OK. It's a little bit after 12:15 and we have a critical mass, a great turnout. So I think we'll get started. So we want to thank everybody for coming to our Women In Medicine network sponsored Grand Rounds this year. We're thrilled to have Dr. Aadia Rana with us. It's been a really fun two days. You know it's a good visit when it doesn't feel like it's long enough, so I think that's a success. 

And we've had a lot of opportunities for our trainees, both in internal medicine and infectious diseases, to meet with Dr. Rana. Who's here from the University of Alabama at Birmingham, where she studies HIV and has a Career Development Award to do so, and has been studying, how can we improve care for women living with HIV in that postpartum time, when people generally start to disengage? 

Dr. Rana has a huge portfolio of research, spanning from everything from clinical trials to behavioral medicine, and we're thrilled to have her here to share her knowledge with us. Thank you. 

[APPLAUSE] 

[INAUDIBLE] 

Can everyone hear me? Is it close enough? All right. Too short usually to stand behind podiums, so I'm going to-- even though I wore my heels today. So I'm going to be moving around. So just watch out for the move. So thank you so much, Kate. And thank you to the organizers. It's really an honor to be part of the Women In Medicine lecture series this year. 

And it's really been a great two days, sincerely, to meet with these really dynamic, inspiring women, who are working and learning actually, both locally, nationally and internationally. You know from Kennedy, working in eastern shores of Virginia, in potato and tomato farms, providing primary care to migrant workers. To Brianna, who's been traveling out west to see if she can adapt interventions specifically targeted against adolescent and perinatal women, to improve their engagement in care. 

And of course, the dynamic duo here of Kate and Becca, who are I think such an inspiration to the faculty here, and certainly to me in the mentorship and the support, and this really positive community you've provided for women in medicine. It's really fantastic. 

And so I sort of want to take this opportunity in this Women In Medicine lecture, to spotlight research on women. And I'm sure you all have maybe heard the headlines about the Ending the Epidemic initiative that's been released in this past month or so. And I'll go into a little bit of the details of that. And what I want to posit during my talk is, for those of us who work in the HIV field, we all know that we've made some dramatic improvements in our care that we can provide, and certainly the outcomes. 

But we still have a ways to go. And we do know that if we truly want to get to the end of the epidemic, we're going to have to take advantage of every opportunity that we have. And so what I'm going to present is the natal phase as one of those potentially critical opportunities that we're going to have to utilize in order to truly end the epidemic. And I'll be focusing here on the domestic epidemic in the United States. 

So I'll be describing the epidemic here. We'll review some of the tools that we have at our disposal to impact the epidemic. I'm going to talk a little bit about what we know about what the Ending the Epidemic initiative is. Full disclosure-- we don't have the full details on what that initiative is, so we're all eagerly anticipating what that's going to be. And I'm going to present some of the challenges, some of the work that I've done describing the challenges of engagement in HIV care. And maybe discuss some potential future directions as well. 

So the HIV epidemic in the US. There's a little over a million people estimated to be living with HIV in this country, and there's been about 700,000 deaths since the beginning of the epidemic. But we're at a stagnant rate of about 40,000 new infections per year. And it's not this across the board there's 40,000. There's certainly disparities in who gets infected. And it's a gross disproportion among the gay and bisexual men, and certainly African-American and poor, and then geography as this distribution. 

So as you can see, the south accounts for about half the number of HIV diagnoses in 2017. When you look at that's the absolute number. And when you look at the incidence rates, eight of the top 10 states are in the deep south. With regards to racial disparities, it's even more accentuated when you talk about women. African-American women make up about 13% of the overall population in the US, yet they make up almost 60% of all new HIV infections among women. 

And so when we talk about how far we've come in the HIV epidemic, now we have very well tolerated fixed-dose daily combination therapy. One pill once a day, and you can live a long and healthy life, and die of something other than HIV. 

And we have studies, including the Start Study from the Insight study group, that found when they compared early or immediate antiretroviral therapy initiation versus delayed, that both AIDS and non-AIDS related complications were significantly reduced in the immediate r. So much so that this study was interrupted early by the DSMB for the significant differences, and the guidelines were changed to reflect this finding. 

We also have this concept of treatment as prevention. So in 2011, Mike Cohen and HIV Prevention Trials Network published this data, looking at individuals who were started on ART in discordant couples-- one is positive, one is negative-- and to see if there was any decrease in transmission for those who were on therapy, versus who started therapy later. 

And the findings, which clearly indicated a public health benefit-- something that a lot of us who work in HIV were familiar with, but you always need the RTC to show you to change the guidelines-- was actually chosen in Science as the breakthrough of the year. And this has been supported by other studies, including the Partners Study, and last summer at Amsterdam, the Partners II Study, which showed that in over 1,000 mixed-status couples, If your partner was virally suppressed and on effective treatment, even with almost 60,000 sex acts without a condom, there were zero transmission of HIV. 

And subsequently, we also have pre-exposure prophylaxis. So combination antiretroviral therapy for those at risk of HIV, in a variety of studies show that people who take this either regularly-- and in one study, in men who have sex with men on what we call on-demand prep-- also had over 90% reduction in the risk of HIV. 

And so the treatment as prevention, I just want to highlight this. Last month, the NIAID and the division of AIDS really solidified this statement of undetectable equals un-transmittable. So we would always say, OK, if you're on meds and you're on therapy, you have a very low risk of transmission. Or it's close to 0, or not zero, but not quite zero. Or we don't know exactly what's going to happen. 

And this is not a very affirming message. If I'm hearing this message, clearly I can potentially still transmit HIV. And so with the data that we present that I presented in the earlier slide, DAIDS, and IID, the CDC, put out this message that said HIV viral load and transmissibility of HIV infection-- if you are undetectable you will not transmit HIV. 

And I think this is a key message for our policymakers to acknowledge, as we frame what our initiatives are going to be to end the epidemic, and to acknowledge that in our modeling estimates for where we need to target our interventions. And so this is just a summary of the vast tools that we have in our box to end the epidemic. 

And what Tony Fauci, the head of NIAID will emphasize is, these are all the tools that we need, right? And so from the biomedical, whether it's treatment as prevention, prep, harm reduction strategies, behavioral interventions, screening, condoms, the PMTCT-- prevention of mother to child transmission programs-- all of these arrows point to the potential for ending the epidemic. 

But I just told you we still have 40,000 new infections every year. And the challenge is, is how are we implementing these strategies? Are we implementing them to the right people? Are we implementing them in the right place? And are we implementing them so that they can be durable, and cost effective, and sustainable? 

And so some of the answers to those questions do inform this Ending the Epidemic initiative, that was released as a multi-agency plan by the NIH, the CDC, and the Department of Health and Human Services. And what they focus on is that of the 3,700 counties in the United States, there are 48 counties that account for over 50% of all new infections in our country. 

And so they want to target the efforts for ending the epidemic in these 48 counties. On top of that, they also have identified seven states where the epidemic is predominantly rural. And so rather than focusing on the specific counties where the numbers may not be that high but the outcomes may be worse, they have highlighted South Carolina, Kentucky, Missouri, Oklahoma, Arkansas, Alabama, and Mississippi. 

And so the NIH is proposing to use the 19 Centers for AIDS Research around the country as their method of ending the epidemic. The CFARs are going to help drive the science and the implementation science of ending this epidemic. And as you can see with the red ribbons, these are the 19 CFARs. There's only one, two, three, four, five, six, that are in the south, right? And they were clustered mostly in urban areas. They're tied to academic centers. And none of the rural states, other than Alabama, even have a Center for AIDS Research. 

The second thing is the NIH has described a plan briefly, to fund HIV care and prevention research in vulnerable southern US communities. So these are pilot grants that are being funded, or will be funded, through the CFARs, which are meant to then lead to large implementation programs. Is the intention for that implementation to be in coordination with health departments? Is the CDC going to be a part of that? We're not exactly sure. Awaiting further directives in that, but this is the general framework. 

This is their four-point plan. So when we got the RFA for the NIH pilot grants, they said that you had to respond to this indicating that you were going to address one of these four points as part of Ending the Epidemic initiative. So how are you proposing to diagnose all people with HIV as early as possible after infection? To treat the infection rapidly and effectively to achieve sustained viral suppression. 

Protect. So protect people at risk for HIV using potent and proven prevention interventions, including PREP, a medication that can prevent HIV infections. Respond rapidly to detect and respond to growing HIV clusters, and prevent new HIV infections. And then this last point is the HIV Health Force. So the HIV Health Force will establish local teams committed to the success of the initiative in each jurisdiction. 

And addressing these is meant to result in a 75% reduction in new HIV infections in five years, and a 90% reduction in 10 years. So by 2030, we're looking at very few-- Ending the Epidemic doesn't mean there's zero. It's very low transmission. So by 2030, we're meant to end the epidemic in this country. 

Now we all have questions about how that's really going to happen. You know currently in the yellow bar you have-- Protect people, including PREP. Well, how are we going to provide this PREP to people who are at risk? Who is going to pay for that? 

Currently, the Ryan White funding mechanism, which provides some prevention, and testing services, and counseling services for people living with HIV, it's specifically written that you cannot provide medications such as PREP to prevent HIV. So what is going to be the format for funding? How is this going to be operationalized? These are some of the details that we haven't heard of, but we're certainly eager and pleased that somebody has finally realize that the HIV epidemic affects the south. 

So at the Prevention Conference last week, the CDC released this data looking at modeling the risk of transmission based on your HIV status. So whether you don't know whether you have HIV, whether you know you have HIV but aren't in care, in care but not virally suppressed, or taking HIV medicine and virally suppressed. And the big change in this model is this last one. So if you take HIV medicine and virally suppressed, that will account for 0% of new transmissions, because u equals u. The prior model did not indicate that. 

But the thing that I want to highlight here is that the majority of infections are related to people who know their status, but are either not in care-- 43% of all new transmissions-- or are in care-- so one in five are related to those who are in care, but not virally suppressed. And so this is a key population that certainly needs, I think still dramatic, and probably the most costly interventions, in order to change and to shift these numbers. 

So where are we right now when it comes to that particular model? So we estimate that about 86% of all people living with HIV are aware of their diagnosis. So that last 14% are responsible for a good chunk of the new transmissions. 63% had any evidence of receipt of care. And receipt of care is estimated using a lab test. 

So 39 jurisdictions, states, and territories around the US report their CD4 count and HIV viral load directly to the Health Department. And so we use that as a proxy of care. There's been some debate as to whether it really translates to care, but only 63% had evidence of one CD4 viral load checked in a year. The second is retained in care. This is a HRSA measure that looks at having at least two lab tests divided by 60 days. 

And then the goal is really viral suppression, and we estimate that only about half of all people living with HIV achieve that final goal of viral suppression, which is what we need in order to have good outcomes for the patient, and then, of course, reduce transmission of HIV. 

And how are we doing compared to other countries? And so the Kaiser Family Foundation out of DC released this data last week, coinciding with the Prevention Conference. And so other high income countries, in terms of viral suppression, are as high as 84%, 76%, up to Canada, which is 63%. 

And the United States is at 54%. And so the question is why? What are the factors, what are the issues that are specific to our country, and to our local epidemic, that are informing this dramatically lower rate of viral suppression in the United States? 

And I want to talk about this, I think fairly elegant study by Kim Powers at UNC, that really speaks to understanding your local epidemic. So she used surveillance data from the Health Department in North Carolina from all new HIV diagnoses from 2006 to 2015. And so it's about 16,000 patients. And she used that same CD4 viral load as proxies of care, to see how well they engaged in care at every three months or every six months after their diagnosis. 

And she ended up classifying patients based on that engagement in care. And as you can see, about a quarter of people, after they were diagnosed, consistently high. About a quarter of people, after they were diagnosed, consistently low. And then in between you have some people who engage, and then decline. You have people who don't engage, and then later on engage. And then you have some people who don't engage, but then re-engage early on. 

But who are they? What predicts these patterns of engagement? And of course, there's very limited data that you can get from surveillance, which basically collects mostly just demographic data. But I would also posit that the answers to those questions differ based on where you are, and based on who you are. So the answer to this question in North Carolina is probably going to be very different to the answer to this question in the 52 counties that the HIV clinic here is responsible for. 

And so being able to understand this context is imperative as we develop our local strategies, our local health care force that we're meant to enact to end the epidemic. And so I'm talking about women. And so how are women doing compared to men? So when you look at the general HIV care continuum of everybody who's living with HIV, and has had receipt of care, and is virally retained in care, virally suppressed, there's really not that much of a difference. Both men and women aren't doing that well when it comes to viral suppression. They're doing equally as poorly. 

But when you cut it a different way, of those who are engaging in care-- so they've now linked to care, so our denominator is changing-- we're all about denominators here, right? And so of those who end up engaging in care, is there a difference between men and women? So an equal number of those who engage in care get prescribed antiretroviral therapy. 

And this is data from the CDC Medical Monitoring Project, which is in about 17 sites around the country looking at people who are engaged in care and answering annual surveys and abstraction of charts. But when we go to any viral suppression 81% of men have evidence of any viral suppression, versus 76% of women. 

And when we talk about sustained viral suppression, which they counted as individuals who all of their viral loads, even if they only had one, were suppressed in the year, there is also a difference. So what is informing this? They're being linked to care. They're being prescribed ART. But why are there these differences in viral suppression both any and sustained? 

So this is a pretty interesting study done by Meditz et al, all looking at all new seroconverters. Actually, this was acute HIV infections that were detected over a period of about five years. And they followed these individuals longitudinally, and wanted to look at their outcomes, both in terms of development of AIDS or mortality, and to see differences based on sex, based on geographic location, and also based on race. And the worst outcomes occurred both in terms of mortality, as well as development of AIDS-defining conditions, were non-white women who lived in the south. 

And so to bring in the opportunity that we may have. So as HIV has become a chronic disease, a growing number of HIV infected women are giving birth. And the prenatal phase is this unique opportunity where women who may not otherwise ever engage with health care, do engage at least once, when they deliver the baby. So could that be an opportunity of engagement? Could we take advantage of that opportunity to improve their engagement in care? 

Of course, the question is, is there a problem with their engagement in care after delivery? I think you may know the answer to that question already. It's why I'm here. So this is actually a clinical trial looking at adherence to antiretroviral among US women, during and after pregnancy. And so in that first line, you can see that there were 468 women who were on study. And this was self report of adherence. And 95% of these women reported adherence to their therapy. 

They're motivated. They're being counseled. We don't want to transmit HIV to our child. But by the time you get to even six weeks or 24 weeks postpartum, now only half of the women are reporting greater than 95% adherence to therapy. The other number I want to point out is we started off with 468 women on study, and within one year, we've lost half of them. So we don't even know what their adherence is. We don't know what's going on with them. They just disappear. 

And what a meta-analysis looking at adherence to antiretroviral therapy in low income, middle income, and high income countries, looked at the differences in adherence that's reported in studies based on their pregnancy stage-- so whether before delivery, and after delivery. And in this meta-analysis, certainly there was worse adherence reported postpartum. 

Surprisingly, there was actually-- the study's published, and this may be a bias and the study's published-- but the worse adherence was in high income countries, compared to low and middle income countries. 

In the study done at UAB, using both urban and rural HIV clinics, we followed women during pregnancy and up to about three years postpartum. The red line indicates the proportion of women who had testing who had evidence of viral suppression, and the black line is the number of women who had any lab count as well. 

And as you can see, by the end of third trimester is where we have our peak. 63% of women had evidence of viral suppression, and 205 women actually had some lab evidence of care. But then you're just six months postpartum, and you have this dramatic drop, and that drop actually continues up to three years. So even if we're talking about the immediate chaos of a newborn, whatever informs their disengagement in care is continuing even three years postpartum. 

And in this study in Philadelphia, which used surveillance data-- Florence Momplaisir and her group looked at evidence of HIV care during pregnancy, evidence of viral suppression at delivery, and then looked at predictors of engagement in care and viral suppression at both one year and two years postpartum. And these were women who were seen between 2010 and 2013. And as you can see, that drop in engagement in care during pregnancy, you have 92% of women who have evidence of HIV care and delivery, and then within 90 days it's down to 38%. And at two years postpartum, only a quarter of women are regularly engaged in care, with only a third of these women virally suppressed. 

The other thing is to show that this latest data from the CDC, this is continuing to be a growing problem. So African-American women make up the bulk of new infections among women infected with HIV in this country. And whereas the other races are having a decrease in the proportion of AIDS diagnoses, they're still increasing among African-American women. And so, again, how can we change this? And why is this happening? 

So certainly, when we talk about postpartum women, we're talking about competing responsibilities, right? I don't know if you guys have seen this movie or read the novel Precious, based on the novel Push by Sapphire. But there's this scene where she's emerging from the train station. She's holding her child. And there's this voiceover going on, and she says, they tell me I have HIV and I could die, and I need to take my medications. But I don't have time for that. I have to take care of my kids. 

And I think that that sort of emphasis on competing responsibilities, particularly among young mothers in this country, where there is also limited support or fractured health care system, certainly needs to be taken into consideration. So various cohort studies have looked at women being more likely to postpone care due to these competing responsibilities. 

In the women's interagency HIV study, they were actually able to correlate having more than two children at home were less likely to be adherent to their ART regimen. It's not a surprise, but they certainly found that correlation. Women are also more likely to report structural barriers. So the same cost and services utilization study found that women were more likely to postpone care because they lack transportation. 

And particularly in the south, and I know in talking to the staff members here, you certainly experience this here in Virginia, that the organizational structure and location of clinics can impede access to care. And that's usually mediated by lack of transportation, and that the cost themselves can certainly limit women from attending the clinic. 

Depression has certainly played a role in engagement with care, in both men and women. So depressive symptoms and AIDS-related mortality. So those who reported chronic depression had higher rates of mortality in this study. And then specifically looking at rates of perinatal depression and adherence. So higher rates of period perinatal depression were associated with lower rates of adherence in HIV infected women. 

So intimate partner violence has also been shown. So Catherine Schaefer and Becca Dillingham did a study here in this clinic, showing a clear association with reports of intimate partner violence or threatened violence with lower CD4 counts, higher viral loads, and higher no-show rates. And this has been shown in other literature to be highly associated adherence and detectable viral load in women. And that women who missed medical visits were also twice as likely to report intimate partner violence. 

And then there's stigma, and it's the stigma of HIV. And I've been spending a lot of time in this literature, and it's interesting to read about even though 91% of all HIV infected women's risk factor is heterosexual, and oftentimes they report monogamous relationships. But they're often assumed to have been infected through more judgmental means, as it were-- injection drug use, promiscuity, or prostitution. 

And experience of stigma is more common in African-American women. And the women who are often able to mitigate the worst effects of stigmatization are usually socially advantaged. So they're usually non-minority or middle class. And since they were less likely to be associated with having HIV infection, they're also less likely to suffer the consequences of delayed diagnosis. 

But that's just HIV-related stigma. And that's not the only stigma that women living with HIV often have to encounter. And so what we have to identify is this growing understanding of intersectional stigma, right? So poverty, gender, gender discrimination, racial discriminations, class structure, and then HIV-related stigma, how do they interact? Not just how they're additive, they're compounded. 

We do analysis based on discrete-- OK, this socioeconomic status had this outcome, this gender had this outcome. In real life, that's not how it works. We're not just discrete definitions. It's how all of these interact, how they can inform in different situations to then result in outcome. So what is the level of social support that can mitigate some of these or can not? And how does that inform their quality of life, their engagement in care, and their overall outcome? 

So I'm not a structural equation modelist, but I think understanding this as health care providers when we see our patients, to know that it's not just one thing, and to understand how all of these things may be interacting to inform the non-adherence of the patient sitting in front of you, is going to be critical. 

So that takes me to Mississippi. So I started working in Mississippi as a first-year fellow when I was at Brown. So Brown has had a longstanding relationship with Jackson State University, a historically black college university, and Tougaloo College in Jackson. And we were interested in establishing a relationship looking at perinatal outcomes of HIV-infected women. 

And so went down there, and met with University of Mississippi Medical Center, and asked them how their women were doing after they delivered. They'd done an excellent job in limiting mother-to-child transmission, which is the near elimination, is one of the vast public health successes in this country. But what happened to the women after they delivered? 

And the answer was, well, we're kind of too busy to figure this out. So hence a collaboration started. And so, Mississippi, it's a state of about 3 million or so people, predominantly rural. The capital is in Jackson. And the HIV incidence and prevalence-- about 48% of the people living with HIV live outside an urban metropolitan statistical area. Jackson's the only one. And that's compared to about less than 10% in the entire United States that live outside an urban metropolitan statistical area. So quite the rural epidemic compared to other areas. 

And Mississippi was divided into these different health districts that have their own medical officer, their own HIV social worker, and so their own funding. And so their ability to do disease interventions had the DIS officers go out and link people to care, and bring them back into care. 

So there's about 10,000 people living with HIV in Mississippi. Annually, about 509 people, with about 21% of them being female. And the disparities are pretty vast. African-American case rate is nine times the rate of white women. But there are these nine Ryan White funding clinics. Two of the health districts don't have a Ryan White funded clinic, and so transportation certainly can be an issue in that state. 

The Jackson MSA actually has the fourth highest aids case rate in the nation. And as Kate was telling me, they've recently gotten extra funding because of some of these issues with regards to their increasing incidents, particularly as it relates to young black MSM. And I'm sure you guys have heard the statistic that in the deep south it's estimated that one in two gay and bisexual minority men will eventually develop or acquire HIV. 

So Mississippi recently changed their format to these three large health public health regions, but the clinics have not changed. And honestly, the structure of the medical officers hasn't changed either, so I'm not quite sure why they did this, but I didn't want to misrepresent what their health regions currently are. 

And the epidemic in Mississippi is really centered in Jackson in that area-- so Hinds, Rankin, and Yazoo county. And also in the Northwest in the delta. So this delta, this is a fertile region, primarily agricultural, and it experiences racial disparities of many stripes. So it's predominantly African-American, and in this population you have life expectancy that is one of the lowest in the country. People die of diabetes, cardiac disease, cancer. And so not surprisingly, this is where there's also the higher rates of HIV in the state as well. 

So we did this first study looking just at follow-up care of HIV-infected women in the year after delivery-- so just one year after delivery. And I was abstracting charts often, which were some Post-it notes, and some database as well. And the one nice thing about Mississippi is the care is fairly centralized, which may make it challenging when it comes to transportation, but the database is all in one place the University of Mississippi Medical Center. 

So between 1999 and 2006, there were about 300 deliveries. And the median age was 25. Not surprisingly, 90% of these women were black. About a third of these women were newly diagnosed around the prenatal period, really emphasizing the importance of opt-out HIV testing. And the majority of these women presented either in first or second trimester, but about a quarter of the women did present late, meaning, in the third trimester. And 2% presented at the time of delivery. 

17% reported substance use. This was predominantly marijuana. And about a quarter of the women had any evidence of STI. So we were just looking at engagement in care in the year after delivery. And we had this statewide database, so we could see whether or not they sought care at any of the Ryan White funded clinics. 

And we found that 46% of the women had what we defined as suboptimal care, meaning they only had had 0 or 1 visit after delivery. And 36% had no visits. 17% we did not know. We found no evidence of care. We found no evidence of ER visits. We couldn't find anything. So overall, even in that first year after delivery, low engagement. 

We looked at predictors. Who could we target? Who was more likely to not engage in care? And what we found is that actually aged between 25 to 32 was a little bit more predictive. As well as late presentation trimester. Primary HIV care provider as well. I mean, whether they were already engaged in care certainly, they were more likely to still engage in care. And being employed-- probably a competing responsibility was actually a negative predictor. 

But on multivariate analysis, if you presented in first or second trimester, you were much more likely to engage in care. It seems obvious if you're more likely to engage in care early, you are going to probably more likely to continue to engage in care. But at the same time, it also indicates this is the population. The third trimester presenters are really where we want to try to focus some of our resources. 

And so I'll go through this quickly. They did a cross-sectional study. Basically, it was primarily for the qualitative. There's only so much you can ask a database review. And we really wanted to explore, through in-depth qualitative interviews, the socioeconomic behavioral instrumental barriers and facilitators to follow-up care. 

So actually, the demographic and HIV-related data, even seven or eight years after my initial study, had not changed that much. And so what we found was that-- we were just looking simply at linkage after delivery. So 62% of the women linked to their OB visit, and about 83% linked, meaning just had that one visit with their HIV provider after delivery. 

But what we really wanted to do was talk to these women, and ask them what are their barriers and facilitators to care. And certainly the issues of transportation came up. And one woman said, when I had my last baby, I was getting ready in the transportation vehicle, and they said if she-- referring to her infant-- not on the passenger list, then she can't go. And I was like, what I supposed to do? Leave her at home by herself? 

So she's supposed to go for her appointment and she has transportation, but she can't take her baby along. And so if she can't take her baby along, she's not going to go to the appointment. And so she talks certainly the challenges with those competing responsibilities. 

The confidentiality. It was interesting to me how even some of the transportation issues and overall care were really couched in this concern about confidentiality. Not wanting to use the Medicaid transportation because they walk in and they talk about, oh, I'm bringing the HIV patient in. Or concerns that the person who's transporting them will disclose their status. And certainly, because a lot of these will bring you, and they sit in the doctor's office with you, and say, oh, they're going to the HIV clinic. They've got HIV. And people really need transportation where nobody's going to go back and tell them where they came. 

Certainly women talk about competing responsibilities. And the relationship with the provider and the clinic was critical. I wasn't comfortable there. It seems like they don't really care. Kind of mean like, because of what I have. And clarified with this woman, was she talking about the OB visit, or is she talking about her HIV visit? And she was talking about her HIV visit. 

Insurance. So I think this was a very astute woman. So I'm having the Medicaid now that I'm pregnant. I would think that once I'm done being pregnant, and I don't have Medicaid no more, then that would affect me getting to my appointments. She's probably right about that. 

So we talked about different options for interventions, and when it came to intensive case management and calls versus home visits, it was very interesting. They really didn't care about the phenotype of the case manager who they would work with. Because we talked about, oh, do you want somebody living with HIV? Do you want someone who's African-American? Do you want a man? Do you want a woman? All of that didn't matter. What they were really concerned about was confidentiality. You mean, one more person person's going to know I have HIV? And that was a big concern for them. 

And so women really didn't want to do those home visits, which we think about that being a better personal connection, kind of like a warm handoff. And these women were really much more interested in having maybe phone communication or text communication. And so, again, remember, these are younger women. Median age 24, 25. So much more comfortable with using that technology as well. But they still wanted to remind me, you're not going to talk about HIV in that, right? 

And so, that led to my K work, where I'm actually using now a combination of surveillance data and clinical data to look at long-term outcomes. And my first study was just that year. And then we were also looking at just linkage and getting qualitative data. 

So we did a retrospective analysis looking at 685 deliveries involving 549 HIV infected women, who delivered between 2002 and 2014. We used data from all of the federally-funded Ryan White clinics, and we used data from the Mississippi State Department's Enhanced HIV-AIDS Reporting System. This is where the CD4 and the viral loads are sent. 

Our outcomes of interest were both retention and care, as well as viral suppression. And we looked at, again, the different factors that could be evaluated to associate with these outcomes, including their Public Health District resident, and other insurance status, as well as their year of delivery, CD4 at presentation, and whether or not they successfully linked to HIV care. 

And as I mentioned, those were our data sources. And, again, the demographics are not so different. A little bit older age. Median age at delivery was 26. Most of these women had Medicaid. Again, I want to emphasize this is Medicaid during pregnancy. So in Mississippi, currently, after you deliver, you are eligible for Medicaid as a parent of a minor, but that's only if you make 22% of federal poverty level, which is a little bit less than $300 per month. So if you make more than that, you're not eligible for Medicaid after pregnancy. And now they're adding a work requirement too. 

All right. So then looking at geography, not surprisingly most of these women lived in both District Three or Five. Three is the delta, and Five is the Jackson area. And then we were able to actually look at the eHARS data, and see which of these women, as of the most current available residents, actually still lived in Mississippi. Because one of the challenges is always, oh, how do you know they're lost to follow-up? They could have just moved away. And so this was one of the ways where we attempt to do that. 

So in terms of their HIV outcomes, still a little over a third of the women were diagnosed around pregnancy. Interestingly, only 12% of the women developed AIDS within one year of HIV diagnosis. Now, as a reminder, they are young, right? So they're fairly recently diagnosed. But over half of them eventually went on to develop AIDS at some point. 

And in this cohort, I don't have access to the actual mother-to-infant linkage data, but in the same frame, including women who are from Mississippi and delivered in Mississippi, there were nine total perinatal transmissions, the last one being that 2010 Mississippi baby, who they thought was cured, but actually isn't cured. 

So this is the care continuum in this cohort. So 67% of these women were virally suppressed at delivery. But similar to the Philadelphia cohort, and perhaps even more dramatically, you had immediate drop in care engagement within 90 days of delivery, and essentially abysmal rates of engagement in care, both at one year and two years postpartum. The slightly good news is that there was an overall improvement when we compared earlier years versus later years. But you're still looking at engagement in care in the later years of about 20% or so. 

And the more surprising, and disappointing, and upsetting thing were the unexpected rates of high mortality in this population. So there were 12% of these women were deceased. We can talk about what is retention, and what is viral suppression, and what is sustained, but we really can't argue about death. 

And so we found that the median age at the time of death was 32. And the median time from their last delivery-- so they're healthy enough to have a baby, and then five years later they're deceased. And what we were able to find initially on some of these women, not all of these women, what was their last available CD4? What was their last available viral load? And the sources of some of this information was not outpatient care, but hospitalized care. 

And so seems to be that these were AIDS-related, but we didn't know. Could there have been trauma? Was there suicide? Did they get run over by a bus? What happened to these women? So we updated our request, and amended our IRB to look at cause of death. 

So we were able to access Mississippi's vital stats reports-- and found that 80% of these women actually did die of an AIDS-related complication. And 15% were unknown. And of those who died of HIV-related cause of death, the report said either HIV unspecified, opportunistic infection, other pneumonias, HIV other infection, or HIV with malignancy. 

And when we looked at predictors of mortality, I think the first two are not too surprising. At some point, if you develop AIDS, you probably are at higher risk of death. If you're presenting CD4 at the time of pregnancy, was less than 200. You had a higher rate of mortality. But I think this connection of being uninsured postpartum, and higher rate of mortality is really-- again, we think we know this, but it sort of hits you in the face with data, that having this lack of access to care in these young women, clearly resulted in the mortality. 

So these young HIV-infected women, they experience low rates of retention and viral suppression, and significant morbidity and mortality following delivery. And despite slightly improving temporal trends, we're still not in good shape when it comes to engagement and care in this population. 

And so really interventions potentially initiated during pregnancy and continued through the postpartum phase, they may improve longitudinally. We certainly have that opportunity. We certainly have the challenge and the requirement to try to see if we can engage them enough to improve their longitudinal treatment adherence, and of course their health outcomes. 

So we are going to do some geospatial analytics to try and focus, work closely with the Health Department to see what resources we can use to impact these outcomes. And I'm also enrolling women prospectively and following them longitudinally for two years, where we're going to do some annual assessments of both structural and behavioral barriers to care, and then also abstract their chart for care engagement and health outcomes. 

So in the meantime, we recently got this RO1. I'm doing a randomized control trial of a testing the effectiveness of a peer-led intervention to improve postpartum retention and care. So this is with Florence Momplaisir, who did the work in Philadelphia. And we're doing this in Philadelphia, as well as DC, Atlanta, and Birmingham. 

And so we'll use a peer-delivered social support-- face-to-face interactions combined with weekly text education role modeling. The intervention will start during the second trimester, where there will be three face-to-face visits, and then eight additional visits postpartum before six months postpartum. And we'll be looking at retention in care at one year, and viral suppression at one year. The training has started, and we'll start this intervention over the summer. 

So I just want to highlight in the last couple of minutes, a couple of the things that we're working on in Alabama right now. So our Centers for AIDS Research, as part of our reapplication last year, started a scientific working group called Ending HIV in Alabama. And so what this scientific working group proposes to do is-- 

We are all working on different projects focused on ending the epidemic, but to cohesively bring together individuals who are both researchers but public health and community partners, to work collaboratively, cohesively to implement all of those tools that I presented in a more deliberate manner, targeting certain aspects of the care continuum, but actually utilizing the framework of the UNAIDS 90-90-90 Initiative. So that's getting 90% of people aware of their diagnosis. Of those 90% in care on treatment, and 90% viral suppression. 

So we have these benchmarks that we want to achieve, and the scientific working group hopes to bring together this collaborative expertise as we focus on this goal. And as part of that, we submitted an RO1. We just got our notice of award on this, and working with a social worker looking at geographic differences in time to viral suppression after new diagnosis. So after you're diagnosed, how long does it take you to achieve that very first benchmark? 

And while we're doing that in three states in the south-- Alabama, Mississippi, and Louisiana-- we hope to augment that data with qualitative research to look at places where there are the longest delays in viral suppression, how we can implement interventions focused on rapid linkage to care and rapid initiation of ART. 

So I like to think certainly, all of the people that I've worked with for my work in Mississippi, including the Health Department, and all of my collaborators in Mississippi. And all of the Ryan White clinics, who've been so generous in sharing their data, and working with me, and accepting my annoying calls, and travels to all of their sites. And for the Center for AIDS Research, for all of the work that we are commencing on, and hoping to do, and hoping to collaborate with others with, as we try to end this epidemic. That's it. Thank you. 

[APPLAUSE]