"Out of Care" HIV Case Investigations: A Collaborative Analysis Across 6 States in the Northwest US

Data to Care Pilot Program in Chicago: Experience, Outcomes, and Direction for the Future

CONTEXT

Data to Care (D2C) involves sharing HIV surveillance data between health care facilities and health departments to improve continuity of care for people living with HIV (PLWH). The Chicago Department of Public Health (CDPH) initiated a D2C pilot program at the University of Chicago Medicine (UCM) from June 2016 to September 2019.

OBJECTIVES

To describe the proportion of patients reported by UCM as not in care who were able to be matched to CDPH enhanced HIV/AIDS Reporting System (eHARS) and to report the individual-level factors associated with matching and viral suppression.

DESIGN

Retrospective program evaluation.

SETTING

UCM, an academic health care center that provides HIV care to adults via a Ryan White clinic on the south side of Chicago.

PARTICIPANTS

Adult PLWH who had received care at UCM but did not have current documented HIV care visit(s).

MAIN OUTCOME MEASURE

Proportion of matched patients; factors associated with matching and viral suppression.

RESULTS

Overall, 72.4% (n = 813/1123) of patients reported by UCM were matched by CDPH to eHARS. Individuals aged 40 to 49 years (odds ratio [OR] = 1.99; 95% confidence interval [CI], 1.10-3.62), 50 to 59 years (OR = 2.47; 95% CI, 1.37-4.47), and 60 years or older (OR = 6.18; 95% CI, 3.18-12.32) were more likely to match in eHARS. People who lived outside of Chicago (OR = 0.09; 95% CI, 0.05-0.15) or with unknown zip codes (OR = 0.08; 95% CI, 0.05-0.12) were less likely to match. Men who have sex with men and persons older than 50 years were more likely to be virally suppressed.

CONCLUSIONS

D2C is an evidence-based strategy for reengagement of PLWH; however, program implementation relies on successful data matching. We found that a large proportion of patients from UCM were not matched, particularly those who were younger or lived outside of Chicago. Additional research is needed to understand ways to improve data matching to facilitate reengagement in HIV care.

Adopting Data to Care to Identify and Address Gaps in Services for Children and Adolescents Living With HIV in Mozambique

BACKGROUND

The Data to Care (D2C) strategy uses multiple sources of complementary data on HIV clients and related services to identify individuals with gaps in HIV treatment. Although D2C has been widely used in the United States, there is no evidence on its use in other settings, such as countries most affected by the epidemic.

STRATEGY IMPLEMENTATION

The D2C strategy was implemented within the context of a project that provided community-based support to children and adolescents living with HIV (C/ALHIV) in Mozambique. A data tracking tool and a standard operating procedure manual for local partner community organizations and health care facilities were developed to support the effort. Project staff met with local project implementing partners to discuss and coordinate the intervention in pilot health facilities.

STRATEGY PILOTING

The project initiated a pilot D2C intervention in 2019, working with 14 health facilities across 5 additional districts within 1 province. COVida project data were compared with clinical data from facilities serving C/ALHIV. The D2C intervention identified gaps in HIV treatment for a substantial number of C/ALHIV, and targeted support services were provided to address those gaps. Viral load (VL) monitoring was added in March 2020. Before the intervention, 71% of C/ALHIV reported to be on HIV treatment by their caregivers were documented as on treatment in health facilities. Support interventions targeted those not on treatment, and this proportion increased to 96% within 1 year of implementation. Additionally, 12 months later, the proportion of C/ALHIV with a documented VL test increased from 52% to 72%.

CONCLUSION

Introducing the D2C pilot intervention was associated with substantial improvements in HIV treatment for C/ALHIV, including increased linkage to and continuity in treatment and increased VL testing. D2C may be a useful approach to improve health outcomes for C/ALHIV in settings outside of the United States.

Leveraging social networks for identification of people with HIV who are virally unsuppressed

OBJECTIVES

This study investigates primary peer-referral engagement (PRE) strategies to assess which strategy results in engaging higher numbers of people with HIV (PWH) who are virally unsuppressed.

DESIGN

We develop a modeling study that simulates an HIV epidemic (transmission, disease progression, and viral evolution) over 6 years using an agent-based model followed by simulating PRE strategies. We investigate two PRE strategies where referrals are based on social network strategies (SNS) or sexual partner contact tracing (SPCT).

METHODS

We parameterize, calibrate, and validate our study using data from Chicago on Black sexual minority men to assess these strategies for a population with high incidence and prevalence of HIV. For each strategy, we calculate the number of PWH recruited who are undiagnosed or out-of-care (OoC) and the number of direct or indirect transmissions.

RESULTS

SNS and SPCT identified 256.5 [95% confidence interval (CI) 234-279] and 15 (95% CI 7-27) PWH, respectively. Of these, SNS identified 159 (95% CI 142-177) PWH OoC and 32 (95% CI 21-43) PWH undiagnosed compared with 9 (95% CI 3-18) and 2 (95% CI 0-5) for SPCT. SNS identified 15.5 (95% CI 6-25) and 7.5 (95% CI 2-11) indirect and direct transmission pairs, whereas SPCT identified 6 (95% CI 0-8) and 5 (95% CI 0-8), respectively.

CONCLUSION

With no testing constraints, SNS is the more effective strategy to identify undiagnosed and OoC PWH. Neither strategy is successful at identifying sufficient indirect or direct transmission pairs to investigate transmission networks.

Viewpoint on Human Immunodeficiency Virus Medical Care Retention Guidelines in the Coronavirus 2019 Pandemic Era and Beyond: Lessons Learned From Electronic Health Record Screening and Outreach

In this viewpoint, we discuss retention in care for people with human immunodeficiency virus (HIV) and call into question the methodology used to characterize retention, as well as the definitions themselves. Optimal retention for people with HIV (PWH) is defined in multiple ways by major healthcare leaders in the United States, typically focusing on appointment attendance or laboratory work. Yet, these definitions rely on in-person encounters, an approach to care that is becoming less common due to the rise of telehealth visits, particularly in light of the coronavirus disease 2019 pandemic. Our recent work showed that relying on electronic health records to identify PWH who were not retained in care not only failed to capture the nuances of modern HIV medical treatment engagement, but also led to misidentification of patients' retention status due to limitations in the record system. As such, we recommend a reevaluation of how HIV medical care retention is defined and reported.

Expanding Data to Care Programs to Improve HIV Care Continuum Among Men Who Have Sex With Men and Transgender Persons: Key Processes and Outcomes From Project PrIDE, 2015-2019

OBJECTIVES

During 2015-2019, five local and state health department jurisdictions implemented Data to Care (D2C) programs supported by Project PrIDE (Pre-exposure prophylaxis, Implementation, Data to Care, and Evaluation) to improve linkage or reengagement in HIV medical care among persons with HIV (PWH) who had gaps in care, particularly among men who have sex with men (MSM) and transgender persons. We describe findings from the cross-jurisdiction evaluation of the project.

METHODS

We conducted a qualitative analysis of the final progress reports submitted by PrIDE jurisdictions to the Centers for Disease Control and Prevention to identify key D2C activities implemented and challenges encountered. We also conducted descriptive analysis on aggregate quantitative data to summarize key D2C program outcomes.

RESULTS

PrIDE jurisdictions implemented multiple activities to build their D2C capacity, identify PWH who were not in care or virally suppressed, provide linkage/reengagement services, and monitor outcomes. Overall, 11 463 PWH were selected for follow-up, 45% of whom were MSM or transgender persons. Investigations were completed for 8935 (77.9%) PWH. Only 2323 (26.0%) PWH were confirmed not in care or virally suppressed; 1194 (51.4%) were subsequently linked/reengaged in care; among those, 679 (56.9%) were virally suppressed at last test. PrIDE jurisdictions identified data-related (eg, incomplete or delayed laboratory results), program capacity (eg, insufficient staff), and social and structural (eg, unstable housing) challenges that affected their D2C implementation.

CONCLUSIONS

PrIDE jurisdictions successfully enhanced their D2C capacity, reached priority populations who were not in care or virally suppressed, and improved their engagement in care and health outcomes. Data-related and non-data-related challenges limited the efficiency of D2C programs. Findings can help inform other D2C programs and contribute to national HIV prevention goals.

Advancing a Data Justice Framework for Public Health Surveillance

BACKGROUND

Bioethical debates about privacy, big data, and public health surveillance have not sufficiently engaged the perspectives of those being surveilled. The data justice framework suggests that big data applications have the potential to create disproportionate harm for socially marginalized groups. Using examples from our research on HIV surveillance for individuals incarcerated in jails, we analyze ethical issues in deploying big data in public health surveillance.

METHODS

We conducted qualitative, semi-structured interviews with 24 people living with HIV who had been previously incarcerated in county jails about their perspectives on and experiences with HIV surveillance, as part of a larger study to characterize ethical considerations in leveraging big data techniques to enhance continuity of care for incarcerated people living with HIV.

RESULTS

Most participants expressed support for the state health department tracking HIV testing results and viral load data. Several viewed HIV surveillance as a violation of privacy, and several had actively avoided contact from state public health outreach workers. Participants were most likely to express reservations about surveillance when they viewed the state's motives as self-interested. Perspectives highlight the mistrust that structurally vulnerable people may have in the state's capacity to act as an agent of welfare. Findings suggest that adopting a nuanced, context-sensitive view on surveillance is essential.

CONCLUSIONS

Establishing trustworthiness through interpersonal interactions with public health personnel is important to reversing historical legacies of harm to racial minorities and structurally vulnerable groups. Empowering stakeholders to participate in the design and implementation of data infrastructure and governance is critical for advancing a data justice agenda, and can offset privacy concerns. The next steps in advancing the data justice framework in public health surveillance will be to innovate ways to represent the voices of structurally vulnerable groups in the design and governance of big data initiatives.

Advancing data to care strategies for persons with HIV using an innovative reconciliation process

Background

UN AIDS has set ambitious 95-95-95 HIV care continuum targets for global HIV elimination by 2030. The U.S. HIV Care Continuum in 2018 showed that 65% of persons with HIV(PWH) are virally suppressed and 58% retained in care. Incomplete care-engagement not only affects individual health but drives ongoing HIV transmission. Data to Care (D2C) is a strategy using public health surveillance data to identify and re-engage out-of-care (OOC) PWH. Optimization of this strategy is needed.

Setting

Statewide partnership with Connecticut Department of Public Health (CT DPH), 23 HIV clinics and Yale University School of Medicine (YSM). Our site was one of 3 participants in the CDC-sponsored RCT evaluating the efficacy of DPH-employed Disease Intervention Specialists (DIS) for re-engagement in care.

Methods

From 11/2016-7/2018, a data reconciliation process using public health surveillance and clinic visit data was used to identify patients eligible for randomization (defined as in-Care for 12 months and OOC for subsequent 6-months) to receive DIS intervention. Clinic staff further reviewed this list and designated those who would not be randomized based on established criteria.

Results

2958 patients were eligible for randomization; 655 (22.1%) were randomized. Reasons for non-randomizing included: well patient [499 (16.9%)]; recent visit [946 (32.0%)]; upcoming visit [398 (13.5%)]. Compared to non-randomized patients, those who were randomized were likely to be younger (mean age 46.1 vs. 51.6, p < .001), Black (40% vs 35%)/Hispanic (37% vs 32.8%) [(p < .001)], have CD4<200 cells/ul (15.9% vs 8.5%, p < .001) and viral load >20 copies/ml (43.8% vs. 24.1%, 0<0.001). Extrapolating these estimates to a statewide HIV care continuum suggests that only 8.3% of prevalent PWH are truly OOC.

Conclusions

A D2C process that integrated DPH surveillance and clinic data successfully refined the selection of newly OOC PWH eligible for DIS intervention. This approach more accurately reflects real world care engagement and can help prioritize DPH resources.

Evaluation of a Public Health Referral System to Re-Engage Individuals Living With HIV Who Have Interrupted Antiretroviral Therapy in British Columbia, Canada

BACKGROUND

In 2016, the British Columbia HIV/AIDS Drug Treatment Program modified its prescriber alert system for antiretroviral therapy (ART) interruptions to include referrals to regional public health nursing teams for direct outreach support for those who remain off treatment for 4 months or longer. We evaluated clinically relevant outcomes of this Re-Engagement and Engagement in Treatment for Antiretroviral Interrupted and Naïve populations (RETAIN) initiative, in comparison to previous time-periods.

METHODS

We analyzed ART interruptions triggering alerts in pre-RETAIN (July 2013-April 2016) and post-RETAIN periods (May 2016-October 2017) with follow-up continuing until October 2018. We compared the proportions of those who restarted ART and achieved viral suppression in pre-RETAIN and post-RETAIN periods and the time to ART restart using generalized estimating equations. Cox proportional hazards modelling was used to examine associations with time-to-ART-restart.

RESULTS

A total of 1805 individuals experienced ART interruptions triggering 3219 alerts; 2050 in pre-RETAIN and 1169 in post-RETAIN periods. Participants were predominantly men (74%) and had a median duration of ART of 5 years. Among persons who remained interrupted >4 months after an ART interruption alert was sent, the median time from interruption to ART re-initiation declined from 8.7 months to 7.4 months (P < 0.001) from pre-to post-RETAIN periods. Interruptions in the post-RETAIN era were associated with an increased hazard of restarting ART (adjusted hazard ratio 1.51; 95% CI: 1.34 to 1.69).

CONCLUSIONS

Public health referrals shortened the length of ART interruptions after alerts sent to prescribers had not resulted in re-engagement. Similar programs should be considered in other jurisdictions.

Increased reengagement of out-of-care HIV patients using Lost & Found, a clinic-based intervention

BACKGROUND

Negative health outcomes associated with being out of HIV care (OOC) warrant reengagement strategies. We aimed to assess effectiveness of Lost & Found, a clinic-based intervention to identify and reengage OOC patients.

METHODS

Developed and delivered using implementation science, Lost & Found consists of two core elements: identification, operationalized through nurse validation of a real-time list of possible OOC patients; and contact, via nurse-led phone calls. It was implemented over a 12-month period (2018-2019) at the Chronic Viral Illness Service, McGill University Health Centre (CVIS-MUHC) during a type-II implementation-effectiveness hybrid pilot study. Descriptive outcomes of interest were identification as possibly OOC, OOC confirmation, contact, and successful reengagement. We present results from a pre-post analysis comparing overall reengagement to the year prior, using robust Poisson regression controlled for sex, age, and Canadian birth. Time to reengagement is reported using a Cox proportional hazards model.

RESULTS

Over half (56%; 1312 of 2354) of CVIS-MUHC patients were identified as possibly OOC. Among these, 44% (n = 578) were followed elsewhere, 19% (n = 249) engaged in care, 3% (n = 33) deceased, 2% (n = 29) otherwise not followed, and 32% (n = 423) OOC. Of OOC patients contacted (85%; 359/423), 250 (70%) reengaged and 40 (11%) had upcoming appointments; the remainder were unreachable, declined care, or missed given appointments. Pre-post results indicate people who received Lost & Found were 1.18 [95% confidence interval (CI) 1.02-1.36] times more likely to reengage, and reengaged a median 55 days (95% CI 14-98) sooner.

CONCLUSION

Lost & Found may be a viable clinic-based reengagement intervention for OOC patients. More robust evaluations are needed.

Access to HIV care in jails: Perspectives from people living with HIV in North Carolina

Most incarcerations for people living with HIV (PLWH) occur in jails, yet studies of HIV care during jail incarceration are limited. As part of a larger study to explore the ethical considerations in extending public health HIV surveillance to jail settings, we conducted semi-structured interviews with twenty-three PLWH with more than 300 distinct jail incarcerations post HIV diagnosis in 21 unique North Carolina jails. Interviews included questions about HIV disclosure in jail, the type of HIV care received in jail, and overall experiences with HIV care in jail. We report on participants' experiences and perspectives in four domains: access to HIV care in jail; impact of jail incarceration on continuity of HIV care; privacy and stigma; and satisfaction with HIV care in jail. Although most participants received HIV medications and saw providers while in jail, almost half reported that their greatest challenge in regard to HIV care was obtaining their HIV medications in the face of limited jail resources or policies that made access to medications difficult. Findings from this study suggest that jail leadership should review internal policies regarding HIV medications to ensure that PLWH can receive them quickly upon entry into jail. Findings also suggest that more external resources are needed, for example from state and local health departments, so that jails can provide timely HIV medications for PLWH incarcerated in their facilities.

Evaluation of an Emergency Department and Hospital-Based Data Exchange to Improve HIV Care Engagement and Viral Suppression

BACKGROUND

Emergency department (ED) visits and inpatient (IP) admissions may provide an opportunity to reengage poorly engaged people living with HIV and facilitate viral suppression. In 2015, Public Health Seattle and King County partnered with the University of Washington Medicine to implement a real-time data exchange to identify virally unsuppressed people living with HIV seen at the ED/IP hospital and reengage them in HIV care. We evaluated the impact of the data exchange on care engagement and viral suppression.

METHODS

Public Health Seattle and King County received a text alert on weekdays 8 AM to 6 PM for ED/IP patients previously diagnosed with HIV with a most recent viral load ≥200 copies/mL. We compared viral load testing <3 months and viral suppression <6 months after an alert-eligible visit in the 2 years after intervention and the 7 to 30 months before intervention. To account for secular trends, we used difference-in-differences models to compare patients with alert-window visits to patients with visits outside the alert window before and after intervention.

RESULTS

Patients with visits within the alert window in the postintervention period were 1.08 (95% confidence interval [CI], 0.97-1.20) times more likely to have a viral load test within 3 months after an ED visit/IP admission and 1.50 (95% CI, 1.27-1.76) times more likely to achieve viral suppression within 6 months than patients in the preintervention period. However, care engagement (difference-in-differences relative risk, 1.00; 95% CI, 0.84-1.18) and viral suppression (difference-in-differences relative risk, 1.01; 95% CI, 0.84-1.20) trends were similar among patients with visits outside the alert window.

CONCLUSIONS

Real-time data exchange with ED/IP hospitals was associated with improved viral suppression, but not increased care engagement. However, our results may reflect secular trends resulting from diverse interventions, of which ours was only one. More efforts are needed to improve the effectiveness of relinkage interventions guided by real-time data exchange.

"Is a Bird in the Hand Worth 5 in the Bush?": A Comparison of 3 Data-to-Care Referral Strategies on HIV Care Continuum Outcomes in San Francisco

Background

Health departments utilize HIV surveillance data to identify people with HIV (PWH) who need re-linkage to HIV care as part of an approach known as Data to Care (D2C.) The most accurate, effective, and efficient method of identifying PWH for re-linkage is unknown.

Methods

We evaluated referral and care continuum outcomes among PWH identified using 3 D2C referral strategies: health care providers, surveillance, and a combination list derived by matching an electronic medical record registry to HIV surveillance. PWH who were enrolled in the re-linkage intervention received short-term case management for up to 90 days. Relative risks and 95% confidence intervals were calculated to compare proportions of PWH retained and virally suppressed before and after re-linkage. Durable viral suppression was defined as having suppressed viral loads at all viral load measurements in the 12 months after re-linkage.

Results

After initial investigation, 233 (24%) of 954 referrals were located and enrolled in navigation. Although the numbers of surveillance and provider referrals were similar, 72% of enrolled PWH were identified by providers, 16% by surveillance, and 12% by combination list. Overall, retention and viral suppression improved, although relative increases in retention and viral suppression were only significant among individuals identified by surveillance or providers. Seventy percent of PWH who achieved viral suppression after the intervention remained durably virally suppressed.

Conclusions

PWH referred by providers were more likely to be located and enrolled in navigation than PWH identified by surveillance or combination lists. Overall, D2C re-linkage efforts improved retention, viral suppression, and durable viral suppression.

Falling Through the Cracks: Risk Factors for Becoming Lost to HIV Care After Incarceration in a Southern Jail

Using a retrospective cohort analysis of inmates released from Dallas County Jail between January 2011 and November 2013, this study characterizes people living with HIV/AIDS (PLWHA) who are lost to care after release from jail. We used Kaplan-Meier analysis to estimate the risk of becoming lost to post-release HIV care and a Cox proportional hazards regression model to identify associated factors. The majority of individuals (78.2%) were men and 65.5% were black. Of the incarcerations that ended with release to the community, approximately 43% failed to link to community HIV care. Non-Hispanic Whites were more likely than Hispanics or Blacks to drop out of care after release. Individuals with histories of substance use or severe mental illness were more likely to become lost, while those under HIV care prior to incarceration and/or who had adhered to antiretroviral therapy (ART) were more likely to resume care upon release. Targeted efforts such as rapid linkage to care and re-entry residence programs could encourage formerly incarcerated individuals to re-engage in care.

Informing Data to Care: Contacting Persons Sampled for the Medical Monitoring Project

BACKGROUND

Data to care (D2C) is a public health strategy that uses HIV surveillance and other data to identify persons in need of HIV medical care. The Medical Monitoring Project (MMP), which uses similar methods to contact and recruit HIV-positive persons, may inform predictors of successful contact for D2C programs.

SETTING

MMP is a Centers for Disease Control and Prevention-funded surveillance system that collects nationally representative data on adults with diagnosed HIV in the United States and Puerto Rico.

METHODS

Using MMP's 2016 data collection cycle, we present contact rates (ie, proportion of HIV-positive persons successfully contacted for MMP) by the age of contact information and age of laboratory test results available from HIV surveillance data.

RESULTS

Nationally, 27.6% of eligible persons did not have a recorded laboratory test performed within the past year (project area range: 10.8%-54.6%). The national contact rate among persons with laboratory tests older than 1 year was 37.0% (project area range: 16.5%-67.1%). Higher contact rates were found among persons with more recent laboratory tests. Similar results were found by the age of contact information. Nationally, the most common reason for MMP ineligibility was that the person was deceased; the most common reason for not being contacted was lack of correct contact information.

CONCLUSIONS

MMP findings suggest that D2C programs would benefit from efforts to improve the quality of HIV surveillance data and local surveillance practices-in particular, death ascertainment, the completeness of laboratory reporting, and the routine updating of contact information. Strengthening collaboration and integration with existing MMP programs may be beneficial.

Cross-Jurisdictional Data to Care: Lessons Learned in New York State and Florida

BACKGROUND

Data-to-Care (D2C) programming is an important strategy in locating and relinking persons with HIV who are not in care (NIC), back to care. However, Health Department D2C programs have found a large proportion of individuals who seem NIC are living outside of their jurisdiction. Jurisdictions are limited in ability to cross-communicate regarding such individuals.

SETTING

Two D2C programs [New York State (NYS) and Florida (FL)] funded through the Partnerships-for-Care Demonstration Project, partnered to conduct a feasibility pilot project to test cross-jurisdictional D2C reciprocity.

METHODS

Jurisdictions made efforts to set up infrastructure for cross-jurisdictional D2C, and NYS worked to identify persons reported in NYS presumed in need of linkage/relinkage efforts in FL using 3 years of NYS D2C program outcomes.

RESULTS

One hundred forty NYS NIC individuals were presumed to need linkage/relinkage efforts in FL. However, case dispositions for these individuals were not able to be advanced beyond determining HIV care status due to 4 critical challenges: (1) Local legal and regulatory permissibility for sharing identifiable HIV surveillance information outside of a specific jurisdiction varies; (2) Electronic infrastructure in place does not support public health follow-up of individuals who are not within a jurisdiction's HIV surveillance system; (3) An individual's verifiable current residence is not easily attained; and (4) Roles, responsibilities, and case prioritization within each state, and across jurisdictions vary and require clear delineation.

CONCLUSIONS

Although programmatic challenges during this D2C feasibility pilot project were unsurmountable for NYS and FL, potential solutions presented may facilitate broader national cross-jurisdictional D2C reciprocity.

Data to Care Opportunities: An Evaluation of Persons Living With HIV Reported to Be "Current to Care" Without Current HIV-Related Labs

BACKGROUND

Data to care (D2C) is an effective strategy using HIV surveillance data to link/relink persons living with HIV into medical care. However, some appearing to be not in care (NIC) report being in care (persons "current to care").

SETTING

New York State's Expanded Partner Services (ExPS) D2C program has identified many persons reported as "current to care." This evaluation describes these persons after 24 months of follow-up and identifies HIV-related laboratory-based testing patterns and results to determine whether this cohort could benefit from further programmatic intervention.

METHODOLOGY

Data from ExPS assignments from September 2013 to May 2016 were used. Persons "current to care" were compared with persons NIC on demographics, subsequent HIV-related laboratory-based testing, and viral load suppression status. Persons "current to care" receiving subsequent HIV-related laboratory-based testing were compared with those who did not receive HIV-related labs.

RESULTS

Persons "current to care" significantly differed from persons NIC on demographics and subsequent HIV-related laboratory-based testing (82% of persons "current to care" had subsequent HIV-related labs, versus 99% of those NIC who were relinked to care). Persons "current to care" were more likely to be virally suppressed at their subsequent lab than persons NIC who were relinked to care (72% vs. 47%). Minor differences were noted for persons "current to care" receiving subsequent HIV-related labs compared with those who did not.

CONCLUSIONS

Persons "current to care" reflect a unique cohort who might benefit from further programmatic intervention. Although most received additional HIV-related labs, some were without labs for the duration of follow-up.

Comparing Methods for Record Linkage for Public Health Action: Matching Algorithm Validation Study

Background

Many public health departments use record linkage between surveillance data and external data sources to inform public health interventions. However, little guidance is available to inform these activities, and many health departments rely on deterministic algorithms that may miss many true matches. In the context of public health action, these missed matches lead to missed opportunities to deliver interventions and may exacerbate existing health inequities.

Objective

This study aimed to compare the performance of record linkage algorithms commonly used in public health practice.

Methods

We compared five deterministic (exact, Stenger, Ocampo 1, Ocampo 2, and Bosh) and two probabilistic record linkage algorithms (fastLink and beta record linkage [BRL]) using simulations and a real-world scenario. We simulated pairs of datasets with varying numbers of errors per record and the number of matching records between the two datasets (ie, overlap). We matched the datasets using each algorithm and calculated their recall (ie, sensitivity, the proportion of true matches identified by the algorithm) and precision (ie, positive predictive value, the proportion of matches identified by the algorithm that were true matches). We estimated the average computation time by performing a match with each algorithm 20 times while varying the size of the datasets being matched. In a real-world scenario, HIV and sexually transmitted disease surveillance data from King County, Washington, were matched to identify people living with HIV who had a syphilis diagnosis in 2017. We calculated the recall and precision of each algorithm compared with a composite standard based on the agreement in matching decisions across all the algorithms and manual review.

Results

In simulations, BRL and fastLink maintained a high recall at nearly all data quality levels, while being comparable with deterministic algorithms in terms of precision. Deterministic algorithms typically failed to identify matches in scenarios with low data quality. All the deterministic algorithms had a shorter average computation time than the probabilistic algorithms. BRL had the slowest overall computation time (14 min when both datasets contained 2000 records). In the real-world scenario, BRL had the lowest trade-off between recall (309/309, 100.0%) and precision (309/312, 99.0%).

Conclusions

Probabilistic record linkage algorithms maximize the number of true matches identified, reducing gaps in the coverage of interventions and maximizing the reach of public health action.

A type II implementation-effectiveness hybrid quasi-experimental pilot study of a clinical intervention to re-engage people living with HIV into care, 'Lost & Found': an implementation science protocol

Background

At the McGill University Health Centre (MUHC), 10% of patients living with HIV do not return for care annually. Currently, no formal system exists to re-engage out-of-care (OOC) patients. Lost & Found, developed using an implementation science approach, is an intervention to re-engage OOC patients. It is based on existing evidence-based interventions and will be adapted for use by nurses at the MUHC. The aims of this study are to simultaneously assess both implementation and effectiveness of Lost & Found in order to determine the viability of a future multisite stepped-wedge cluster randomised trial.

Methods

Lost & Found consists of two core elements: identifying and contacting OOC patients. Based on formative work involving MUHC nurses, and the use of a combined implementation framework (enhanced Replicating Effective Programs, Tailored Implementation for Chronic Diseases, and Proctor et al.’s implementation outcomes), we will adapt the intervention to our clinic. Adaptations include the creation of an OOC risk prediction tool, an automated real-time OOC list, and prioritization of high-risk OOC patients for re-engagement. Delivery and ongoing adaptation of the intervention will follow a three-pronged implementation strategy consisting of (1) promoting adaptability; (2) planning, engaging, executing, evaluating, and reflecting cycles; and (3) internal facilitation. This 15-month quasi-experimental pilot study adopts a type II implementation-effectiveness hybrid design. To evaluate implementation, a convergent parallel mixed-methods approach will guide the mixing of qualitative and quantitative data at time points throughout the study. In addition, descriptive and pre-post analyses, for each of the implementation and sustainability phases, will inform evaluations of the cumulative effectiveness and sustainability of the Lost & Found intervention.

Discussion

This study will provide preliminary evidence for (1) the utility of our chosen implementation strategies and (2) the effectiveness of the intervention. Ultimately, this information may be used to inform future re-engagement efforts using implementation science in other HIV care centres. In addition, the procedures and measurement tools developed for this study will be foundational to the development of a multi-site, randomised stepped wedge study that would provide more robust evidence in support of the Lost & Found intervention.

Cross-site Monitoring and Evaluation of the Care and Prevention in the United States Demonstration Project, 2012-2016: Selected Process and Short-term Outcomes

OBJECTIVE

The Care and Prevention in the United States (CAPUS) Demonstration Project was a 4-year (2012-2016) cross-agency demonstration project that aimed to reduce HIV/AIDS-related morbidity and mortality among racial/ethnic minority groups in 8 states (Georgia, Illinois, Louisiana, Mississippi, Missouri, North Carolina, Tennessee, and Virginia). Its goals were to increase the identification of undiagnosed HIV infections and optimize the linkage to, reengagement with, and retention in care and prevention services for people with HIV (PWH). We present descriptive findings to answer selected cross-site process and short-term outcome monitoring and evaluation questions.

METHODS

We answered a set of monitoring and evaluation questions by using data submitted by grantees. We used a descriptive qualitative method to identify key themes of activities implemented and summarized quantitative data to describe program outputs and outcomes.

RESULTS

Of 155 343 total HIV tests conducted by all grantees, 558 (0.36%) tests identified people with newly diagnosed HIV infection. Of 4952 PWH who were presumptively not in care, 1811 (36.6%) were confirmed as not in care through Data to Care programs. Navigation and other linkage, retention, and reengagement programs reached 10 382 people and linked to or reengaged with care 5425 of 7017 (77.3%) PWH who were never in care or who had dropped out of care. Programs offered capacity-building trainings to providers to improve cultural competency, developed social marketing and social media campaigns to destigmatize HIV testing and care, and expanded access to support services, such as transitional housing and vocational training.

CONCLUSIONS

CAPUS grantees substantially expanded their capacity to deliver HIV-related services and reach racial/ethnic minority groups at risk for or living with HIV infection. Our findings demonstrate the feasibility of implementing novel and integrated programs that address social and structural barriers to HIV care and prevention.

A Cluster Randomized Evaluation of a Health Department Data to Care Intervention Designed to Increase Engagement in HIV Care and Antiretroviral Use

BACKGROUND

Many US health departments have implemented Data to Care interventions, which use HIV surveillance data to identify persons who are inadequately engaged in HIV medical care and assist them with care reengagement, but the effectiveness of this strategy is uncertain.

METHODS

We conducted a stepped-wedge, cluster-randomized evaluation of a Data to Care intervention in King County, Washington, 2011 to 2014. Persons diagnosed as having HIV for at least 6 months were eligible based on 1 of 2 criteria: (1) viral load (VL) greater than 500 copies/mL and CD4 less than 350 cells/μL at the last report in the past 12 months or (2) no CD4 or VL reported to the health department for at least 12 months. The intervention included medical provider contact, patient contact, and a structured individual interview. Health department staff assisted patients with reengagement using health systems navigation, brief counseling, and referral to support services. We clustered all eligible cases in the county by the last known medical provider and randomized the order of clusters for intervention, creating contemporaneous intervention and control periods (cases in later clusters contributed person-time to the control period at the same time that cases in earlier clusters contributed person-time to the intervention period). We compared the time to viral suppression (VL <200 copies/mL) for individuals during intervention and control periods using a Cox proportional hazards model.

RESULTS

We identified 997 persons (intention to treat [ITT]), 18% of whom had moved or died. Of the remaining 822 (modified ITT), 161 (20%) had an undetectable VL reported before contact and 164 (20%) completed the individual interview. The hazard ratio (HR) for time to viral suppression did not differ between the intervention and control periods in ITT (HR, 1.21 [95% confidence interval, 0.85-1.71]) or modified ITT (HR, 1.18 [95% confidence interval, 0.83-1.68]) analysis.

CONCLUSIONS

The Data to Care intervention did not impact time to viral suppression.

"Closing the Loop" Developing State-Level Data Sharing Interventions to Promote Optimum Outcomes Along the HIV Continuum of Care

This manuscript describes the experiences of three state departments of health (SDoH) that successfully launched data sharing interventions involving surveillance and/or patient data collected in clinics to improve care outcomes among people living with HIV. We examined 58 key informant interviews, gathered at two time points, to describe the development and implementation of data sharing interventions. We identified three common themes across states' experiences: creating standard practices, fostering interoperability, and negotiating the policy environment. Projects were successful when state teams adapted to changing circumstances and were committed to a consistent communication process. Once implemented, the interventions streamlined processes to promote linkage and retention in care among low-income populations living with HIV. Despite using routinely collected data, key informants emphasized the labor-intensive process to develop and sustain the interventions. Lessons learned from these three state experiences can help inform best practices for other SDoH that are considering launching similar interventions.

Using HIV Surveillance Data to Link People to HIV Medical Care, 5 US States, 2012-2015

INTRODUCTION

From 2012 through 2015, the Centers for Disease Control and Prevention (CDC) provided funding to 5 health departments for demonstration projects using HIV surveillance data to link people with newly diagnosed HIV to care. We assessed how well these health departments established linkage to care, how the demonstration projects helped them with this work, and if they sustained these activities after CDC funding ended.

MATERIALS AND METHODS

We obtained quantitative and qualitative data on linkage-to-care activities from health department communications and progress reports submitted to CDC. We calculated and combined linkage-to-care results for the 5 health departments, and we compared these results with the combined linkage-to-care results for 61 health departments that received CDC funding for routine HIV prevention activities (eg, HIV testing, linkage to and reengagement in HIV care, HIV partner services) and for the same 5 health departments when they used only routine HIV prevention activities for linkage to care.

RESULTS

Of 1269 people with a new HIV diagnosis at the 5 health departments, 1124 (89%) were linked to care, a result that exceeded the 2010-2015 National HIV/AIDS Strategy goal (85%), the CDC Funding Opportunity Announcement performance standard (80%), and combined results for the 61 health departments (63%) and the same 5 health departments (66%) using routine HIV prevention activities. Benefits of the projects were improved collaboration and coordination and more accurate, up-to-date surveillance data. All health departments continued linkage-to-care activities after funding ended.

PRACTICE IMPLICATIONS

Using HIV surveillance data to link people with HIV to care resulted in substantial clinical and public health benefits. Our observations underscore the importance of collaboration among medical providers, public health staff members, community-based organizations, and people with HIV to ensure the best possible clinical and public health outcomes.

CROI 2018: Advances in Antiretroviral Therapy

The 2018 Conference on Retroviruses and Opportunistic Infections (CROI) showcased exciting data on new investigational agents including MK-8591 and tri-specific antibody targeting 3 highly conserved epitopes on HIV-1 in a single antibody. Clinical trials of initial antiretroviral therapy (ART) and switch studies involving bictegravir/emtricitabine/tenofovir alafenamide were presented. Intensification of initial ART with integrase strand transfer inhibitors did not increase the risk of immune reconstitution inflammatory syndrome. Pharmacokinetic issues were discussed, including the substantial drug-drug interactions between efavirenz-based ART and hormonal contraception delivered via a vaginal ring. Studies on pre-ART drug resistance and emergence of drug resistance after initial and second-line ART in different settings and populations were highlighted. Novel technologies to identify drug resistance included a free, cloud-based web service for HIV genotyping analysis and a promising technology for point-of-care drug resistance mutations testing. New strategies to improve the HIV care continuum included home-based testing with initiation of same-day ART and stratified care with specialized clinics to serve those disengaged in care, but the data on financial incentives were not encouraging. Several studies provided insights into the impact of early ART on decreasing the size of the HIV reservoir in HIV-infected infants. Pertinent conference findings relating to women's health issues included similar clinical outcomes between breastfeeding and formula feeding HIV-infected women, the problem of viral rebound and ART nonadherence in pregnancy and postpartum.

The Max Clinic: Medical Care Designed to Engage the Hardest-to-Reach Persons Living with HIV in Seattle and King County, Washington

The Max Clinic in Seattle, Washington is designed to engage patients who have extensive barriers to HIV care. In this article, we describe the clinic's evolution and outcomes of patients enrolled in the first 2 years. The clinic is a high-intensity, low-threshold, incentivized care model that includes walk-in access to primary care in a Sexually Transmitted Disease Clinic. Patients who have failed to engage in care and achieve viral suppression with lower intensity support are referred by clinicians, case managers, and the health department Data to Care program. The clinic offers food vouchers, cash incentives, no-cost bus passes, and cell phones, as well as intensive case management with cross-agency coordinated care. The primary evaluation outcome was the percentage of patients who achieved viral suppression (HIV RNA <200 copies/mL) at least once after enrollment. Secondary outcomes were continuous viral suppression (≥2 suppressed results in a row ≥60 days apart) and engagement in care (≥2 completed medical visits ≥60 days apart). During January 2015-December 2016, 263 patients were referred; 170 (65%) were eligible, and 95 (56% of eligible) were enrolled. Most patients used illicit drugs or hazardous levels of alcohol (86%) and had diagnosed psychiatric illness (72%) and unstable housing (65%). During the year after enrollment, 90 (95%) patients engaged in care. As of the end of 2016, 76 (80%) had achieved viral suppression, and 54% had continuous viral suppression. The Max Clinic successfully treated HIV in high-need patients and, to date, has been sustainable through a combination of federal, state, and local funding.

Defining Care Patterns and Outcomes Among Persons Living with HIV in Washington, DC: Linkage of Clinical Cohort and Surveillance Data

Background

Triangulation of data from multiple sources such as clinical cohort and surveillance data can help improve our ability to describe care patterns, service utilization, comorbidities, and ultimately measure and monitor clinical outcomes among persons living with HIV infection.

Objectives

The objective of this study was to determine whether linkage of clinical cohort data and routinely collected HIV surveillance data would enhance the completeness and accuracy of each database and improve the understanding of care patterns and clinical outcomes.

Methods

We linked data from the District of Columbia (DC) Cohort, a large HIV observational clinical cohort, with Washington, DC, Department of Health (DOH) surveillance data between January 2011 and June 2015. We determined percent concordance between select variables in the pre- and postlinked databases using kappa test statistics. We compared retention in care (RIC), viral suppression (VS), sexually transmitted diseases (STDs), and non-HIV comorbid conditions (eg, hypertension) and compared HIV clinic visit patterns determined using the prelinked database (DC Cohort) versus the postlinked database (DC Cohort + DOH) using chi-square testing. Additionally, we compared sociodemographic characteristics, RIC, and VS among participants receiving HIV care at ≥3 sites versus <3 sites using chi-square testing.

Results

Of the 6054 DC Cohort participants, 5521 (91.19%) were included in the postlinked database and enrolled at a single DC Cohort site. The majority of the participants was male, black, and had men who have sex with men (MSM) as their HIV risk factor. In the postlinked database, 619 STD diagnoses previously unknown to the DC Cohort were identified. Additionally, the proportion of participants with RIC was higher compared with the prelinked database (59.83%, 2678/4476 vs 64.95%, 2907/4476; P<.001) and the proportion with VS was lower (87.85%, 2277/2592 vs 85.15%, 2391/2808; P<.001). Almost a quarter of participants (23.06%, 1279/5521) were identified as receiving HIV care at ≥2 sites (postlinked database). The participants using ≥3 care sites were more likely to achieve RIC (80.7%, 234/290 vs 62.61%, 2197/3509) but less likely to achieve VS (72.3%, 154/213 vs 89.51%, 1869/2088). The participants using ≥3 care sites were more likely to have unstable housing (15.1%, 64/424 vs 8.96%, 380/4242), public insurance (86.1%, 365/424 vs 57.57%, 2442/4242), comorbid conditions (eg, hypertension) (37.7%, 160/424 vs 22.98%, 975/4242), and have acquired immunodeficiency syndrome (77.8%, 330/424 vs 61.20%, 2596/4242) (all P<.001).

Conclusions

Linking surveillance and clinical data resulted in the improved completeness of each database and a larger volume of available data to evaluate HIV outcomes, allowing for refinement of HIV care continuum estimates. The postlinked database also highlighted important differences between participants who sought HIV care at multiple clinical sites. Our findings suggest that combined datasets can enhance evaluation of HIV-related outcomes across an entire metropolitan area. Future research will evaluate how to best utilize this information to improve outcomes in addition to monitoring them.

Locating People Diagnosed With HIV for Public Health Action: Utility of HIV Case Surveillance and Other Data Sources

INTRODUCTION

Human immunodeficiency virus (HIV) case surveillance and other health care databases are increasingly being used for public health action, which has the potential to optimize the health outcomes of people living with HIV (PLWH). However, often PLWH cannot be located based on the contact information available in these data sources. We assessed the accuracy of contact information for PLWH in HIV case surveillance and additional data sources and whether time since diagnosis was associated with accurate contact information in HIV case surveillance and successful contact.

MATERIALS AND METHODS

The Case Surveillance-Based Sampling (CSBS) project was a pilot HIV surveillance system that selected a random population-based sample of people diagnosed with HIV from HIV case surveillance registries in 5 state and metropolitan areas. From November 2012 through June 2014, CSBS staff members attempted to locate and interview 1800 sampled people and used 22 data sources to search for contact information.

RESULTS

Among 1063 contacted PLWH, HIV case surveillance data provided accurate telephone number, address, or HIV care facility information for 239 (22%), 412 (39%), and 827 (78%) sampled people, respectively. CSBS staff members used additional data sources, such as support services and commercial people-search databases, to locate and contact PLWH with insufficient contact information in HIV case surveillance. PLWH diagnosed <1 year ago were more likely to have accurate contact information in HIV case surveillance than were PLWH diagnosed ≥1 year ago ( P = .002), and the benefit from using additional data sources was greater for PLWH with more longstanding HIV infection ( P < .001).

PRACTICE IMPLICATIONS

When HIV case surveillance cannot provide accurate contact information, health departments can prioritize searching additional data sources, especially for people with more longstanding HIV infection.