HIV/AIDS Surveillance in Michigan

Michigan HIV/AIDS Surveillance Statistics with latest reports attached

Special Reports/ Special PowerPoint Presentations/ Epi Profiles / Reporting HIV/AIDS Cases / HIV/AIDS Reporting Contacts for Michigan/Resources for Reporting HIV/AIDS Cases in Michigan

Award Winning Surveillance Team

Melissa Reznar, HIV epidemiology specialist (center) surrounded by the women of the MDCH Surveillance Data Analysis & Management Team, following receipt of her Women and AIDS Committee Award on April 25 in Detroit. Left to right:
Marianne O'Connor, Yolande Moore, former team member Sharon Boyd, Vivian Griffin, Emily Higgins, Melissa Reznar, Gail Allen, Monica Smith, HIV/AIDS Epidemiology Manager Eve Mokotoff, and former Surveillance team member Hollie Malamud-Price, Ryan White Part D coordinator.
 

MDCH HIV/AIDS Surveillance Section Special Reports/Projects

Special Reports and Publications

Annual Review of HIV Trends in Michigan 2002-2006

Key findings are:

• Adolescent and young adult diagnoses (13-24 year olds) have increased for the third consecutive year.
• Three quarters of newly diagnosed adolescents and young adults are black compared with 59% of persons diagnosed at older ages.
• 13-24 year olds are much more likely to be black MSM compared with those diagnosed at older ages - 48% vs 19%.
• New diagnoses among MSM increased by an average of 4% per year 2002-2006.
• New diagnoses among IDUs decreased by an average 7% per year 2002-2006.
• An average of 890 persons were diagnosed with HIV each year from 2002-2006.
• New HIV diagnoses are highest among MSM, black men, 25 -44 year olds and residents of SE Michigan.

This document can also be found on the MDCH website: www.michigan.gov/hivstd

Historically we have also released a similar document on trends in new HIV diagnoses in Southeast Michigan. We expect to release that document by the end of next month.

The Adult and Adolescent Spectrum of Disease (ASD) project

was a supplemental surveillance project sponsored by the Centers for Disease Control and Prevention (CDC) to learn more about the disease status of HIV-infected persons. Health departments in eleven U.S. cities, including Detroit, collected data for a period of 14 years, 1990-2003.  The data from ASD formed the basis for the revision of the AIDS surveillance case definition in 1993 to include CD4⁺ T-cell count <200 cells/mm³ as an AIDS-defining event. In the following years, 1994-2003, ASD continued to track developments in the natural history of HIV infection, such as the improved health status of HIV-infected persons following introduction of more effective therapies for HIV and for opportunistic illnesses, the side-effects of these therapies, and the rise of liver disease in persons co-infected with HIV and hepatitis. The report summarizes the Detroit ASD data. It will also be posted on www.michigan.gov/hivstd in the near future.

Mokotoff ED, Glynn MK. Surveillance for HIV/AIDS in the United States. Chapter 16 in Infectious Disease Surveillance. Editors: Mikanatha N, Lynfi eld R, Van Beneden CA, deValk H. Blackwell Publishers 2007. McNaghten, A, Wolfe, M, Onorato, I Nakashima, A, Valdiserri, R, Mokotoff, E, Romaguera, R, Kroliczak, A Janssen, R, and Sullivan, P.

Annual HIV/AIDS Trend Reports
released 5/7/07

Characteristics of Persons With Recently Acquired HIV Infection: Application of the Serologic Testing Algorithm for Recent HIV Seroconversion in 10 US Cities
J Acquir Immune Defic Syndr. 2007;44(1):112-115. ©2007 Lippincott Williams & Wilkins
Posted 03/14/2007 http://www.medscape.com/viewarticle/551828_print

This reported research on the serologic testing algorithm for recent HIV seroconversion (STARHS) project. STARHS is a relatively new testing strategy that can distinguish persons whose HIV infection was acquired, on average, in the past 6 months from those who have been HIV infected longer. Using data collected as part of a multisite (including Detroit)study of primary HIV drug resistance, the researchers compared the characteristics of persons whose HIV diagnosis was made within 6 months of acquiring HIV infection with characteristics of persons whose HIV diagnosis was made more than 6 months after infection.
Authors of the study included Garald Goza, MS, Manager, HIV/STD & Bloodborne Infections Surveillance Section, Michigan Department of Community, Health.
 

New Confidential Case Report Form
MDCH - HIV Surveillance has released (3.2.07) the new Michigan Adult HIV/AIDS Confidential Case Report Form (CRF) and instructions. Please use the CRF to report cases of HIV and/or AIDS in persons age 13 or older and replace/recycle any copies of the adult case report form that you currently have (CDC 50.42A) with this version (DCH-1355).  Paper copies are available from your HIV/AIDS surveillance contact person or by calling 313.876.0353 or 517.335.9271.

CDC requires that we include particular variables to count cases as HIV or AIDS but states are free to develop their own case report forms, as long as they include these variables (for example, race, sex). This revised case report form incorporates patient HIV testing history, marital status, genotype testing date and pregnancy history.

May 31, 2006
1) Status of the HIV Epidemic in SE MI
2) Status of the HIV Epidemic in MI

See also: An MDCH press release highlighting the major findings of the MI document; and speaking points that were sent to MDCH community partners in advance of the press release.
 

Special PowerPoint Presentations

2006 Epidemiologic Profile of HIV/AIDS in Michigan - PowerPoint presentation to MHAC by Elizabeth Hamilton, M.P.H. on September 13, 2006 (for a basic primer see Epi 101).

Racial Disparities in HIV/AIDS: Michigan & US - HIV Surveillance Presentation from Black AIDS Awareness Rally by Melissa Reznar, MPH
January 10, 2006

HIV/AIDS Rates by Race/Ethnicity in the 22 Highest HIV Prevalence Counties in Michigan: Focus on Hispanics

2006 EPI Profiles

http://www.michigan.gov/mdch/0,1607,7-132-2944_5320-36307--,00.html

2006 Epidemiologic Profile of HIV/AIDS in Michigan - PowerPoint presentation to MHAC by Elizabeth Hamilton, M.P.H. on September 13, 2006 (for a basic primer see Epi 101).

compare to: 2004 Epidemiologic Profile of HIV/AIDS in Michigan - PowerPoint presentation to MHAC by Elizabeth Hamilton, M.P.H. on November 10, 2004.

Michigan HIV/AIDS Surveillance Statistics

Note: The MDCH HIV/AIDS Surveillance Section stopped using the US mail to distribute this quarterly report. You can subscribe and unsubscribe to the electronic e-mailing list at: http://www.localhealth.net/hivstats/subscribe.aspx 

April 2008 Michigan HIV/AIDS Surveillance Statistics

The MDCH HIV/AIDS Surveillance team conducted in-depth analyses to investigate causes for the increased statewide prevalence estimate reported in the January 2008 statistics. Based on the findings of our investigation we found no evidence to support that the increase was due to enhanced or focused testing efforts at publicly funded clinics. Instead, we have concluded that the increase is a consequence of receiving increased laboratory reporting as a result of passing PA 514 in December 2004. PA 514 removed the exemption of laboratories to report HIV test results directly to MDCH and was implemented in April and July 2005.

• Trends
  As in prior years we have again run an analysis of trends in new HIV diagnoses for the previous 5 years. We expect them to be available soon and we will send them to the HIV stats listserve in the near future.

• HIV Testing and Treatment History information
  The HIV Testing and Treatment History information in Section VIII of the Michigan Adult HIV/AIDS Confidential Case Report Form is critical for estimates of HIV incidence in the general population. While obtaining patient history, please ask patients directly about:

(see the PDF full report on the topics below)

• NEW CASE REPORT FORM TO HELP WITH INCIDENCE SURVEILLANCE
  
  MDCH expects to release a revised version of the Adult HIV/AIDS Case report form before the end of the calendar year. The primary reason behind this revision is to incorporate testing history questions into the case report form. This will further integrate incidence surveillance into routine case reporting and help accurately assess HIV incidence. PDF full report

• EFFECTS OF CHANGE IN HIV/AIDS REPORTING SOFTWARE SYSTEM
  
  In July 2006, the HIV surveillance program upgraded its surveillance system software from a DOS-based system called HARS (HIV/AIDS Reporting System) to a restricted-access browser-based system called eHARS (the "e" stands for Evaluation). This change in software necessitated changes in the way HIV and AIDS cases are counted (e.g. race is now required for all cases reported after January 1, 2002 in order for the cases to be counted). Thus, the case counts included in the October 2006 statistics may be different than expected. Throughout the next quarter, we plan to resolve the discrepancies between the two software systems in order to provide statistics that are more representative of the epidemic in January. PDF full report

• Laboratory Reporting Data Used for Ryan White CARE Act (RWCA) Title I Grant Application
  
  Annually, the HIV surveillance program provides data to the MDCH HIV/AIDS Prevention and Intervention Section as well as the City of Detroit for the Title I and Title II RWCA grant applications. One important component of these grants that we provide data for is called “unmet need.” Unmet need refers to the population of HIV positive persons who have been notified of their positive HIV status but are not receiving minimally adequate HIV-related services, defined as receiving at least one viral load or CD4 count in a year. PDF full report

• Fact Sheet: HIV Among Black Women in the Detroit Metro Area.
  
   

July  2006 Quarterly HIV/AIDS Analysis

• As a read only PowerPoint presentation with notes
  
  Special Reports
• Upgraded Surveillance System Software

  The HIV Surveillance section recently upgraded its surveillance system software from a DOS-based system called HARS (HIV/AIDS Reporting
  System) to a restricted-access browser-based system called eHARS (the e stands for Evaluation). The CDC is planning to implement this upgrade nationwide, and is currently working on deploying its fifth site (Michigan was number four). This change in software necessitated changes in the way HIV and AIDS cases are counted (e.g. race is now required for all cases reported after January 1, 2002 in order for the cases to be counted). Thus, the case counts included in next quarters statistics (October 1, 2006) may be different than expected. eHARS will also enable us to monitor completeness and timeliness of reporting more accurately.
  As such, we hope to collect variables such as risk and facility/physician of diagnosis more rigorously (note that physician of diagnosis is a new variable we are now collecting).

   

• HIV INCIDENCE AND RESISTANCE SURVEILLANCE IN MICHIGAN
  
  Implementation of incidence surveillance in Michigan continues, with most laboratory systems in Michigan submitting remnant Western blot sera for incidence testing. Newly reported cases are eligible for the incidence test (as well as genotyping, see below). Testing history questionnaires are a required part of incidence surveillance and are sent to health care providers to be completed by newly reported individuals at their next visit. Answers to a few testing history questions are needed to the generalize data we receive on persons who are diagnosed as HIV-infected to the total population, including those who are not yet diagnosed. Please contact the HIV Incidence Surveillance Coordinator with any questions or concerns: Marianne OConnor 313-876-0854, oconnormf@michigan.gov  .
  
  Antiretroviral resistance testing is entering its third year in Michigan with just over two-thirds of all newly diagnosed HIV positive testers routinely genotyped as part of their diagnostic HIV protocol.
  Genotypes are performed in Lansing at our state health department laboratory on remnant diagnostic serum and returned to clinical providers within 3 weeks of receipt. If you would like additional information about how to submit serum to MDCH so that this routine testing can be performed free of charge for your confidential testers please contact Mary-Grace Brandt at 313 876-4115 or brandtmg@michigan.gov.

• HIV CLASSIFICATION SYSTEM
  
  In June Eve Mokotoff attended a consultation in Atlanta to participate in the process of updating the current HIV classification system. The most recently published system (December 1992) was never widely implemented and CDC is interested in updating it to make it relevant, clinically useful and to integrate AIDS as a severe stage of HIV disease into the classification system. The purposes of the classification system are to predict prognosis, guide treatment and provide a common language for: 1) clinical research, 2) epidemiologic studies, 3) disease reporting and surveillance, 4) prevention and control activities, and
  5) public health policy and planning, It would have a hierarchical design usually associated with disease severity/progression. The proposed system would have three levels and be primarily CD4 based with clinical evidence required only for AIDS (the third and most severe level).

• DEVELOPMENT OF A DEFINITION FOR ACUTE HIV INFECTION
  
  The June consultation also discussed development of a definition for acute HIV infection (AHI). An acute HIV infection occurs immediately after initial infection with HIV, and infectiousness lasts for about
  4+
  weeks at an extremely high level. It is estimated that during this stage of HIV, a person has the highest viral loads and is the most infectious of any time in their whole clinical course until death. About 40+% of cases have identifiable symptoms that could lead to diagnosis (if a clinician considered the diagnosis in their differential and ordered the nucleic acid-based tests necessary to make the diagnosis.) Because the patients feel relatively well during this time, they usually continue the same HIV high-risk behavior that led to their infection.
  There are several potential benefits to identifying cases of AHI, including the chance to interrupt high-level transmission through education and treatment of the patient and to prioritize partner notification assistance. The proposed surveillance case definition
  includes: 1) documented evidence of detectable plasma or serum HIV RNA, DNA or p24 antigen along with a negative or indeterminate HIV antibody test, followed by later conversion to a positive HIV antibody test and
  2) a documented negative HIV serology followed within 3-6 months by a documented positive HIV serology test. The consultants recommended adding AHI to the proposed HIV classification system as a fourth category.
  
  The challenge is to educate primary care physicians who are in practices likely to encounter patients with AHI as to how to recognize a clinically suspicious case and how to do a confirmatory test. If you or your colleagues have a patient with a negative antibody test but a high viral load please make it a high priority to report the person so we can help prioritize the person for assistance with notifying partners.
   

April 2006 Quarterly HIV/AIDS Analysis

(See the MDCH website for all archived HIV/AIDS statistics http://www.michigan.gov/mdch/0,1607,7-132-2940_2955_2982_46000_46003-35962--,00.html)

Special Reports:

• PARTNER COUNSELING AND REFERRAL SERVICES TRAINING (PCRS)
  
  The MDCH HIV/AIDS Surveillance staff are available to clinical sites to conduct trainings on PCRS (formerly known as Partner Notification or PN) for clinical staff. These trainings can be small meetings with just a few staff or a presentation to a larger group. The HIV/AIDS case report form is the most common way assistance with PCRS for newly diagnosed patients is requested. Please contact your staff person (see list below) to request trainings on this topic.

• HIV INCIDENCE AND RESISTANCE SURVEILLANCE IN MICHIGAN
  
  Michigan is one of 34 sites nationally in the process of implementing incidence surveillance by using a test that distinguishes recent infection from recent diagnosis among persons newly reported with HIV. The test uses remnant serum from positive Western blot specimens. This protocol has been reviewed by both the Centers for Disease Control and Prevention (CDC) and the MDCH Institutional Review Boards (IRB) and was determined by both to be surveillance and not research and is, therefore, exempt from IRB review.
  
  Health care providers may receive a short questionnaire in the mail inquiring about the patient's past HIV testing history, reasons for testing and recent medication for HIV or Hepatitis B. These questions will eventually be included on a revised HIV/AIDS case report form, so please begin to gather the information routinely from patients. Testing history will be used to weight test results to obtain incidence estimates for the general population, a very high priority for CDC, MDCH and the U.S. Congress. Your timely response to these questions will enable us to calculate population estimates of persons recently infected. CDC and MDCH plan to use this information to target prevention messages to persons most recently infected with HIV.
  
  The incidence test is FDA approved for surveillance purposes only and reliability has not been established for individuals, therefore results cannot be returned to patients nor clinicians. Please direct any questions to Marianne O'Connor, HIV Incidence Coordinator using the contact information at the bottom of this memo.
  
  Another related CDC HIV surveillance project that has been operational within the MDCH laboratory system for almost 2 years is VARHS, or Variant, Atypical and Resistant HIV Surveillance. Through VARHS, genotype drug resistance and subtype information is provided on all newly diagnosed HIV positive specimens sent to the MDCH lab system free of charge. These results - run automatically on all positive remnant HIV diagnostic testing serum as part of the new standard of care for HIV testing in Michigan - are returned upon request to providers. Please contact Mary-Grace Brandt using the contact information at the bottom of this memo if you should have questions, require additional information, or would like to obtain a genotype on a newly diagnosed HIV positive individual.

• UPDATE ON THE MEDICAL MONITORING PROJECT (MMP)
  
  MMP is a CDC-sponsored, multi-state enhanced HIV surveillance project designed to gather information about the status of HIV-positive persons in care throughout the United States; Michigan has been selected to participate. Data collection will consist of interviewing a sample of patients who are in care for HIV and reviewing their medical records. Consultants at the RAND Corporation are conducting the sampling, using methods that will provide data that are population-based and representative at the national, state, and local levels.
  
  The initial phase of implementation in Michigan is nearing completion. A comprehensive, statewide list of HIV care providers has been assembled, and it consists of 124 outpatient clinics and 40 inpatient facilities. For MMP, an HIV care provider is defined as clinic or facility where CD4+ T-cell counts or viral load measurements are conducted, or where antiretroviral medications are prescribed, for HIV-infected patients. A sample of these providers is being selected at RAND. The sample of HIV care providers will include representatives of the range of sizes and locations of providers throughout the state, and the validity of the project findings will depend upon all of the selected providers participating. After the cooperation of the selected providers is obtained, patients will be randomly selected from their patient populations.
  
  Information derived from the MMP data will be used for public health planning purposes, and will address questions such as the following:
  · How many people living with HIV/AIDS are getting care for HIV?
  · How easy is it to access care and use prevention and support services?
  · What needs of persons living with HIV/AIDS are not met?
  · How is treatment affecting people living with HIV/AIDS?
  A summary of the Michigan data will be given to all the participating providers. At the local and state levels, MMP data will be useful for maintaining Ryan White CARE Act (RWCA) funding, evaluating resource needs for prevention and care, evaluating the impact of prevention programs, and developing the Epidemiologic Profiles of HIV/AIDS in Michigan. Nationally, MMP data will be used to evaluate the impact of RWCA funding and the effectiveness of treatment guidelines in preventing opportunistic infections and slowing progression of HIV disease.
  
  We will contact the HIV care providers selected to participate in 2006 in the next few months. Complete information about participating in the project will be provided, and MMP project leaders will address any questions or concerns the providers may have. MMP staff will perform all data collection. Every effort will be made to minimize the impact of participating in MMP on the providers' time and resources, and to make participating in MMP an interesting and rewarding experience.

STAFF CHANGES

We would like to welcome Danielle Radford to our group. Danielle has been with us since October 2005. Her main duties include processing HIV laboratory reports, communicating with HIV reporting sites, assisting on special projects (STARHS and ALOHA), and providing assistance for the STD Epidemiologist in the data entry and cleaning of STD labs reports.

 

January 2006 Quarterly HIV/AIDS Analysis

Special Reports:

• PREVALENCE ESTIMATES
  
  Since April 2005, MDCH has been implementing PA 514, which requires laboratories to report HIV test results. The addition of laboratory reporting to the HIV surveillance system has increased the case reports received and has improved reporting completeness, bringing the number of reported cases closer to the previously calculated prevalence estimates. However, since this procedure is still new, MDCH has not had enough months of complete laboratory reporting to fully evaluate the impact of PA 514 on the HIV/AIDS prevalence estimates. Consequently, MDCH does not have sufficient data to recalculate the current prevalence estimate and it remains at 16,200. This estimate will be re-calculated for the July 2006 statistics at which time MDCH should have sufficient data to evaluate the impact of PA 514. The estimate is based on adding the following three components and rounding: 1) the number of cases living with HIV/AIDS, 2) the number of known HIV+ cases not yet reported, estimated at 20 percent of the reported living HIV/AIDS cases, and 3) the number of HIV+ cases that have not yet been tested, estimated at 25 percent of the total cases living with HIV/AIDS (identical to the CDC estimate

• CHANGES SEEN SINCE THE IMPLEMENTATION OF LABORATORY REPORTING
  
  Preliminary analyses show that new diagnoses of HIV in MI have been increasing since the implementation of PA 514 in April 2005. Diagnoses of AIDS cases have also been increasing, and at a higher rate, due in large part to the laboratory reporting of CD4 values. These increases cannot be properly measured until we have had a longer stretch of laboratory reporting. MDCH plans to conduct our first analysis of the effect of PA 514 during Summer 2006.
  
  Danielle Radford, Program Assistant is new to the Lansing office. She is helping with the implementation of PA 514 and assisting with HIV surveillance. She can be reached at (517) 335-9028.

• BOOKLET ON MICHIGAN HIV LAWS
  
  A booklet written by the HIV/AIDS Prevention and Intervention Section (HAPIS) entitled Michigan HIV Laws; How They Affect Physicians and Other Health Care Workers has been revised. It now includes information on the lab reporting requirement that went into effect last year. It can also be found at: http://www.michigan.gov/documents/mihivlaws_49845_7.pdf 

• MEASURING INCIDENCE IN MICHIGAN
  
  Michigan has been integrating incidence surveillance into routine case surveillance. As a part of this effort CDC is requiring the answer to several testing history questions. These are needed to use the data we receive on persons who are diagnosed as HIV-infected to estimate incidence in the total population, including those who are not yet diagnosed. Testing history questionnaires are being sent out to providers for newly reported cases and we are considering other ideas for how to best obtain this information from providers. Please contact the HIV Incidence Coordinator with any questions or concerns: Marianne OConnor 313-876-0854 and email.

• ONGOING DEDUPLICATION OF AIDS CASES WITH OTHER STATES
  
  Michigan is participating in a national effort to keep the national HIV and AIDS databases as clean as possible. This means routinely communicating with other states about cases reported in both states. The result is that periodically you may see numbers decrease in some categories. The data from the most recent deduplication effort were uploaded January 2006. Cumulatively, Michigan lost 76 AIDS diagnoses, 88 HIV diagnoses (80 of these cases were HIV in MI and AIDS in the other state) to other states. Considering only living cases, Michigan lost 64 living AIDS cases to other states, which is 1.0% of all living AIDS cases in Michigan. Also, Michigan lost 82 living HIV cases, which is 1.3% of all living cases of HIV, not AIDS in Michigan to other states. Currently, there is no available data on the effect of this deduplication effort on other states.

• PERINATAL HIV
  
  MDCH has two new brochures on the HIV testing requirement for pregnant women. One is for patients and the other is for providers. These can be found on the web at: www.michigan.gov/documents/One-Test-Michigan-01-06_147016_7.pdf  and www.michigan.gov/documents/Its-The-Law-Michigan-01-06_147015_7.pdf 
  
  The brochure for pregnant women, titled "One Test May Save Your Baby's Life" provides information to women to increase their awareness that HIV testing should be a standard test during prenatal care and/or at labor and delivery. It also provides information for women that mother to child HIV transmission can be practically eliminated if a woman knows her HIV status during pregnancy and receive appropriate medical treatment. The brochure for providers, tilted "It's the Law" provides information on Michigan's Compiled Law that requires HIV testing of pregnant women. It also provides information on other Department recommendations, resources, and referrals.
   

October 2005 Quarterly HIV/AIDS Analysis

Special Reports:

• Supplement to HIV/AIDS Surveillance Project (SHAS) II Summary
  
  This summary of recently collected SHAS data contains data from 1174 persons interviewed from 2000-2004 and has been posted on the MDCH website: www.michigan.gov/mdch. SHAS I ended in 2000 and a summary of SHAS I data can be found also be found on the MDCH website.
  
  SHAS was a collaborative effort between CDC and 16 health departments in the United States. It was conducted in Detroit from 1990-2004. Individuals who receive HIV related care at selected health care facilities in SE Michigan and are at least 18 years of age, were invited to a one-time interview to obtain descriptive information. SHAS collected information on demographic and socioeconomic characteristics, drug use history, sexual behavior and disease history, reproductive/gynecological history and child health, preventive therapy, and medical and social service use information.

• Evaluation Project Summary
  
  During 2002, Michigan was one of 10 states participating in an evaluation of HIV/AIDS reporting. It was a comprehensive evaluation and overall we did well. A summary of this project is enclosed with this quarter s statistics. We expect several of these measures (specifically timeliness and completeness) to improve dramatically with the implementation of laboratory reporting of HIV-related tests. We will analyze our data in 2006 to assess any changes in these measures.

• Behavioral Surveillance Data on HIV Infection among Black Men who have Sex with Men
  
  In 2004 CDC funded 17 cities to study HIV-related behaviors among MSM. (Michigan was not part of the 2004 study). The results from five of those cities (Baltimore, Los Angeles, Miami, New York City, and San Francisco) were published in the June 24, 2005 MMWR http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5424a2.htm . The study showed that 46 percent of Black MSM in the study were HIV-positive and 67 percent were unaware of their infection before study participation. Although the study was not conducted in Detroit, these are very high proportions and MDCH will continue to target this vulnerable group for testing, prevention and care.
  
  Behavioral surveillance is conducted in cycles and Michigan joined this surveillance study during the current IDU cycle. Next year high-risk heterosexuals will be the target group and, in 2007, Michigan will participate in the MSM cycle.

• Using Viral Loads as a Proxy Test for HIV-infection
  
  As the state continues to implement lab reporting of HIV and related tests we have observed the use, by some physicians, of the viral load test in persons who have not been previously diagnosed as HIV-infected using antibody tests. There are varying reasons for this practice. Some believe that it is a better test than the antibody test. In other cases it appears to be used to screen patients before surgery. Given this latter scenario we share the information below from Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis. (MMWR R&R September 30, 2005 Vol 54 No. RR-9):http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm
  
  The use of source-person viral load as a surrogate measure of viral titer for assessing transmission risk has not yet been established. Plasma viral load (e.g., HIV RNA) reflects only the level of cell-free virus in the peripheral blood; latently infected cells might transmit infection in the absence of viremia. Although a lower viral load (e.g., <1,500 RNA copies/mL) or one that is below the limits of detection probably indicates a lower titer exposure, it does not rule out the possibility of transmission.
  
   

July 2005 Quarterly HIV/AIDS Analysis

Special Reports

• HITS Data summary
  Enclosed please find two summaries of the HIV Testing Survey (HITS) that was conducted in 2002 in Michigan in Detroit, Oakland County and Grand Rapids. One summarizes Michigan-wide data and the other summarizes just the Detroit data. They can also be found on the above-referenced web page. These surveys were conducted at bars among men who have sex with men, at public health department STD clinics among high-risk heterosexuals and on the street and at needle exchanges among IDUs. Information collected includes: rates of testing, reasons for testing (or not testing), needle sharing and numbers of sex partners.
   

April 2005 Quarterly HIV/AIDS Analysis


Special Reports:

• Morbidity Monitoring Project (MMP) - The Michigan Department of Community Health (MDCH) has been awarded funding from the Centers for Disease Control and Prevention (CDC) to participate in a new enhanced HIV surveillance project, the Morbidity Monitoring Project (MMP) for the next four years. Since 1999, MDCH has participated in the pilot project, the Survey of HIV Disease and Care (SHDC), which included medical record reviews 1999-2004, and, in 2004, interviews. MMP will consist of interviews and medical record reviews of persons in care for HIV and replaces both the Adult/Adolescent Spectrum of Disease (ASD) and Supplement to HIV/AIDS (SHAS) projects that Michigan participated in from 1990 until they were discontinued by CDC in June 2004. While ASD and SHAS were conducted in Detroit, the MMP will be statewide. Linkage of data from interviews and medical record reviews will be a powerful tool for studying the influences of behavioral and environmental factors on HIV disease status and vice versa. For example, MMP interviews will address access to and utilization of health care by HIV-infected persons, and quality of life among persons living with HIV. MMP medical record reviews will address, for example, the treatments prescribed and diagnoses of conditions that may be related to HIV.
      MMP will provide data that is population-based and representative at the national, state, and local levels. Consultants from the Rand Corporation are doing the sampling. They are using a three-stage sampling scheme similar to the one they used for the HIV Cost and Services Utilization Study (HCSUS). The statewide sample of facilities and individual physicians that provide HIV-related care will include all sizes and locations of providers, and the participation of all selected providers will be crucial for the validity of the national, state, and local data analyses.
• DISPARITIES BY RACE AND Sex IN THE HOSPITALIZATION OF HIV-INFECTED PERSONS, SOUTHEAST MI, 1990-2003 - Enclosed with this quarter's statistics is a poster summarizing ASD data that was presented at the American Foundation for AIDS Research 2005 National Update Conference in Oakland CA in mid April. It shows that, even after adjusting for injection and non-injection drug use, number of clinic visits, public health insurance and history of AIDS defining illnesses, black men and women were still more likely than white men to be hospitalized.
• Pregnancy and Other Factors Associated with Higher CD4 counts at HIV Diagnosis - In another ASD analysis recently published in Medscape General Medicine, we looked at factors associated with higher CD4 counts in persons presenting for care at our two ASD sites in Detroit. We found that pregnant women were significantly more likely to have higher CD4 counts at initial HIV diagnosis than either non-pregnant women or men. We concluded that routinely offering HIV testing in prenatal care, as required by Michigan law, resulted in earlier diagnoses of HIV in pregnant women, as indicated by their higher CD4+ T-cell counts. Increasing routine HIV testing of all persons seeking medical care may increase the overall proportion of HIV diagnoses that are made early in the disease process. A copy of this paper is enclosed with these April statistics.
• Foreign Born Analysis - Enclosed with this quarter s statistics is an analysis of persons reported with HIV/AIDS in Michigan who were born outside of the United States. You will see that in Berrien and Kent Counties that the number of foreign born HIV-infected blacks (Berrien County) and Hispanics (Kent County) in recent years is larger than members of those race/ethnic groups born in the United States.
  
   

January 2005 Quarterly HIV/AIDS Analysis

• Cover memo
• New HIV reporting law and
• Frequently Asked Questions - FAQs about Public Act 514 – Laboratory HIV Reporting
• Winter 2005 quarterly statistics
• Two trend documents (one for Michigan and one for the Detroit Metro Area)
• Interstate Duplication Evaluation Project (IDEP) - an unduplication process MDCH participated in late last year that affects our reported number of cases.

Links to the statistics can always be found on this website in Statistics.

Reporting HIV/AIDS Cases

New Confidential Case Report Form
MDCH - HIV Surveillance has released (3.2.07) the new Michigan Adult HIV/AIDS Confidential Case Report Form (CRF) and instructions. Please use the CRF to report cases of HIV and/or AIDS in persons age 13 or older and replace/recycle any copies of the adult case report form that you currently have (CDC 50.42A) with this version (DCH-1355).  Paper copies are available from your HIV/AIDS surveillance contact person or by calling 313.876.0353 or 517.335.9271.

CDC requires that we include particular variables to count cases as HIV or AIDS but states are free to develop their own case report forms, as long as they include these variables (for example, race, sex). This revised case report form incorporates patient HIV testing history, marital status, genotype testing date and pregnancy history.

Laboratory Reporting of HIV Test Results

During 2005, PA 514, requiring laboratories to report HIV test results, is being implemented. Most facilities in Michigan send specimens for HIV testing out to a reference lab. Therefore, MDCH has asked those facilities that actually perform Western Blots, CD4s, and Viral Loads to report their results. The deadline for reporting of all these tests was July 1, 2005. At this time, all facilities are reporting or are actively working out a method of report. We have been extremely pleased with the progress.

Next year we plan to analyze the impact of the addition of laboratory reporting to our previously clinically based system. We expect it will increase both timeliness and completeness of reporting.

DOCUMENTATION OF MODE OF HIV TRANSMISSION

Information on how persons living with HIV/AIDS became infected continues to be vital to prevention planning efforts. In addition, national surveillance data on HIV/AIDS transmission category, as well as demographic risk factors (geographic location of residence, age, sex, race/ethnicity) are used to allocate funds for HIV prevention programs and services and target and evaluate interventions and programs, among other uses. Therefore it is crucial to have complete and accurate data for these variables.

In the Michigan July 2004 statistics, 14% of persons living with AIDS and 21% of those living with HIV/not AIDS had no known mode of transmission. The reasons for ongoing high levels of these cases may be due to fatigue in reporting, surveillance or provider staff turnover, limited resources in both health departments and provider settings, inadequate training and retraining of health department staff and of providers in taking sex and drug risk factor histories, and/or physicians not conducting risk factor assessment for fear of offending patients with sexual behavior questions.

Despite the obstacles, MDCH Surveillance staff continues to pursue this information as a part of the case reporting process. They appreciate your documentation of modes of HIV transmission in the patient's medical record and/or your documentation of this information on the HIV/AIDS case report form. In addition, please call your contact on their staff (see list below) if you have a patient with a suspected unusual mode of transmission. Examples of these include an HIV-infected child whose biological mother is not HIV-infected, a person who has reported no sexual contact in the previous years, patient report of exposure to possible HIV-infected blood or body fluids or of transfusions in countries outside of the USA.

Implementation of the new HIV Reporting Law

(1/11/05) - A new law (PA 514) will change the way HIV is reported in Michigan. Now, physicians and testing sites will share the responsibility with clinical labs to report confirmed positive HIV tests. (See Lab Based Reporting of HIV). It is important to note that this does not affect the ability of individuals in our state to obtain anonymous testing at MDCH designated testing sites.

It will, however, help to provide a more accurate picture of the epidemic in Michigan. And it will pave the way for a more equitable assessment of need for Ryan White CARE Act funding. As more states provide accounting of HIV cases, the federal government will change its criteria for CARE funding from numbers of AIDS cases to the numbers of those living with HIV.

PA 514 goes into effect on April 1. For more information on the ramifications of this new law, see the PowerPoint Presentation made by Eve Mokotoff at the March 2005 MHAC meeting  Also, see the letter sent to clinicians by MDCH regarding the implementation of this new law at http://www.mihivnews.com/stats/PA514.Clinicianinfo.Memo.pdf.
 

Lab-Based Reporting of HIV

PA 514 will amend the “Public Health Code” regarding HIV reporting in the State and add to the completeness of reporting of both HIV and AIDS.

Licensed clinical labs are now required to report positive HIV tests, and also “test results ordered for the management and surveillance of the infection” (CD4 test results under 200 and viral load test results) which would indicate an AIDS diagnosis. Under the former law, Michigan had name-based reporting of HIV positive tests to local public health departments by physicians and testing sites for testing that is not requested to be done anonymously. Medical providers are also required by law to report AIDS diagnosis.

Michigan was actually ahead of the national game for requiring HIV name-based reporting. It was written into the public health code as part of a package of HIV laws passed back in 1988. Prior to the Governor signing PA 514 in December, Michigan was the only name-based HIV reporting state that did not require the clinical laboratory to report HIV according to Eve Mokotoff, HIV/AIDS Epidemiology Manager for MDCH.

“An integrated, clinically-based HIV/AIDS surveillance system worked well in the late 1980’s and early 1990’s,” stated Mokotoff in a presentation to MHAC. (However), as medical care became more decentralized, the system’s dependence on conducting surveillance with a manageable number of key physicians became less reliable.”

This new law will not affect a person’s ability to be tested anonymously in Michigan, which has been unique in allowing anonymous reporting from the non-anonymous care setting (i.e., physician’s offices) according to Mokotoff. “We are not interested in, and have no plans for, changing the availability of anonymous reporting in Michigan.”

See the PowerPoint presentation by Eve Mokotoff, which explains the ramifications of the bill on surveillance and the possible impact on future Ryan White funding at http://www.mihivnews.com/stats/labreportingSB1129.pdf

See the other Michigan HIV Laws How They Affect Physicians and Other Health Care Providers Revised September 2002.

Resources for Reporting HIV/AIDS Cases in Michigan

Many of the forms and information often requested are available on line. The following summarizes the location of: 1) the booklet, Michigan HIV Laws: How They Affect Physicians and Other Health Care Providers, 2) adult and pediatric case report forms and instructions for completion, 3) Form DCH-1221 Confidential Request for Local Health Department Assistance for Partner Counseling & Referral Services (PCRS) and 4) the Michigan Communicable Disease rules 5) PCRS fact sheet

Risk Ascertainment

A reminder from MDCH Surveillance: Ascertainment of mode of transmission of HIV continues to be important information for planning and evaluating HIV prevention and care services. Although we know how HIV is transmitted, obtaining information on how HIV-infected persons were most likely to have acquired their infection allows us to target persons at highest risk. Please continue to provide this information in medical records and on any case report forms you complete. Risk Assessment Form

Finding Michigan HIV/AIDS Laws booklet online:

http://www.michigan.gov/documents/mihivlaws_49845_7.pdf

Or navigate through the MDCH website:
www.michigan.gov/mdch
>Physical Health and Prevention
>Prevention
>HIV/STD: Under “HIV” click: HIV/AIDS
>Click here to open a copy of the booklet, Michigan HIV Laws: How They Affect Physicians and Other Health Care Providers



Finding Adult HIV/AIDS Case Report form or instructions online:

Form:
http://www.michigan.gov/documents/Frm5042A_6861_7.pdf

Instructions:
http://www.michigan.gov/documents/CRFINST9-02_41194_7.pdf

Or navigate through the MDCH website:
www.michigan.gov/mdch
>Providers
>Departmental Forms
>Communicable Disease Case Definitions and History Forms:
Click on Form # “CDC 50.42A Adult HIV/AIDS” or “Instructions”


Finding Pediatric HIV/AIDS Case Report form or instructions online:

Form:
http://www.michigan.gov/documents/frm5042b_6862_7.pdf

Instructions:
http://www.michigan.gov/documents/PEDCRF9-02_41195_7.pdf

Or navigate through the MDCH website:
www.michigan.gov/mdch
>Providers
>Departmental Forms
>Communicable Disease Case Definitions and History Forms:
Click on Form # “CDC 50.42B Pediatric HIV/AIDS” or “Instructions”




Finding DCH-1221 Confidential Request for Local Health Department Assistance for Partner Counseling & Referral Services online:

https://www.hapis.org/dc/PublicPages/DCH1121.pdf

Or navigate through the HAPIS website:
www.hapis.org 
Scroll down beyond the username and password boxes.
Under “Partner Counseling & Referral Services Material, click:
“Confidential Request for LHD Assistance for PCRS (Obsoletes Form HP-139)”


Finding the Michigan Communicable Disease Rules online:

http://www.state.mi.us/orr/emi/admincode.asp?AdminCode=Single&Admin_Num=32500171&Dpt=CH&RngHigh=

Or navigate through the MDCH website:
www.michigan.gov/mdch 
>Providers
>Communicable and Chronic Diseases
>Communicable Disease Reporting in Michigan
Click on “Michigan Communicable Disease Rules”


 

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