race/Ethnicity, Alive on 12/31/2010 . 23Table 17 – Female HIV Cases by Current Age and Race/Ethnicity, Alive on 12/31/2010 . 24Section VII – HIV Exposure Category . 25Table 18 – Adult/Adolescent HIV Cases by Exposure Category and Sex at Birth, Diagnoses during 2010 . 25Table 19 – Adult/Adolescent AIDS Cases by Exposure Category and Sex at Birth, Diagnoses during 2010 . 26Table 20 – Adult/Adolescent HIV Cases by Exposure Category and Sex at Birth, Alive on 12/31/2010 . 27Table 21 – Adult/Adolescent HIV Cases by Exposure Category, Race/Ethnicity, and Sex at Birth, Alive on12/31/2010 . 28Table 22 – CD4 Testing for Adult/Adolescent HIV Cases by Exposure Category, Alive on 12/31/2010 . 29Table 23 – HIV Viral Load Testing for Adult/Adolescent HIV Cases by Exposure Category, Alive on 12/31/2010 29Section VIII – Disease Progression and Mortality. 30Figure 7 – Trends in Disease Progression by Year of HIV Diagnosis, 1985-2009 . 30Figure 8 – Trends in Survival Times by Year of AIDS Diagnosis, 1985-2009 . 31Section IX – Pediatric Cases . 32Figure 9 – Trends in Pediatric HIV Cases, 1985-2010 . 32Table 24 – Pediatric HIV Cases by Jurisdiction, HIV Diagnosis during 2010, Alive on 12/31/2010 . 33Table 25 – Pediatric HIV Cases by Demographics, HIV Diagnosis during 2010, Alive on 12/31/2010. 33Baltimore-Towson MSA HIV/AIDS Epidemiological Profile – Fourth Quarter 2011Page 2
Section I – Background InformationHIV/AIDS Reporting RequirementsThe Maryland HIV/AIDS Reporting Act of 2007 went into effect on April 24, 2007. The law expanded HIV/AIDS reportingand required that HIV cases be reported by name. The following highlights the reporting requirements of Health-GeneralArticles 18-201.1, 18-202.1, and 18-205 of the Annotated Code of Maryland, as specified in COMAR 10.18.02.Physicians are required to report patients in their care with diagnoses of HIV or AIDS immediately to the LocalHealth Department where the physician’s office is located by mailing DHMH Form 1140. Reports are alsoaccepted by phone.Physicians are required to report infants born to HIV positive mothers within 48 hours to the State HealthDepartment by mailing DHMH Form 1140. Reports are also accepted by phone.Clinical and infection control practitioners in hospitals, nursing homes, hospice facilities, medical clinics incorrectional facilities, inpatient psychiatric facilities, and inpatient drug rehabilitation facilities are required to reportpatients in the care of the institution with diagnoses of HIV or AIDS within 48 hours to the Local HealthDepartment where the institution is located by mailing DHMH Form 1140. Reports are also accepted by phone.Facilities with large volumes are encouraged to contact the State Health Department to establish electronicreporting.Laboratory directors are required to report patients with laboratory results indicating HIV infection (e.g., positiveconfirmatory HIV diagnostic tests, all CD4 immunological tests, all HIV viral load tests, and all HIV genotype andphenotype tests) within 48 hours to the Local Health Department where the laboratory is located, or if out of stateto the Maryland State Health Department, by mailing DHMH Form 4492. Laboratories are encouraged to contactthe State Health Department to establish electronic reporting.Reporting forms and instructions are available on our /sitepages/reporting-material.aspxFor Assistance with HIV/AIDS ReportingFor assistance with reporting, including establishment of routine, electronic, or other alternate methods of reporting to theHealth Department, please contact the Center for HIV Surveillance, Epidemiology and Evaluation in the MarylandDepartment of Health and Mental Hygiene at 410-767-5061.Limitations in the HIV/AIDS DataThis epidemiological profile only contains data for HIV and AIDS cases that have been diagnosed by a health careprovider, were reported to the health department by name, and were residents of Maryland at the time of diagnosis.Nationally, it has been estimated that 20% of people living with HIV infection are undiagnosed. In addition, despite amassive effort during which over 17,000 HIV cases were reported after the Maryland HIV reporting law changed on April24, 2007, not all diagnosed HIV cases previously reported by Maryland’s code-based identifier were located and rereported by name, so the number of living HIV cases is lower than previously reported. In addition, many of the rereported HIV cases were identified by a recent diagnosis and not by their earliest diagnosis, resulting in an underreporting of HIV diagnoses before 2001 and an over-reporting of HIV diagnoses from 2001 to 2008. Caution should beexercised in using the number of living HIV cases without AIDS and in interpreting trends in the number of reported HIVdiagnoses. The laboratory data are only available for cases receiving medical care, usually only at facilities in Maryland,and only includes test results that have been reported to the health department.Baltimore-Towson MSA HIV/AIDS Epidemiological Profile – Fourth Quarter 2011Page 3
Stages of a Case of HIV/AIDSUntreated HIV disease progresses from HIV infection to AIDS to death. These are biological events that occur whether ornot a person receives any medical care. For example, a person can be HIV infected but never have an HIV test and sothey do not have an HIV diagnosis. A medical provider diagnoses that these biological events have occurred and recordsthem as a medical event. The law requires medical providers to report these medical events to the Health Department,thereby creating a surveillance event.Time Point123456789Biological EventHIV InfectionMedical EventSurveillance EventHIV DiagnosisHIV ReportAIDS ConditionsAIDS DiagnosisAIDS ReportDeathDeath DiagnosisDeath ReportA case of HIV/AIDS can only move through time in one direction, from HIV infection to death report [from time point 1 totime point 9], but may skip over individual stages. Events can occur simultaneously, but usually there is a time lagbetween them. The time lag between events can be measured in days, months, and years.For example, the time between HIV infection [time point 1] and the test that diagnoses HIV [time point 2] may be severalyears, and it may then take several days for the laboratory and physician to report the diagnosis to the health department[time point 3]. In a second example, a person with diagnosed and reported HIV infection [time point 3] may die [time point7] without developing AIDS, thereby skipping the three AIDS events (conditions, diagnosis, and report [time points 4, 5and 6]). And in a third example, a person with undiagnosed HIV infection [time point 1] may become sick, enter thehospital, and die [time point 7] of what is later determined to be AIDS. In that situation, HIV diagnosis [time point 2], AIDSdiagnosis [time point 5], and death diagnosis [time point 8] would all occur at the same time, and that would probably bemany years after the initial HIV infection [time point 1].Changes in Case TerminologyThe terminology for HIV and AIDS cases was changed from earlier epidemiological profiles to be more precise, withReported Diagnoses replacing Incidence and Living Cases replacing Prevalence. Incidence is a measure of the numberof new events (such as HIV infections) in a population during a period of time. Prevalence is a measure of the number ofpeople living with a condition (such as HIV) in a population at a certain time. Prevalence includes both new and oldcases. For HIV, Incidence and Prevalence cannot be directly measured and must be estimated using statistical methods.The HIV surveillance system is able to provide the actual number of diagnoses and deaths that are reported in thepopulation.For this epidemiological profile, the reports received through a certain time (the end of the year) are used to generate thenumber of diagnoses during the prior years. This one year lag allows for delays in reporting and time to completeinvestigations. For example, the Reported HIV Diagnoses for 2010 are the total of the reported HIV cases with or withoutan AIDS diagnosis, diagnosed with HIV during 1/1/2010-12/31/2010, as reported by name through 12/31/2011.To calculate the number of Living Cases we count up all of the Reported Diagnoses from the beginning of the epidemic(all the new cases each year) and subtract all of the Reported Deaths. For example, the Total Living HIV Cases on12/31/2010 are the total of the reported HIV Cases with or without an AIDS diagnosis and not reported to have died as of12/31/2010 as reported by name through 12/31/2011.Baltimore-Towson MSA HIV/AIDS Epidemiological Profile – Fourth Quarter 2011Page 4
Laboratory DataCD4 tests are measures of a person’s immune system function. An HIV infected person is considered to have AIDS ifthey have less than 200 CD4 cells per microliter of blood. Viral load (VL) tests are measures of the amount of HIV in aperson’s body. The goal of HIV treatment is to have a very low number of copies of virus per milliliter of blood, belowwhat the test can measure, which is called an undetectable level. Treatment recommendations are that a person in HIVmedical care should have their CD4 and VL levels measured at least 2-3 times per year. We use the presence of theselab tests as an indicator that someone has been linked to care after diagnosis or is “in care”.Sources of DataInformation on HIV and AIDS diagnoses, including residence at diagnosis, age, race/ethnicity, sex at birth, country ofbirth, vital status, HIV exposure category, and CD4 and HIV viral load test results are from the Maryland Department ofHealth and Mental Hygiene’s Enhanced HIV/AIDS Reporting System (eHARS), December 31, 2011.Population data by sex, age, and race are from the 2010 U.S. Census and by country-of-birth from the 2010 AmericanCommunity Survey (note the difference in total population due to different source). Due to estimation limitations, somepopulation totals may not equal the sum of its components. When needed, age groups were divided by assuming uniformage distribution within the age group. Non-Hispanic multiple race and Non-Hispanic some other race from the Censuswere combined into one group.Tabulation of Column TotalsFigures in tables and generally in the text have been rounded. Discrepancies in tables between totals and sums ofcomponents are due to rounding.On-line Mapping ToolPlease visit the Maryland Department of Health and Mental Hygiene’s website athttp://ideha.dhmh.maryland.gov/oideor/chse to create your own maps of adult/adolescent HIV rates by jurisdiction ofresidence, subset them by sex at birth and race/ethnicity, zoom in to the jurisdiction level, plot the locations of HIV testingsites, and print out your custom map.Baltimore-Towson MSA HIV/AIDS Epidemiological Profile – Fourth Quarter 2011Page 5
Section II – Trends 1985-2010Figure 1 – Trends in Reported HIV and AIDS Diagnoses and Deaths, 1985-2010Reported HIV Cases with or without an AIDS Diagnosis (Reported HIV Diagnoses) by Year of HIV Diagnosis,Reported HIV Cases with an AIDS Diagnosis (Reported AIDS Diagnosis) by Year of AIDS Diagnosis, and ReportedHIV Cases with an AIDS Diagnosis Reported to have Died of Any Cause (Reported AIDS Deaths) by Year of Death,from 1985 through 2010 as Reported by Name through 12/31/2011.During the 2007-2008 transition to name-based reporting, many HIVcases were reported by a recent HIV diagnosis and not by their earliestHIV diagnosis, resulting in an artificial upward trend in HIV diagnosesduring the period 2001-2008Number of Events1,8001,6001,4001,2001,00080060040020001986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010Year of Diagnosis or DeathReported HIV DiagnosesYEAR OFDIAGNOSISOR DEATH 991,3191,140Reported AIDS 48139971,057842537YEAR OFDIAGNOSISOR 0092010TOTALReported AIDS 1559248555322,482Baltimore-Towson MSA HIV/AIDS Epidemiological Profile – Fourth Quarter 5928123622412,198Page 6
Figure 2 – Trends in Living HIV Cases, 1985-2010stReported HIV Cases with or without an AIDS Diagnosis and Not Reported to have Died as of December 31 ofEach Year (Living HIV Cases without AIDS, Living HIV Cases with AIDS, and Total Living HIV Cases) from 1985through 2010, as Reported by Name through 12/31/2011Number of 04,0002,0000Living HIV Cases without AIDSLiving HIV Cases with AIDS1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010Year of 994199519961997Living HIV Caseswithout 4,0353,8983,937Living HIV Caseswith 2464,849Total LivingHIV 0520062007200820092010Living HIV Caseswithout ,5167,0867,4807,713Living HIV Caseswith ,3969,7079,95610,285Baltimore-Towson MSA HIV/AIDS Epidemiological Profile – Fourth Quarter 2011Total LivingHIV 5514,89315,91216,79317,43617,998Page 7
Figure 3 – Trends in Adult/Adolescent Reported HIV Diagnoses by Sex at Birth, 1985-2010Percent by Sex at Birth of Adult/Adolescent Reported HIV Cases, Age 13 at HIV Diagnosis, with or without anAIDS Diagnosis (Adult/Adolescent Reported HIV Diagnoses) by Year of HIV Diagnosis from 1985 through 2010, asReported by Name through ar of HIV DiagnosisMaleYEAR OFHIVDIAGNOSIS 961997Adult/Adolescent Reported HIV ,4911,3501,3351,2411,263% 9.1%68.0%67.6%67.8%64.8%% %30.9%32.0%32.4%32.2%35.2%FemaleYEAR 2007200820092010TOTALAdult/Adolescent Reported HIV DiagnosesNo.% ,2521,16888880730,933Baltimore-Towson MSA HIV/AIDS Epidemiological Profile – Fourth Quarter 3.1%64.6%65.1%65.3%67.6%% %36.9%35.4%34.9%34.7%32.4%Page 8
Figure 4 – Trends in Adult/Adolescent Reported HIV Diagnoses by Race/Ethnicity, 1985-2010Percent by Race/Ethnicity of Adult/Adolescent Reported HIV Cases, Age 13 at HIV Diagnosis, with or without anAIDS Diagnosis (Adult/Adolescent Reported HIV Diagnoses) by Year of HIV Diagnosis from 1985 through 2010, asReported by Name through 12/31/201190%80%70%Percent60%50%40%30%20%10%0%1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010Year of HIV DiagnosisHispanicNH-BlackNH-WhiteNon-Hispanic Other race not shownYEAR OFHIVDIAGNOSIS /Adolescent Reported HIV Diagnoses% Non-Hispanic % Non-Hispanic% HispanicBlack, onlyWhite, 4.3%3.0%78.0%15.4%3.2%79.6%12.8%1.8%80.2%15.8%% Non-HispanicOther 3.3%3.5%4.5%2.2%Baltimore-Towson MSA HIV/AIDS Epidemiological Profile – Fourth Quarter 2011Page 9
Figure 5 – Trends in Adult/Adolescent Reported HIV Diagnoses by Age at Diagnosis, 19852010Percent by Age at HIV Diagnosis of Adult/Adolescent Reported HIV Cases, Age 13 at HIV Diagnosis, with orwithout an AIDS Diagnosis (Adult/Adolescent Reported HIV Diagnoses) by Year of HIV Diagnosis from 1985through 2010, as Reported by Name through Year of HIV Diagnosis13-19YEAR OFHIVDIAGNOSIS 20092010TOTAL20-2930-3940-4950-5960 and overReported Adult/Adolescent HIV ,2361,2541,2871,2941,2521,16888880730,933% Age 13-19% Age 20-29% Age 30-39% Age 40-49% Age 50-59% Age 60 .3%7.2%5.0%4.3%3.2%Baltimore-Towson MSA HIV/AIDS Epidemiological Profile – Fourth Quarter 2011Page 10
Figure 6 – Trends in Adult/Adolescent Reported HIV Diagnoses by Exposure Category, 19852010Percent by Exposure Category of Adult/Adolescent Reported HIV Cases, Age 13 at HIV Diagnosis, with orwithout an AIDS Diagnosis (Adult/Adolescent Reported HIV Diagnoses) and with Reported Exposure Category byYear of HIV Diagnosis from 1985 through 2010, as Reported by Name through 901992199419961998200020022004200620082010Year of HIV DiagnosisMen who have Sex with Men (MSM)Injection Drug Users (IDU)MSM/IDUHeterosexual Exposure (HET)Other Exposure category not shown.YEAR OFHIVDIAGNOSIS 20092010TOTALAdult/Adolescent Reported HIV DiagnosesWith Exposure 40125226,480% .6%24.4%24.4%25.6%33.8%34.8%39.4%38.5%24.1%% .7%41.4%38.5%38.6%32.0%27.9%22.7%18.3%49.5%% 2.3%2.4%1.5%2.8%4.8%% on MSA HIV/AIDS Epidemiological Profile – Fourth Quarter 2011% %0.6%0.4%0.0%0.5%1.6%0.7%Page 11
Section III – Adult/Adolescent Cases by JurisdictionTable 1 – Adult/Adolescent HIV Cases by Jurisdiction, Diagnoses during 2010Age 13 Population Census on 4/1/2010, Number, Percent of Total, and Rate per 100,000 Population of ReportedAdult/Adolescent HIV Cases, Age 13 at HIV Diagnosis, with or without an AIDS Diagnosis, Diagnosed with HIVduring 1/1/2010-12/31/2010 (Adult/Adolescent Reported HIV Diagnoses), Number and Percent by Jurisdiction ofAdult/Adolescent Reported HIV Diagnoses with a First Reported CD4 Test Result in the 12 Months following HIVDiagnosis (First CD4 Test Result) and Median Count of the First CD4 Test Results, Percent by Jurisdiction ofAdult/Adolescent Reported HIV Diagnoses with a Reported CD4 Test Result or a Reported HIV Viral Load TestResult in the 3 Months following HIV Diagnosis (Linked to Care), and Percent by Jurisdiction of Adult/AdolescentReported HIV Diagnoses with an AIDS Diagnosis in the 12 Months following HIV Diagnosis (Late HIV Diagnosis),by Jurisdiction of Residence at HIV Diagnosis, as Reported by Name through 12/31/2011JURISDICTIONOF RESIDENCEAT HIVDIAGNOSISAnne ArundelBaltimore CityBaltimoreCarrollHarfordHowardQueen Anne’sTotalPopulationAge 13 32,269,27863406291616232807% dolescent Reported HIV DiagnosesFirst CD4 Test ResultRateNo. with% 6%2965.0*********35.656670.1%338%Linkedto Care82.5%63.5%70.8%***56.3%69.6%***67.7%% 5%*** Data withheld due to low population and/or case countsTable 2 – Adult/Adolescent AIDS Cases by Jurisdiction, Diagnoses during 2010Age 13 Population Census on 4/1/2010, Number, Percent of Total, and Rate per 100,000 Population of ReportedAdult/Adolescent HIV Cases, Age 13 at HIV Diagnosis, with an AIDS Diagnosis, Diagnosed with AIDS during1/1/2010-12/31/2010 (Adult/Adolescent Reported AIDS Diagnoses), and Average Years from HIV Diagnosis toAIDS Diagnosis, and Percent by Jurisdiction of Adult/Adolescent Reported AIDS Diagnoses with an HIVDiagnosis in the 12 Months preceding AIDS Diagnosis (Late HIV Diagnosis), by Jurisdiction of Residence at AIDSDiagnosis, as Reported by Name through 12/31/2011JURISDICTIONOF RESIDENCEAT AIDSDIAGNOSISAnne ArundelBaltimore CityBaltimoreCarrollHarfordHowardQueen Anne’sTotalAdult/Adolescent Reported AIDS DiagnosesPopulationAge 13 269,278No.% of 4%100.0%Years from 3.5***3.90.4***4.1% Late * Data withheld due to low population and/or case countsBaltimore-Towson MSA HIV/AIDS Epidemiological Profile – Fourth Quarter 2011Page 12
Table 3 – Adult/Adolescent HIV Cases by Jurisdiction, Alive on 12/31/2010Age 13 Population Census on 4/1/2010, Number, Percent of Total, and Rate per 100,000 Population of ReportedAdult/Adolescent HIV Cases, Age 13 at HIV Diagnosis, with or without an AIDS Diagnosis and Not Reported toHave Died as of 12/31/2010 (Adult/Adolescent Living HIV Cases without AIDS, Living HIV Cases with AIDS, andTotal Living HIV Cases), and Ratio of People per Case (1 case in every X people) for Total Living HIV Cases, byJurisdiction of Residence at the Latter of HIV or AIDS Diagnosis, as Reported by Name through 12/31/2011JURISDICTIONOFRESIDENCEAT DIAGNOSISAnne
Baltimore-Towson MSA HIV/AIDS Epidemiological Profile – Fourth Quarter 2011 Page 3 Section I – Background Information HIV/AIDS Reporting Requirements The Maryland HIV/AIDS Reporting Act of 2007 went into effect on April 24, 2007. The law expanded HIV/AIDS r
