Implementing a Data to Care Strategy to Improve Health Outcomes for People With HIV: A Report From the Care and Prevention in the United States Demonstration Project

Utilizing Big Data analytics and electronic health record data in HIV prevention, treatment, and care research: a literature review

Propelled by the transformative power of modern information and communication technologies, digitalization of data, and the increasing affordability of high-performance computing, Big Data science has brought forth revolutionary advancement in many areas of business, industry, health, and medicine. The HIV research and care service community is no exception to the benefits from the availability and utilization of Big Data analytics. Electronic health record (EHR) data (e.g., administrative and billing data, electronic medical records, or other digital records of information pertinent to individual or population health) are an essential source of health and disease outcome data because of the large amount of real-world, comprehensive, and often longitudinal data, which provide a good opportunity for leveraging advanced Big Data analytics in addressing challenges in HIV prevention, treatment, and care. This review focuses on studies that apply Big Data analytics to EHR data with aims to synthesize the HIV-related issues that EHR data studies can tackle, identify challenges in the utilization of EHR data in HIV research and practice, and discuss future needs and directions that can realize the promising potential role of Big Data in ending the HIV epidemic.

Using Data-To-Care Strategies to Optimize the HIV Care Continuum in Connecticut: Results From a Randomized Controlled Trial

BACKGROUND

Re-engaging people with HIV who are newly out-of-care remains challenging. Data-to-care (D2C) is a potential strategy to re-engage such individuals.

METHODS

A prospective randomized controlled trial compared a D2C strategy using a disease intervention specialist (DIS) vs standard of care where 23 HIV clinics in 3 counties in Connecticut could re-engage clients using existing methods. Using a data reconciliation process to confirm being newly out-of-care, 655 participants were randomized to DIS (N = 333) or standard of care (N = 322). HIV care continuum outcomes included re-engagement at 90 days, retention in care, and viral suppression by 12 months. Multivariable regression models were used to assess factors predictive of attaining HIV care continuum outcomes.

RESULTS

Participants randomized to DIS were more likely to be re-engaged at 90 days (adjusted odds ratios [aOR] = 1.42, P = 0.045). Independent predictors of re-engagement at 90 days were age older than 40 years (aOR = 1.84, P = 0.012) and perinatal HIV risk category (aOR = 3.19, P = 0.030). Predictors of retention at 12 months included re-engagement at 90 days (aOR = 10.31, P < 0.001), drug injection HIV risk category (aOR = 1.83, P = 0.032), detectable HIV-1 RNA before randomization (aOR = 0.40, P = 0.003), and county (Hartford aOR = 1.74, P = 0.049; New Haven aOR = 1.80, P = 0.030). Predictors of viral suppression included re-engagement at 90 days (aOR = 2.85, P < 0.001), retention in HIV care (aOR = 7.07, P < 0.001), and detectable HIV-1 RNA prerandomization (aOR = 0.23, P < 0.001).

CONCLUSIONS

A D2C strategy significantly improved re-engagement at 90 days. Early re-engagement improved downstream benefits along the HIV care continuum like retention in care and viral suppression at 12 months. Moreover, other factors predictive of care continuum outcomes can be used to improve D2C strategies.

Implementing a Surveillance-Based Approach to Create a Statewide Viral Clearance Cascade for Hepatitis C Among People With HIV and HCV Coinfection in Connecticut

OBJECTIVES

Highly effective direct-acting antiviral medications have made it feasible to achieve elimination of hepatis C virus (HCV), including for people with HIV and HCV coinfection. The Centers for Disease Control and Prevention offers guidance for a laboratory surveillance-based HCV viral clearance cascade, which allows public health departments to track the outcomes of people with HCV based on the following steps: ever infected, virally tested, initial infection, and cured or cleared. We examined the feasibility of this approach among people with HIV and HCV coinfection in Connecticut.

METHODS

We matched an HIV surveillance database, which included cases from the enhanced HIV/AIDS Reporting System as of December 31, 2019, and the HCV surveillance database, the Connecticut Electronic Disease Surveillance System, to define a cohort of coinfected people. We used HCV laboratory results obtained from January 1, 2016, through August 3, 2020, to determine HCV status.

RESULTS

Of 1361 people who were ever infected with HCV as of December 31, 2019, 1256 (92.3%) received HCV viral testing, 865 of 1256 people tested (68.9%) were HCV infected, and 336 of 865 infected people (38.8%) were cleared or cured. People who had undetectable HIV viral loads at most recent HIV test (<200 copies/mL) were more likely than those with detectable HIV viral loads to achieve HCV cure (P = .02).

CONCLUSIONS

A surveillance-based approach that includes data based on the Centers for Disease Control and Prevention HCV viral clearance cascade is feasible to implement, can help track population-level outcomes longitudinally, and can help identify gaps to inform HCV elimination strategies.

Study protocol for data to suppression (D2S): a cluster-randomised, stepped-wedge effectiveness trial of a reporting and capacity-building intervention to improve HIV viral suppression in housing and behavioural health programmes in New York City

INTRODUCTION

With progress in the 'diagnose', 'link' and 'retain' stages of the HIV care continuum, viral suppression (VS) gains increasingly hinge on antiretroviral adherence among people with HIV (PWH) retained in care. The Centers for Disease Control and Prevention estimate that unsuppressed viral load among PWH in care accounts for 20% of onward transmission. HIV intervention strategies include 'data to care' (D2C)-using surveillance to identify out-of-care PWH for follow-up. However, most D2C efforts target care linkage, not antiretroviral adherence, and limit client-level data sharing to medical (versus support-service) providers. Drawing on lessons learnt in D2C and successful local pilots, we designed a 'data-to-suppression' intervention that offers HIV support-service programmes surveillance-based reports listing their virally unsuppressed clients and capacity-building assistance for quality-improvement activities. We aimed to scale and test the intervention in agencies delivering Ryan White HIV/AIDS Programme-funded behavioural health and housing services.

METHODS AND ANALYSIS

To estimate intervention effects, this study applies a cross-sectional, stepped-wedge design to the intervention's rollout to 27 agencies randomised within matched pairs to early or delayed implementation. Data from three 12-month periods (pre-implementation, partial implementation and full implementation) will be examined to assess intervention effects on timely VS (within 6 months of a report listing the client as needing follow-up for VS). Based on projected enrolment (n=1619) and a pre-implementation outcome probability of 0.40-0.45, the detectable effect size with 80% power is an OR of 2.12 (relative risk: 1.41-1.46).

ETHICS AND DISSEMINATION

This study was approved by the New York City Department of Health and Mental Hygiene's institutional review board (protocol: 21-036) with a waiver of informed consent. Findings will be disseminated via publications, conferences and meetings including provider-agency representatives.

TRIAL REGISTRATION NUMBER

NCT05140421.

Assessing HIV Pre-exposure Prophylaxis Uptake and Retention Amongst Young Females in Gauteng Province

Although roll-out of HIV pre-exposure prophylaxis (PrEP) has been reported to have changed contexts of HIV risk in areas where it was well-implemented. The rate of its uptake and retention amongst young females has not been described in Gauteng Province. This paper aimed at assessing PrEP uptake and retention among young females in Gauteng Province. Total of young females who tested HIV across five clinics from 01/January/2017 to 31/December/2020 was 19,671 with 17,937 tested HIV negative. Of the HIV tested negative, PrEP was initiated to 1307 (7%). The analysis revealed that 27% of young females returned for their first follow up visit after PrEP initiation, while third month declined to 14%, fourth month to 11%, and fifth month to 3%, sixth month to 2% and seventh month at 1% and from the eighth month, the rate of follow up was 0%. Uptake and retention of PrEP was low among young females as measured against the total tested HIV negative.

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.

Overcoming Challenges to HIV Medical Care-seeking and Treatment Among Data-to-Care Program Clients in Baton Rouge and New Orleans, Louisiana

ABSTRACT

Data to Care (D2C) uses US public health surveillance data to identify persons with diagnosed HIV who are not receiving adequate medical care. These persons are linked to care and ancillary social services through personalized outreach. We conducted semistructured interviews with 36 adults with HIV in Louisiana who were engaged for the first time or reengaged back into HIV care through D2C efforts. Before D2C program staff contact, nearly 40% were not contemplating HIV care. Program clients cited barriers to HIV care, including difficulties with appointment scheduling and transportation, health care service and drug costs, low motivation, and competing non-HIV health needs. Thirty-four of the 36 clients said that D2C staff helped them overcome these barriers. Clients also described psychosocial support from D2C staff. After receiving D2C program assistance, more than 90% of clients reported consistently receiving HIV medical care and taking medications. Our findings suggest that D2C staff successfully identified client needs and provided tailored assistance.

Nurse‐led hospital‐to‐community care, clinical outcomes for people living with HIV and health‐related social needs

AIMS

To evaluate whether patients with HIV enrolled in Linkage to Care (hospital-based only) or Linkage to Care Plus (nurse-led hospital-to-community transitional care) programmes fare better on clinical outcomes; and to investigate how factors such as substance use, mental health or health-related social needs contribute to these outcomes.

BACKGROUND

Social determinants of health contribute to poor HIV outcomes such that only 57% of people living with HIV have achieved the goal of viral suppression nationally, and 50% are retained in clinical care. The programmes evaluated here aimed to increase HIV appointment attendance, retention in care, viral suppression and decrease acute care utilization and mitigate social needs via hospital-to-community transitional support.

DESIGN

A retrospective observational cohort study.

METHODS

We conducted a retrospective patient chart review abstracting data over three time periods between 2017 and 2020 to conduct this longitudinal programme evaluation.

RESULTS

Both programmes had meaningful effects on increasing HIV appointment attendance and viral suppression; Linkage to Care Plus experienced the largest gains. Older age was associated with viral suppression, and housing insecurity and mental health conditions were associated with increased emergency department utilization.

CONCLUSION

Hospital-only and nurse-led hospital-to-community transitional care programmes can positively influence HIV care outcomes. There is a need for enhanced attention and accountability related to health-related social needs, especially housing, and mental and behavioural health, to end the HIV epidemic.

IMPACT

Globally, we are striving to end the HIV epidemic with evidence-informed interventions. The nurse-led hospital-to-community and the hospital-only interventions evaluated here improved HIV outcomes with most gains realized by the nurse-led transitional care model. Integrating lessons from these programmes, with increased attention and accountability for addressing social needs, can improve practice and policies to achieve programmatic and national goals related to HIV and other diseases, and more critically, to meet the goals of the people we serve.

PATIENT OR PUBLIC CONTRIBUTION

Patients, staff and leadership at the University of Maryland Institute of Human Virology JACQUES Initiative and University of Maryland Medical Center THRIVE clinic contributed to the design and implementation of the programmes and informed the programme evaluation study.

"Take care of their hierarchy of needs first": strategies used by data-to-care staff to address barriers to HIV care engagement

Data-to-Care (D2C) is a public health strategy designed to engage out-of-care (OOC) persons with HIV (PWH) in HIV care. OOC PWH are identified through review of state and local HIV data and engaged in care through individualized efforts that address barriers to HIV care. Perspectives of D2C program staff can contribute to D2C program development and sustainability. We conducted semi-structured interviews in 2017 with 20 D2C program staff from Louisiana (n = 10) and Virginia (n = 10), states with distinct D2C programs. We used content and thematic analysis to analyze interview transcripts. In both states, common barriers to care for OOC PWH include limited transportation, stigma, substance use, poverty, homelessness, and mental illness. To address these barriers and engage OOC clients in HIV care, staff and programs provided transportation vouchers and housing assistance, integrated substance use and mental health services into care engagement processes, provided empathy and compassion, and assessed and addressed basic unmet needs. Identifying and addressing social and structural barriers to HIV care is a critical and often a necessary first step in engaging OOC clients in HIV care. These findings can be used for D2C program design and implementation, facilitating engagement in HIV care for OOC PWH.

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.

'PrEP'ing Memphis: A qualitative process evaluation of peer navigation support

BACKGROUND

HIV PrEP (pre-exposure prophylaxis) navigation comprises intervention strategies used to improve PrEP uptake via education, linkage, and follow-up/ongoing engagement. During 2016-2019, the Tennessee Department of Health (TDH) implemented a CDC-funded demonstration project ("Project PrIDE") focused on PrEP navigation in Memphis community-based organizations (CBOs) and the Shelby County Health Department (HD). A process evaluation was conducted to determine facilitators and barriers to the implementation of the Memphis-based Project PrIDE PrEP navigation activities.

METHODS

A total of fourteen in-depth qualitative interviews were conducted, with nine PrEP navigators in evaluation year 1 (2018) and five of the original navigators in evaluation year 2 (2019), to understand the navigation processes using thematic analysis.

RESULTS

Facilitators of PrEP navigation included accessing clients at testing events, accompanying clients to first appointments, rapport building with patient and clinic staff, and maintaining consistent engagement with clients. Factors impeding PrEP navigation included difficulties assessing client readiness, tracking client navigation status, and stigmatizing clinic and social experiences for clients.

CONCLUSIONS AND LESSONS LEARNED

Findings have informed the scale-up of PrEP navigation implementation statewide, along with priority setting and resource allocation for the local Ending the HIV Epidemic (EHE) initiative in Memphis.

The Cooperative Re-Engagement Controlled trial (CoRECT): A randomised trial to assess a collaborative data to care model to improve HIV care continuum outcomes

Background

Persons with HIV (PWH), aware of their HIV infection but not in care account for an estimated 42.6% of HIV transmissions in the United States. Health departments and clinics implemented a collaborative data-to-care strategy to identify persons newly out-of-care with the objective of increasing re-engagement, retention in medical care, and viral load suppression.

Methods

A multi-site, prospective randomised trial was conducted to identify newly out-of-care PWH using surveillance and clinic data in Connecticut (CT), Massachusetts (MA) and Philadelphia (PHL). All out-of-care participants were randomised to receive standard of care or an active public health intervention. Re-engagement in care was defined as having a documented CD4 count and/or HIV viral load within 90 days of randomization. Retention was defined as having at least two CD4 count and/or HIV viral load results ≥ 3 months apart within 12 months of randomization, and viral load suppression as having a viral load < 200 copies/ml within 12 months of randomization.

Findings

Between August 2016 and July 2018, 1893 out-of-care participants were randomised from CT (N = 654), MA (N = 630), and PHL (N = 609). Participants were male (69.5%), non-Hispanic Black (48.3%) and men who have sex with men (38.8%). Re-engagement within 90 days was significantly higher for the intervention group overall and in all three jurisdictions (All sites: 54.9% vs 42.1%, p < 0.0001; CT: 51.2% vs 41.9%, p = 0.02; MA: 52.7% vs 44.1%, p = 0.03; PHL 61.2% vs 40.3%, p < 0.0001). Retention in care over 12 months improved overall (p = 0.04). Median time to viral suppression was reduced overall (p = 0.0006); CT (p = 0.32), MA (p = 0.02) and PHL (p < 0.0001).

Interpretation

This trial showed that a collaborative, data-to-care strategy, and active public health intervention led by health departments significantly increases the proportion of PWH re-engaged in HIV care and may improve retention in care and decrease time to viral suppression.

Inadequate Engagement in HIV Care Among People With HIV Newly Diagnosed With a Sexually Transmitted Disease: A Multijurisdictional Analysis

BACKGROUND

A key challenge of HIV surveillance-based HIV care reengagement is locating people living with HIV (PLWH) who seem to be out of care to reengage them in care. Providing reengagement services to PLWH diagnosed with a sexually transmitted disease (STD)-individuals who are in jurisdiction and connected to the health care system-could be an efficient means of promoting HIV treatment and reducing HIV transmission.

METHODS

Early and late syphilis (ES/LS) and gonorrhea (GC) cases diagnosed in 2016 and 2017 in Louisiana, Michigan, Mississippi, Oregon, Rhode Island, and Texas were matched to each state's HIV surveillance data to determine the proportion of PLWH with these infections who (1) did not have evidence of a CD4 count or viral load in the prior ≥13 months (out of care) or (2) had a viral load ≥1500 copies/mL on their most recent HIV RNA test before STD diagnosis (viremic).

RESULTS

Previously diagnosed HIV infection was common among persons diagnosed with ES (n = 6942; 39%), LS (n = 4329; 27%), and GC (n = 9509; 6%). Among these ES, LS, and GC cases, 26% (n = 1543), 33% (n = 1113), and 29% (n = 2391) were out of HIV medical care or viremic at the time of STD diagnosis.

CONCLUSIONS

A large proportion of STD cases with prior HIV diagnosis are out of care or viremic. Integrating relinkage to care activities into STD partner services and/or the use of matching STD and HIV data systems to prioritize data to care activities could be an efficient means for relinking patients to care and promoting viral suppression.

Partnering With State Health Departments to Address Injection-Related Infections During the Opioid Epidemic: Experience at a Safety Net Hospital

Massachusetts is one of the epicenters of the opioid epidemic and has been severely impacted by injection-related viral and bacterial infections. A recent increase in newly diagnosed human immunodeficiency virus (HIV) infections among persons who inject drugs in the state highlights the urgent need to address and bridge the overlapping epidemics of opioid use disorder (OUD) and injection-related infections. Building on an established relationship between the Massachusetts Department of Public Health and Boston Medical Center, the Infectious Diseases section has contributed to the development and implementation of a cohesive response involving ambulatory, inpatient, emergency department, and community-based services. We describe this comprehensive approach including the rapid delivery of antimicrobials for the prevention and treatment of HIV, sexually transmitted diseases, systemic infections such as endocarditis, bone and joint infections, as well as curative therapy for chronic hepatitis C virus in a manner that is accessible to patients on the addiction-recovery continuum. We also provide an overview of programs that provide access to medications for OUD, harm reduction services including overdose education, and distribution of naloxone. Finally, we outline lessons learned to inform initiatives in other settings.

Practice Transformation in HIV Primary Care: Perspectives of Coaches and Champions in the Southeast United States

INTRODUCTION/OBJECTIVES

Across the United States, and particularly in the South, there is an urgent need to improve health outcomes for people with HIV. In response, the Southeast AIDS Education & Training Center (AETC) conducted a 4-year Practice Transformation (PT) initiative (2015-2018) in 12 mostly primary care clinics across 4 states in the region. Drawing on the leadership of PT facilitators ("coaches") from AETC partner sites throughout the region and specific clinic staff members ("champions"), clinics worked toward self-selected organizational goals to increase their HIV care capacity and improve HIV health outcomes.

METHODS

To explore coaches' and champions' experiences and perspectives of PT, we conducted 2 focus group sessions, 1 tailored for coaches (n = 5) and another for champions (n = 9).

RESULTS

Content analysis of qualitative data revealed 4 major themes around coaches' and champions' experiences and perspectives of PT. These themes include Challenges, Facilitators, Successes, and Suggestions for PT Improvement.

CONCLUSION

Primary care and infectious diseases/HIV clinics can help improve HIV Care Continuum outcomes through increasing their capacity to serve the needs of their clients, as facilitated through coaches and clinic champions. Since no single clinic or clinic patient population is alike, it is important work within organizations to address specific needs and leverage unique skillsets. Future PT initiatives can learn from experiences of this PT program to optimize the effectiveness of their programs.

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.

Epidemiology of HIV in the USA: epidemic burden, inequities, contexts, and responses

The HIV epidemic in the USA began as a bicoastal epidemic focused in large cities but, over nearly four decades, the epidemiology of HIV has changed. Public health surveillance data can inform an understanding of the evolution of the HIV epidemic in terms of the populations and geographical areas most affected. We analysed publicly available HIV surveillance data and census data to describe: current HIV prevalence and new HIV diagnoses by region, race or ethnicity, and age; trends in HIV diagnoses over time by HIV acquisition risk and age; and the distribution of HIV prevalence by geographical area. We reviewed published literature to explore the reasons for the current distribution of HIV cases and important disparities in HIV prevalence. We identified opportunities to improve public health surveillance systems and uses of data for planning and monitoring public health responses. The current US HIV epidemic is marked by geographical concentration in the US South and profound disparities between regions and by race or ethnicity. Rural areas vary in HIV prevalence; rural areas in the South are more likely to have a high HIV prevalence than rural areas in other US Census regions. Ongoing disparities in HIV in the South are probably driven by the restricted expansion of Medicaid, health-care provider shortages, low health literacy, and HIV stigma. HIV diagnoses overall declined in 2009-18, but HIV diagnoses among individuals aged 25-34 years increased during the same period. HIV diagnoses decreased for all risk groups in 2009-18; among men who have sex with men (MSM), new diagnoses decreased overall and for White MSM, remained stable for Black MSM, and increased for Hispanic or Latino MSM. Surveillance data indicate profound and ongoing disparities in HIV cases, with disproportionate impact among people in the South, racial or ethnic minorities, and MSM.

Improving Engagement in HIV Care Using a Data-to-Care and Patient Navigation System in Louisiana, United States

An estimated 57% of persons living with HIV (PLWH) in the United States are not connected to regular medical care or have lapsed from regular care (Centers for Disease Control and Prevention, 2018), increasing risk of HIV progression and transmission and delaying viral suppression. The state of Louisiana has consistently ranked in the top five US states for HIV case rates. We evaluated the impact of a combined data-to-care and patient navigation system that was implemented in 3 cities in Louisiana from 2013 to 2015. The program, LA Links, used a surveillance system to identify PLWH who were not in regular health care and connected them to a patient navigator. During the intervention period, persons who lapsed from care were 17% more likely to reengage in care than persons in the comparison group, and persons newly diagnosed during the intervention period were 56% more likely to link to care.

A Nurse-Led Initiative to Improve Implementation of HIV Preconception Care Services

ABSTRACT

United States guidelines recommend preconception care (PCC) as an integral part of primary care to improve maternal and fetal/newborn outcomes and promote planned pregnancies. Persons living with HIV have additional, specialized needs for PCC. However, PCC is not reliably integrated in HIV care, and few studies have examined strategies to improve the provision of PCC services. We describe a successful, nurse-led initiative that incorporated collaborative strategic planning in conjunction with staff education and continuous quality improvement to strengthen implementation of PCC in a small urban HIV care clinic. Key features of this project included consensus building, training, and action planning with clinic staff; addressing clinic-specific barriers; and providing ongoing support/technical assistance. Continuous quality improvement reviews at 12, 18, and 36 months demonstrated improved and sustained implementation of PCC services for women and men. Our experiences serve as a model for HIV primary care clinics working to advance implementation of PCC services.

Comparison of effectiveness and cost for different HIV screening strategies implemented at large urban medical centre in the United States

INTRODUCTION

Incident HIV infections persist in the United States (U.S.) among marginalized populations. Targeted and cost-efficient testing strategies can help in reaching HIV elimination. This analysis compares the effectiveness and cost of three HIV testing strategies in a high HIV burden area in the U.S. in identifying new HIV infections.

METHODS

We performed a cost analysis comparing three HIV testing strategies in Chicago: (1) routine screening (RS) in an inpatient and outpatient setting, (2) modified partner services (MPS) among networks of the recently HIV infected and diagnosed, and (3) a respondent drive sampling (RDS)-based social network (SN) approach targeting young African-American men who have sex with men. All occurred at the same academic medical centre during the following times: routine testing, 2011 to 2016; MPS, 2013 to 2016; SN: 2013 to 2014. Costs were in 2016 dollars and included personnel, HIV testing, training, materials, overhead. Outcomes included cost per test, HIV-positive test and new diagnosis. Sensitivity analyses were performed to assess the impact of population demographics.

RESULTS

The RS programme completed 57,308 HIV tests resulting in 360 (0.6%) HIV-positive tests and 165 new HIV diagnoses (0.28%). The MPS completed 146 HIV tests, resulting in 79 (54%) HIV-positive tests and eight new HIV diagnoses (5%). The SN strategy completed 508 HIV tests, resulting in 210 (41%) HIV-positive tests and 37 new HIV diagnoses (7.2%). Labour accounted for the majority of costs in all strategies. The estimated cost per new HIV diagnosis was $16,773 for the RS programme, $61,418 for the MPS programme and $15,683 for the SN testing programme. These costs were reduced for the RS and MPS strategies in sensitivity analyses limiting testing efficacy to the highest prevalence patient populations ($2,841 and $33,233 respectively).

CONCLUSIONS

The SN strategy yielded the highest proportion of new diagnoses, followed closely by the MPS programme. Both the SN strategy and RS programme were comparable in the cost per new diagnosis. A simultaneous approach that consists of RS in combination with SN testing may be most effective for identifying new HIV infections in settings with heterogeneous epidemics with both high rates of HIV prevalence and HIV testing.

Practical and Ethical Concerns in Implementing Enhanced Surveillance Methods to Improve Continuity of HIV Care: Qualitative Expert Stakeholder Study

BACKGROUND

Retention in HIV care is critical to maintaining viral suppression and preventing further transmission, yet less than 50% of people living with HIV in the United States are engaged in care. All US states have a funding mandate to implement Data-to-Care (D2C) programs, which use surveillance data (eg, laboratory, Medicaid billing) to identify out-of-care HIV-positive persons and relink them to treatment.

OBJECTIVE

The purpose of this qualitative study was to identify and describe practical and ethical considerations that arise in planning for and implementing D2C.

METHODS

Via purposive sampling, we recruited 43 expert stakeholders-including ethicists, privacy experts, researchers, public health personnel, HIV medical providers, legal experts, and community advocates-to participate in audio-recorded semistructured interviews to share their perspectives on D2C. Interview transcripts were analyzed across a priori and inductively derived thematic categories.

RESULTS

Stakeholders reported practical and ethical concerns in seven key domains: permission and consent, government assistance versus overreach, privacy and confidentiality, stigma, HIV exceptionalism, criminalization, and data integrity and sharing.

CONCLUSIONS

Participants expressed a great deal of support for D2C, yet also stressed the role of public trust and transparency in addressing the practical and ethical concerns they identified.

HIV Data to Care-Using Public Health Data to Improve HIV Care and Prevention

BACKGROUND

"Data to Care" (D2C) is a public health strategy that uses surveillance and other data to improve continuity of HIV care for persons with HIV (PWH) by identifying those who are in need of medical care or other services and facilitating linkage to these services. The primary goal of D2C is to increase the number of PWH who are engaged in care and virally suppressed.

METHODS

Data to Care can be implemented using several approaches. Surveillance-based D2C is usually initiated by health departments, using HIV surveillance and other data to identify those not in care. Health care providers may also initiate D2C by identifying patients who may have fallen out of care and working collaboratively with health departments to investigate, locate, and relink the patients to medical care or other needed services.

RESULTS

Although D2C is a relatively new strategy, health department D2C programs have reported both promising results (eg, improved surveillance data quality and successful linkage to or re-engagement in care for PWH) and challenges (eg, incomplete or inaccurate data in surveillance systems, barriers to data sharing, and limitations of existing data systems).

CONCLUSIONS

Data to Care is expected to enable health departments to move closer toward achieving national HIV prevention goals. However, additional information on appropriate implementation practices at each step of the D2C process is needed. This JAIDS Special Supplement explores how CDC funding to state health departments (eg, technical assistance and demonstration projects), and partnerships across federal agencies, are advancing our knowledge of D2C.

Data to Care: Lessons Learned From Delivering Technical Assistance to 20 Health Departments

BACKGROUND

Data to Care (D2C) is a public health strategy that uses HIV surveillance and other data to identify persons living with HIV who are "not in care" to link them to medical care or other services. To support health department implementation of D2C, the Centers for Disease Control and Prevention supported direct technical assistance (TA) to build health department D2C capacity.

METHODS

Between 2013 and 2017, 2 contracting organizations worked with the Centers for Disease Control and Prevention to provide intensive D2C TA to 20 US health departments. A requirement for applying for TA was the mandatory reporting of all CD4 T-lymphocyte and HIV viral load test results by laboratories to the health department's HIV surveillance system. Health department selection criteria included organizational factors; jurisdiction laws/policies about data confidentiality and sharing; and HIV morbidity level.

RESULTS

Peer-to-peer consultation, technical consultation, training, information transfer, materials development, materials distribution, and technology transfer were methods used for delivering TA based on the health department's needs and preferences. TA supported health department progress in areas such as confidentiality and data security, stakeholder engagement, quality of HIV surveillance data, data sharing, staffing resources, creating "not-in-care" lists, and program evaluation.

CONCLUSION

Developing D2C programs is not a linear process, and there is no one standardized approach. Health departments made the most rapid progress when TA included peer-to-peer support among health departments. Participation in this project facilitated, in some cases for the first time, collaboration between staff across HIV surveillance, prevention, and care programs.

Expert stakeholders' perspectives on a Data-to-Care strategy for improving care among HIV-positive individuals incarcerated in jails

Data-to-Care (D2C) uses surveillance data (e.g., laboratory, Medicaid billing) to identify out-of-care HIV-positive persons to re-link them to care. Most US states are implementing D2C, yet few studies have explored stakeholders' perspectives on D2C, and none have addressed these perspectives in the context of D2C in jail. This article reports findings from qualitative, semi-structured interviews conducted with expert stakeholders regarding their perspectives on the ethical challenges of utilizing D2C to understand and improve continuity of care among individuals incarcerated in jails. Participants included 47 professionals with expertise in ethics and privacy, public health and HIV care, the criminal justice system, and community advocacy. While participants expressed a great deal of support for extending D2C to jails, they also identified many possible risks. Stakeholders discussed many issues specific to D2C in jails, such as heightened stigma in the jail setting, the need for training of jail staff and additional non-medical community-based resources, and the high priority of this vulnerable population. Many experts suggested that the actual likelihood of benefits and harms would depend on contextual details. Implementation of D2C in jails may require novel strategies to minimize risk of disclosing out-of-care patients' HIV status.

HIV Care for Patients With Complex Needs: A Controlled Evaluation of a Walk-In, Incentivized Care Model

BACKGROUND

New approaches are needed to provide care to persons with HIV who do not engage in conventionally organized HIV clinics. The Max Clinic in Seattle, Washington, is a walk-in, incentivized HIV care model located in a public health STD clinic that provides care in collaboration with a comprehensive HIV primary care clinic (the Madison Clinic).

METHODS

We compared outcomes in the first 50 patients enrolled in Max Clinic and 100 randomly selected matched Madison Clinic control patients; patients in both groups were virally unsuppressed (viral load [VL] >200 copies/mL) at baseline. The primary outcome was any VL indicating viral suppression (≥1 VL <200 copies/mL) during the 12 months postbaseline. Secondary outcomes were continuous viral suppression (≥2 consecutive suppressed VLs ≥60 days apart) and engagement in care (≥2 medical visits ≥60 days apart). We compared outcomes in the 12 months pre- and postbaseline and used generalized estimating equations to compare changes in Max vs control patients, adjusting for unstable housing, substance use, and psychiatric disorders.

RESULTS

Viral suppression improved in both groups pre-to-post (20% to 82% Max patients; P < .001; and 51% to 65% controls; P = .04), with a larger improvement in Max patients (adjusted relative risk ratio [aRRR], 3.2; 95% confidence interval [CI], 1.8-5.9). Continuous viral suppression and engagement in care increased in both groups but did not differ significantly (continuous viral suppression: aRRR, 1.5; 95% CI, 0.5-5.2; engagement: aRRR, 1.3; 95% CI, 0.9-1.9).

CONCLUSIONS

The Max Clinic improved viral suppression among patients with complex medical and social needs.

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.