An exploratory study to characterize the HIV testing-to-care continuum to improve outcomes for Black and Latinx residents of South Los Angeles

Background

South Los Angeles (SPA6), with mostly Black (27.4%) and Latinx (68.2%) residents, has the second highest rates of new HIV diagnoses (31 per 100,000) in Los Angeles County. However, there is limited understanding of the HIV testing-to-care continuum among newly diagnosed in this setting.

Methods

We conducted an exploratory study that analyzed de-identified data, including demographic characteristics and biomedical outcomes, from the electronic medical records of individuals newly diagnosed with HIV from 2016–2020 at the only public safety-net, county-run health department HIV clinic in SPA 6. We used Pearson Chi-square and Fisher’s Exact test to explore associations with HIV outcomes and a Kaplan-Meier survival curve to assess the time to linkage to care.

Results

A total of 281 patients were identified. The majority (74.1%) presented with a baseline CD4 <500, many of which presented with a CD4<200 (39.2%). We found twice as many newly diagnosed Black individuals in our study population (48.2%) when compared to LAC (23%), despite only accounting for 27.4% of residents in SPA 6. The majority were linked to care within 30 days of positive test and prescribed anti-retroviral therapy. Viral suppression (59.8%) and undetectable VL (52.6%) were achieved within the year following diagnosis, with 9.3% lost to follow-up. Of those who became virally suppressed, 20.7% experienced viral rebound within the year following diagnosis.

Conclusion

The large proportion of patients with a baseline CD4 <500 raises concerns about late diagnoses. Despite high rates of linkage to care and ART prescription, achievement of sustained viral suppression remains low with high rates of viral rebound. Longitudinal studies are needed to understand the barriers to early testing, retention in care, and treatment adherence to develop strategies and interventions with community organizations that respond to the unique needs of people living with HIV in South Los Angeles.

BASHH 2018 UK national audit of HIV partner notification

HIV partner notification (PN) is a highly effective strategy to identify people living with undiagnosed HIV infection. This national audit of HIV PN is against the 2015 British Association of Sexual Health and HIV (BASHH)/British HIV Association (BHIVA)/Society of Sexual Health Advisers (SHAA)/National AIDS Trust (NAT) HIV PN standards, developed in response to the 2013 BASHH/BHIVA national HIV PN audit. We report significant improvements in the number of contacts tested per index case, likely due, in part, to clearer definitions as well as better ascertainment and reporting. There remains scope for improvement with informing and testing contactable contacts. Recommendations from this audit include further refinement of definitions and development of a national proforma for HIV PN.

Adaptions to the National Diabetes Prevention Programme lifestyle change curriculum by Hawai'i Federally Qualified Health Centers: a qualitative descriptive study

OBJECTIVE

The objective of this qualitative study was to describe the community-appropriate and culturally appropriate adaptations made by lifestyle change programme (LCP) coaches to the National Diabetes Prevention Programme curriculum for Federally Qualified Health Center (FQHC) patients in Hawai'i, an ethnically diverse state with a high proportion of Native Hawaiians and Pacific Islanders (NHPI).

RESEARCH DESIGN AND METHODS

We used a qualitative descriptive approach. First, we conducted a document review of existing programmatic notes and materials followed by video interview calls with 13 lifestyle coaches at 7 FQHCs implementing in-person LCPs. Lifestyle coaches catalogued, described and explained the rationale for adaptations. The research team counted adaptations if they met a specific adaptation definition derived from several sources. Community and cultural relevancy of adaptations were analysed using an existing framework for weight loss and diabetes prevention for NHPIs.

RESULTS

The average number of adaptations per FQHC was 8.61 (range: 4-16). Adaptations fell into 11 broad categories such as off-site community field trips, food-related and nutrition-related activities, and physical activity opportunities. Novel adaptations included goal setting with motivational interviewing and dyadic recruitment. Field trips and in-class food demonstrations addressed the most constructs related to weight loss and diabetes prevention for NHPI, including social and community barriers, familial barriers and barriers to self-efficacy.

CONCLUSIONS

Lifestyle coaches were culturally attuned to the needs of LCP participants, particularly from NHPI communities. Policy-makers should recognise the extra work that LCP coaches do in order to increase enrollment and retention in these types of programmes.

Risk factors associated with group A Streptococcus acquisition in a large, urban homeless shelter outbreak

OBJECTIVE

Group A Streptococcus (GAS) is a frequent cause of outbreaks in healthcare institutions, yet outbreak reports in the literature from homeless shelters are less common, despite an increased risk of severe GAS infection in homeless populations. In 2016, we conducted a case-control study to identify significant risk factors associated with GAS acquisition in a protracted, 19-month outbreak of GAS in a large, urban men's homeless shelter in Ontario, Canada.

METHODS

Cases (individuals with either clinical GAS emm74 infection or asymptomatic carriers of GAS emm74) and controls were identified from shelter residents from February to September 2016. Information on demographics, clinical presentation, pre-existing health conditions, and risk factors for GAS transmission were collected for all study participants from a variety of sources, including the public health notifiable disease information system, electronic health records, the shelter electronic information system, and interviews with client services workers.

RESULTS

From the multivariable logistic regression model, younger individuals (OR 9.1; 95% CI 1.57-52.9), those with previous skin conditions (OR 56.2; 95% CI 2.73-1160), and those with recent wounds (with wound care: OR 51.5, 95% CI 8.86-299, and without wound care: OR 77.4, 95% CI 7.38-812) were found to be at increased risk of acquiring GAS in this outbreak.

CONCLUSION

The outbreak investigation clearly demonstrated the need for improved wound care and infection prevention and control practices, for early screening and detection of skin and soft tissue infections, and for a comprehensive, integrated electronic information system in homeless shelters.

Improving HIV test uptake and case finding with assisted partner notification services

OBJECTIVE

Despite the enormous expansion of HIV testing services (HTS), an estimated 40% of people with HIV infection remain undiagnosed. To enhance the efficiency of HTS, new approaches are needed. The WHO conducted a systematic review on the effectiveness of assisted partner notification in improving HIV test uptake and diagnosis, and the occurrence of adverse events, to inform the development of normative guidelines.

METHODS

We systematically searched five electronic databases through June 2016. We also contacted experts in the field and study authors for additional information where needed. Eligible studies compared assisted HIV partner notification services to passive or no notification. Where multiple studies reported comparable outcomes, meta-analysis was conducted using a random-effects model to produce relative risks (RRs) or risk ratios and 95% confidence intervals (CIs).

RESULTS

Of 1742 citations identified, four randomized controlled trials and six observational studies totalling 5150 index patients from eight countries were included. Meta-analysis of three individually randomized trials showed that assisted partner notification services resulted in a 1.5-fold increase in HTS uptake among partners compared with passive referral (RR = 1.46; 95% CI: 1.22-1.75; I = 0%). The proportion of HIV-positive partners was 1.5 times higher with assisted partner notification than with passive referral (RR = 1.47; 95% CI: 1.12-1.92; I = 0%). Few instances of violence or harm occurred.

CONCLUSION

Assisted partner notification improved partner testing and diagnosis of HIV-positive partners, with few reports of harm. WHO strongly recommends voluntary assisted HIV partner notification services to be offered as part of a comprehensive package of testing and care.

Loss to follow-up in the Australian HIV Observational Database

BACKGROUND

Loss to follow-up (LTFU) in HIV-positive cohorts is an important surrogate for interrupted clinical care, which can potentially influence the assessment of HIV disease status and outcomes. After preliminary evaluation of LTFU rates and patient characteristics, we evaluated the risk of mortality by LTFU status in a high-resource setting.

METHODS

Rates of LTFU were measured in the Australian HIV Observational Database for a range of patient characteristics. Multivariate repeated measures regression methods were used to identify determinants of LTFU. Mortality by LTFU status was ascertained using linkage to the National Death Index. Survival following combination antiretroviral therapy initiation was investigated using the Kaplan-Meier (KM) method and Cox proportional hazards models.

RESULTS

Of 3,413 patients included in this analysis, 1,632 (47.8%) had at least one episode of LTFU after enrolment. Multivariate predictors of LTFU included viral load (VL)>10,000 copies/ml (rate ratio [RR] 1.63; 95% CI 1.45, 1.84; ref ≤400), time under follow-up (per year; RR 1.03; 95% CI 1.02, 1.04) and prior LTFU (per episode; RR 1.15; 95% CI 1.06, 1.24). KM curves for survival were similar by LTFU status (P=0.484). LTFU was not associated with mortality in Cox proportional hazards models (univariate hazard ratio [HR] 0.93; 95% CI 0.69, 1.26) and multivariate HR 1.04 (95% CI 0.77, 1.43).

CONCLUSIONS

Increased risk of LTFU was identified amongst patients with potentially higher infectiousness. We did not find significant mortality risk associated with LTFU. This is consistent with timely re-engagement with treatment, possibly via high levels of unreported linkage to other health-care providers.