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Multiple Imputation for Transmission Category and the Care Continuum Georgia, 2012

Multiple Imputation for Transmission Category and the Care Continuum Georgia, 2012. Adults and adolescents living with HIV, Georgia , 2012 . Adults and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 46,495 Engaged in care >= 1 CD4 or VL in 2012

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Multiple Imputation for Transmission Category and the Care Continuum Georgia, 2012

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  1. Multiple Imputation for Transmission Category and the Care Continuum Georgia, 2012

  2. Adults and adolescents living with HIV, Georgia, 2012 Adults and adolescents >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 46,495 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Prescribed ART derived from MMP sample Viral suppression (VS) = VL<200 copies/ml Estimated undiagnosed based on CDC projections for proportion undiagnosed nationally

  3. Transmission category definitions • MSM = Male to male sexual contact • IDU = Injection drug use • MSM/IDU = Male to male sexual contact and injection drug use • HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection • Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

  4. Multiple Imputation • Multiple imputation (MI) methods are used to assign transmission categories to those persons whose diagnoses are reported without a risk factor • MI is a statistical approach in which missing transmission categories are replaced with plausible values • CDC uses MI for the national HIV dataset* • Georgia uses the same methodology as CDC *Harrison KM, Kajese T, Hall HI, Song R. Risk factor redistribution of the national HIV/AIDS surveillance data: an alternative approach. Public Health Rep 2008;123:618–27.

  5. More details on MI • MI draws a random sample of missing values • Then, MI replaces each missing value with a set of values according to the relationship with other variables • These multiply-imputed datasets are analyzed • Final estimates are made based on these results • MI is considered a sound approach and the best choice for large datasets* * Rubin DB. Multiple imputation for nonresponse in surveys. New York: John Wiley & Sons; 1987.

  6. Assumptions used in MI • The distribution of risk factors among cases initially submitted with no reported risk factor (NRR) does not change during the period used in calculating weights • Cases reclassified as NRR are representative of all NRR cases • The data are missing at random

  7. Adult and adolescent males living with HIV, by transmission category with multiple imputation, Georgia 2012 Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 34,510 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml Multiple imputation is used to estimate number of persons in each transmission category. *MSM = Male to male sexual contact IDU = Injection drug use MSM/IDU = Male to male sexual contact and injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

  8. Adult and adolescent males living with HIV, by transmission category, no multiple imputation, Georgia 2012 Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 34,510 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml *MSM = Male to male sexual contact IDU = Injection drug use MSM/IDU = Male to male sexual contact and injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

  9. Adult and adolescent females living with HIV, by transmission category with multiple imputation, Georgia 2012 Adult and adolescent females >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 11,715 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml Multiple imputation is used to estimate number of persons in each transmission category. *IDU = Injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

  10. Adult and adolescent females living with HIV, by transmission category, no multiple imputation, Georgia 2012 Adult and adolescent females >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 11,715 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml *IDU = Injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

  11. Black MSM living with HIV, by age (years), with multiple imputation, Georgia 2012 Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 18,987 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml Multiple imputation is used to estimate number of persons in each transmission category. *MSM = Male to male sexual contact IDU = Injection drug use MSM/IDU = Male to male sexual contact and injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

  12. Black MSM living with HIV, by age (years), no multiple imputation, Georgia 2012 Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 10,401 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml Multiple imputation is used to estimate number of persons in each transmission category. *MSM = Male to male sexual contact IDU = Injection drug use MSM/IDU = Male to male sexual contact and injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

  13. White MSM living with HIV, by age (years), with multiple imputation, Georgia 2012 Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 8,071 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml Multiple imputation is used to estimate number of persons in each transmission category. *MSM = Male to male sexual contact IDU = Injection drug use MSM/IDU = Male to male sexual contact and injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

  14. White MSM living with HIV, by age, no multiple imputation, Georgia 2012 Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 4,144 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml Multiple imputation is used to estimate number of persons in each transmission category. *MSM = Male to male sexual contact IDU = Injection drug use MSM/IDU = Male to male sexual contact and injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

  15. Hispanic/Latino MSM living with HIV, by age (years), with multiple imputation, Georgia 2012 Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 1,670 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml Multiple imputation is used to estimate number of persons in each transmission category. *MSM = Male to male sexual contact IDU = Injection drug use MSM/IDU = Male to male sexual contact and injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

  16. Hispanic/Latino MSM living with HIV, by transmission category, no multiple imputation, Georgia 2012 Adult and adolescent males >= age 13, diagnosed by 09/30/2011, living 12/31/2012, Georgia = 906 Engaged in care >= 1 CD4 or VL in 2012 Retained in care >= 2 CD4 or VL at least 3 months apart in 2012 Viral suppression (VS) = VL<200 copies/ml Multiple imputation is used to estimate number of persons in each transmission category. *MSM = Male to male sexual contact IDU = Injection drug use MSM/IDU = Male to male sexual contact and injection drug use HET = Heterosexual contact with a person known to have, or to be at high risk for, HIV infection Other = hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified

  17. Conclusions • Overall, the Care Continuum varied little whether MI is or is not used in the Georgia 2012 estimates • Use of MI underestimates engagement, retention and viral suppression (VS) among MSM compared to analysis without MI in Georgia • This underestimation is greater in groups with a smaller N (e.g., Hispanic/Latino MSM by age) • Among males, MI overestimates engagement, retention and viral suppression by 1-2% points for IDU, HET and MSM/IDU males • Among females, MI overestimates engagement, retention and viral suppression by 0-4% points for both IDU and HET

  18. Limitations • Cannot assess the validity of assumptions made in MI • The pattern of risk factors has changed since the beginning of the epidemic • Cases missing risk may be fundamentally different from those for whom risk is reported. • Results for smaller subgroups may differ statistically with or without use of MI • Under- and overestimates found using MI in the Georgia 2012 prevalent population are not generalizable to new diagnoses or to future years’ analyses • Despite limitations, MI is considered by CDC to be the best currently available method to adjust for missing (not reported) risk factor information

  19. References • Barnard J, Meng XL. Applications of multiple imputation in medical studies: from AIDS to NHANES. Stat Methods Med Res. 1999 Mar;8(1):17-36 • Harrison KM, Kajese T, Hall HI, Song R. Risk factor redistribution of the national HIV/AIDS surveillance data: an alternative approach. Public Health Rep 2008;123:618–27 • Rubin DB. Multiple imputation for nonresponse in surveys. New York: John Wiley & Sons; 1987

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