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AJPH.2017.304069

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RESEARCH AND PRACTICE
Integrating HIV Surveillance and Field Services:
Data Quality and Care Continuum in King County,
Washington, 2010–2015
Julia E. Hood, PhD, MPH, David A. Katz, PhD, MPH, Amy B. Bennett, MPH, Susan E. Buskin, PhD, Julia C. Dombrowski, MD, MPH,
Stephen E. Hawes, PhD, and Matthew R. Golden, MD, MPH
Objectives. To assess how integration of HIV surveillance and field services might
influence surveillance data and linkage to care metrics.
Methods. We used HIV surveillance and field services data from King County,
Washington, to assess potential impact of misclassification of prior diagnoses on
numbers of new diagnoses. The relationship between partner services and linkage to
care was evaluated with multivariable log-binomial regression models.
Results. Of the 2842 people who entered the King County HIV Surveillance System in
2010 to 2015, 52% were newly diagnosed, 41% had a confirmed prior diagnosis in
another state, and 7% had an unconfirmed prior diagnosis. Twelve percent of those
classified as newly diagnosed for purposes of national HIV surveillance self-reported
a prior HIV diagnosis that was unconfirmed. Partner services recipients were more likely
than nonrecipients to link to care within 30 days (adjusted risk ratio [RR] = 1.10; 95%
confidence interval [CI] = 1.03, 1.18) and 90 days (adjusted RR = 1.07; 95% CI = 1.01, 1.14)
of diagnosis.
Conclusions. Integration of HIV surveillance, partner services, and care linkage efforts
may improve the accuracy of HIV surveillance data and facilitate timely linkage to care.
(Am J Public Health. Published online ahead of print October 19, 2017: e1–e6. doi:10.
2105/AJPH.2017.304069)
T
he purpose of HIV surveillance in the
United States is changing. The HIV
surveillance system was initially designed to
monitor the growth of the HIV epidemic and
define the populations most affected by HIV/
AIDS. Scientific evidence demonstrating that
effective treatment prevents HIV transmission,1 that early treatment initiation improves clinical outcomes,2 and that a large
number of people living with HIV are not
engaged with care3 has led to fundamental
changes in HIV prevention, with a new
emphasis on case finding and treatment.
This emphasis has resulted in an increasing
reliance on surveillance data to direct public
health interventions, a strategy the Centers for
Disease Control and Prevention (CDC) has
called “data to care.”4 In this new paradigm,
health department surveillance programs
track the individuals who currently live
within their jurisdictions and their current
Published online ahead of print October 19, 2017
health status, rather than simply collecting
information on case numbers and demographic characteristics, and then use those data
to promote engagement with HIV care and
viral suppression.
Surveillance data are collected and managed by local and state health departments,
and these departments submit data without
identifiers to the CDC. The CDC then
uses nonname identifiers to attempt to
de-duplicate cases. However, without a centralized repository of truly identifiable case
surveillance data, cross-jurisdictional migration can result in duplicate case reporting.5 To
varying extents, health department HIV
programs investigate each case that newly
enters their local surveillance system with the
goals of (1) determining whether a newly
reported case is a new diagnosis and characterizing the epidemiological features of that
case, (2) ensuring that newly diagnosed individuals successfully link to medical care, and
(3) providing partner services, interventions
designed to deliver HIV testing, other prevention services (including preexposure
prophylaxis referrals6), and treatment (if
needed) to the sexual and needle-sharing
partners of people newly diagnosed with
HIV.
In many areas, these 3 goals are not well
integrated. In some instances, each goal is
addressed independently through separate
surveillance activities, partner services, and
links to care teams. Starting in 2001, the
Public Health—Seattle & King County
(PHSKC) HIV/STD (Sexually Transmitted
Disease) Program began integrating surveillance and field services with the objective
of more efficiently achieving each of the 3
goals.7 We have previously described the
outcomes of partner services efforts in
identifying new cases of HIV infection in
King County.8,9 Here we describe our approach to managing newly reported cases
and evaluate how integrating HIV surveillance with field services affects surveillance
ABOUT THE AUTHORS
Julia E. Hood, Amy B. Bennett, Susan E. Buskin, Julia C. Dombrowski, and Matthew R. Golden are with the HIV/STD
Program, Public Health—Seattle & King County, Seattle, WA. David A. Katz is with the Department of Medicine,
University of Washington, Seattle. Stephen E. Hawes is with the Department of Epidemiology, University of Washington,
Seattle.
Correspondence should be sent to Julia E. Hood, PhD, MPH, HIV/STD Program, Public Health—Seattle & King County, 401
5th Ave, Suite 1152, Seattle, WA 98104 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by
clicking the “Reprints” link.
This article was accepted August 5, 2017.
doi: 10.2105/AJPH.2017.304069
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Hood et al.
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data quality and linkage to care and partner
services indicators.
METHODS
HIV/AIDS reporting requirements in
Washington State have evolved over time.
Prior to 1999, only AIDS and symptomatic
HIV cases were reportable by name. From
1999 to 2006, new HIV diagnoses were reportable, but PHSKC used a confidential
code instead of names to identify cases. Since
2006, Washington State law has required that
health care providers report by name all newly
diagnosed HIV and AIDS patients and that
laboratories report by name tests confirming
HIV infections, HIV viral loads (detectable
and undetectable), and CD4+T-lymphocyte
test results of any value.10
The majority of cases are found initially
through receipt of HIV-indicative laboratory
test results. Most laboratories and health care
facilities in Washington submit laboratory data
electronically to the Washington State Department of Health. All data are matched bimonthly against the Enhanced HIV/AIDS
Reporting System (eHARS), a Web-based
platform that enables HIV surveillance data to
be securely entered, stored, managed, and reported to the CDC. Laboratory data that match
a previously existing case are retained in the
Laboratory Tracking Database with a corresponding identifier and subsequently uploaded
into eHARS and linked to existing records
corresponding to the case. Laboratory results
that do not match a known case are returned to
local health jurisdictions (e.g., PHSKC) based
on the geographic location of the ordering
provider/facility for follow-up investigations.
The PHSKC field services unit is divided
into teams assigned to specific infections and
populations. The HIV partner services team is
responsible for promoting HIV testing among
the sexual and needle-sharing partners of
newly diagnosed individuals and ensuring that
individuals with newly diagnosed HIV are
linked to HIV medical care. The field services
team consists of 2 disease intervention specialists (1.4 full-time equivalent) and a surveillance coordinator. The disease intervention
specialist with primary responsibility for the
team’s work is funded through HIV surveillance and partner services grants and shares an
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Peer Reviewed
office with the HIV surveillance coordinator
in the PHSKC STD Clinic.
When a potentially new HIV case is
identified, the team assesses whether the case
was previously recorded in the Washington
State eHARS. If the case does not already
exist in eHARS, staff members review the
individual’s medical records to collect contact
and demographic information and clinical
and epidemiological data. PHSKC has an
agreement with the majority of the large
health care organizations in King County that
provides staff members with remote access to
electronic medical records. If, in the course of
a chart review or other investigation activities
(including partner services interviews), staff
members find evidence suggesting that an
individual moved to Washington after being
diagnosed in another state, they contact the
surveillance team in the other state to determine the individual’s earliest HIV diagnosis
date and residence at diagnosis, resolve
missing or conflicting case data, and discuss
the individual’s probable current residence.
The field services team attempts to provide
partner services to all newly diagnosed HIV
individuals and ensure linkage to care for all
unsuppressed individuals with newly reported
infections. The King County disease intervention specialists have not undergone any
formal training in linkage to care, nor do they
use a defined behavioral intervention to
promote linkage to care. Investigations of
people with newly reported HIV infections
are not closed until care linkage is confirmed
or until the disease intervention specialists,
disease intervention specialist supervisor, and
program medical officer determine that additional efforts to promote linkage would
be futile; the disease intervention specialists
maintain a list of inactive cases in which individuals never linked to care and periodically
assess care engagement, incarceration, and
out-of-jurisdiction migration.
We define confirmed linkages on the basis
of laboratory tests ordered by medical providers and reported to the surveillance team,
medical record reviews, or direct communications with health care facilities verifying
that an HIV care visit occurred. Newly diagnosed individuals (without evidence of an
existing HIV care provider) are invited to
participate in the PHSKC One-on-One
program, which allows individuals to be seen
by a public health medical provider for
Hood et al.
a clinical assessment, initial laboratory evaluation, and counseling, usually within several
days of diagnosis.11 Ensuring that all individuals link to care is a central goal of the
One-on-One program.
The HIV program’s medical officer, surveillance epidemiologists, field services supervisor, and disease intervention specialists
who provide HIV partner services meet
monthly to discuss the status of all newly reported cases, facilitating exchange of information between field services, surveillance,
and medical staff and allowing the team to
develop strategies to assist people with HIV
infection thought to be at high risk for treatment failure or HIV transmission and partners
who are at high risk for HIV acquisition.
Data Sources
Several data sources were used in our analyses: eHARS, reported laboratory records,
STD Clinic records, electronic medical records, and partner services databases. We used
the following eHARS elements in our analysis:
the year the individual entered the King
County surveillance system, date and facility of
the individual’s HIV diagnosis, date of birth,
sex at birth, and risk transmission category.
Date of specimen collection on reported laboratory records was assumed to be a marker for
an HIV care visit and was used to evaluate
linkage to care. One-on-One visit records
were used to identify individuals who participated in the program.
PHSKC has used a series of locally developed databases to capture partner services
interview data and to record investigative
notes. In 2014, we started assigning a disposition to each newly reported person indicating
whether the person was newly diagnosed or
had confirmed or unconfirmed evidence of
being diagnosed within or outside the United
States. Prior to 2014, this information was
captured less systematically in other fields.
Analysis
Our analysis included adults who entered
the King County surveillance system between
2010 and 2015. For the purposes of national
HIV surveillance, individuals with evidence of
a prior diagnosis not confirmed by another
jurisdiction’s HIV surveillance program are
classified as newly diagnosed. In our analysis,
we differentiated individuals with unconfirmed
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RESEARCH AND PRACTICE
evidence of a prior diagnosis (obtained through
self-report or medical record review) from
individuals who appeared to truly have been
newly diagnosed.
Our analysis involved multiple components. First, we evaluated relative proportions
and temporal trends in the number of new
diagnoses and imported cases entering the
King County surveillance system between
2010 and 2015. Second, we compared the
characteristics of cases reported as new diagnoses for the purposes of national HIV
surveillance, cases newly diagnosed without
any evidence of a prior diagnosis, and cases
with unconfirmed evidence of a prior diagnosis; differences between the 2 latter
groups were assessed via the c2 test. All
subsequent analyses were restricted to newly
diagnosed cases without any evidence of
a prior diagnosis.
Third, we evaluated the percentage of
newly diagnosed individuals who participated
in partner services and One-on-One programs. Finally, we determined the percentages (overall and by receipt of partner services)
of newly diagnosed King County individuals
who appeared to link to HIV care within 30,
60, 90, and 365 days of their diagnosis. We
used multivariable log-binomial regression
models to generate adjusted relative risk ratios
(RRs) characterizing the relationship between receiving partner services and linking
to care within 30, 60, 90, and 365 days of
diagnosis after adjustment for year of diagnosis, type of diagnosing facility, age at
diagnosis, sex at birth, race/ethnicity, nativity
status, and risk transmission category. We
used SAS version 9.4 (SAS Institute, Cary,
NC) in conducting all of our analyses.
sex with men, and 28% were known to have
been born outside the United States (Table 1).
People who were reported (for the purposes of
TABLE 1—Characteristics of People Entering the HIV Surveillance System: King County, WA,
2010–2015
Characteristic
Reported New
Diagnosis
(n = 1670),
No. (Column %)
No Evidence of Prior
Diagnosis
(n = 1474),
No. (Column %)
Evidence of Prior
Diagnosis
(n = 196),
No. (Row %)
Male
Female
1449 (87)
221 (13)
1313 (89)
161 (11)
136 (9)
60 (27)
13–19
32 (2)
28 (2)
20–29
473 (28)
439 (29)
34 (7)
30–39
523 (31)
456 (31)
67 (13)
40–49
381 (23)
327 (22)
54 (14)
50–59
200 (12)
175 (12)
25 (13)
‡ 60
61 (4)
49 (3)
12 (20)
Race/ethnicity
Non-Hispanic White
915 (55)
861 (58)
53 (6)
Non-Hispanic Black
329 (20)
240 (16)
89 (27)
Hispanic
237 (14)
222 (15)
17 (7)
Asian
121 (7)
85 (6)
35 (29)
12 (1)
12 (1)
0 (0)
Pacific Islander
13 (1)
12 (1)
1 (8)
Multiracial
43 (3)
42 (1)
1 (2)
1098 (66)
1048 (70)
58 (5)
Foreign-born
465 (28)
335 (23)
131 (28)
Unknown
107 (6)
91 (7)
7 (7)
1105 (66)
1029 (70)
77 (7)
5 (9)
Age at HIV diagnosis, y
American Indian/Alaska
.04
4 (13)
< .001
Native
Nativity
US-born
< .001
< .001
Risk transmission category
MSM
IDU
57 (3)
52 (4)
MSM/IDU
118 (7)
113 (8)
5 (4)
Heterosexual
Unknown
109 (7)
281 (17)
82 (6)
198 (13)
27 (25)
82 (29)
678 (41)
614 (41)
63 (9)
Outpatient
Between 2010 and 2015, 2842 people
newly entered the King County HIV Surveillance System. Of those individuals, 1670
(59%) were classified as being newly diagnosed
with HIV for the purposes of national HIV
surveillance; 196 of these 1670 individuals
(12%) self-reported a prior HIV diagnosis or
had information in their medical record indicating that they had previously been diagnosed with HIV. Of individuals classified as
newly diagnosed for the purposes of national
HIV surveillance, 87% were male, 55% were
P
< .001
Sex at birth
< .001
Diagnosing facility
RESULTS
Published online ahead of print October 19, 2017
non-Hispanic White, 59% were between 20
and 40 years of age at the time of their diagnosis, 73% were known to be men who have
PHSKC STD Clinic
351 (21)
337 (23)
17 (5)
HIV/MSM specialty clinica
309 (19)
220 (15)
88 (29)
Inpatient
140 (8)
129 (9)
11 (8)
HIV community-based
102 (6)
102 (7)
0 (0)
56 (3)
49 (3)
6 (11)
34 (2)
24 (2)
9 (32)
organization
Emergency department/
urgent care
Other
Note. IDU = injection drug users; MSM = men who have sex with men; PHSKC = Public Health—Seattle &
King County; STD = sexually transmitted disease.
a
Refers to clinics that provide HIV care, including the Harborview Madison Clinic, as well as private
practices known to explicitly serve the LGBTQ (lesbian, gay, bisexual, transgender, queer) community.
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national HIV surveillance) to be newly diagnosed but had evidence of a prior diagnosis
were more likely to be female, non-Hispanic
Black or Asian, foreign-born, and heterosexual
than those who had no evidence of a prior
diagnosis; they were also more likely to have
had their “diagnosis” reported by an HIV care
organization.
Nearly half (48%) of the individuals entering the King County HIV Surveillance
System between 2010 and 2015 had been
previously diagnosed outside of Washington.
Of these “imported cases,” 86% had been
diagnosed in another jurisdiction within the
United States, 7% had been diagnosed outside
the country, and 7% had an unknown location of diagnosis (Figure A, available as
a supplement to the online version of this
article at http://www.ajph.org). Over this
6-year period, records corresponding to HIV
diagnoses made in all 50 states (and Puerto
400
Rico) entered the King County HIV Surveillance System.
Figure 1 presents trends in the number of
new diagnoses and imported cases in King
County, separating new diagnoses into those
reported as new for the purposes of national
surveillance (regardless of local evidence of
a previous diagnosis) and those that were new
according to all available data sources (including unconfirmed self-reports). The
number of new diagnoses declined from 2010
to 2015, concurrent with an increase in the
number of imported cases. Coinciding with
a programmatic shift toward more systematic
documentation of information regarding prior
diagnoses, the number of cases with an unknown location of a prior diagnosis declined
and the number of cases with evidence of being
diagnosed outside the United States increased.
All subsequent analyses excluded individuals with confirmed or unconfirmed
New diagnosis
(per national HIV surveillance system
criteria)
New diagnosis
(per PHSKC classification of cases)
350
Imported case
from outside United States
Imported case
(unknown location of diagnosis)
Imported case from another state
(confirmed)
Number of Cases
300
250
200
150
100
50
0
2010
2011
2012
2013
2014
2015
Year
Note. The top line (black dashed line) represents the number of “new” diagnoses that were reported to the
Centers for Disease Control and Prevention. All subsequent lines represent Public Health—Seattle & King
County (PHSKC) classifications of cases according to locally available data. Information about prior diagnoses was
more systematically collected after 2013.
FIGURE 1—Number of People Newly Entering the King County, WA, HIV Surveillance System
in 2010–2015, by Jurisdiction at Diagnosis
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Hood et al.
evidence of a prior HIV diagnosis. A total of
387 newly diagnosed individuals (26%) participated in the One-on-One program at the
STD Clinic, 56% of whom were seen in the
program within 1 week of the date their blood
was obtained for HIV testing. Disease intervention specialists attempted to contact
nearly all (98%) newly diagnosed individuals
for partner services, 84% were successfully
contacted, and 80% were interviewed. The
inability of the disease intervention specialists
to locate individuals and individuals refusing
partner services were the most common
reasons for nonreceipt of services.
The percentages of newly diagnosed individuals linked to care within 30 days and 90
days of their diagnosis increased significantly
between 2010 and 2015 (30 days: 62% to
82%, test-for-trend P < .001; 90 days: 85% to
93%, test-for-trend P = .003). Unadjusted
analyses showed that the percentages of individuals linked to care within 30 and 90 days
of diagnosis were higher among those who
had received partner services than among
those who had not (30 days: 76% vs 66%,
P < .001; 90 days: 90% vs 81%, P < .001;
Figure 2). Similarly, after control for demographic characteristics and other factors,
linkage to care within 30 and 90 days of diagnosis was significantly greater among individuals receiving versus not receiving
partner services (30 days: adjusted RR = 1.10;
95% confidence interval [CI] = 1.03, 1.18;
P = .004; 90 days: adjusted RR = 1.07; 95%
CI = 1.01, 1.14; P = .014; Figure 2).
None of the demographic characteristics
were significantly associated with linkage to
care within 30 days of diagnosis. However,
year of diagnosis and being diagnosed at the
STD Clinic, an HIV community-based organization, or an HIV care clinic were positively associated with individuals being
linked to care within 30 days.
DISCUSSION
Over the past decade, PHSKC has increasingly integrated HIV surveillance investigations with HIV partner services and
efforts to promote linkage to HIV medical
care. Our findings suggest that this process,
along with improvements in national data and
surveillance processes, has allowed our health
department to better estimate the true number
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RESEARCH AND PRACTICE
Percentage Linked to Care
100
No partner services, n = 287
Received partner services, n = 1187
80
60
40
20
0
Days of 1st care visit:
ARR(PS vs No PS)(95% CI):
30 days
60 days
90 days
365 days
1.10 (1.03, 1.18) 1.08 (1.02, 1.16) 1.07 (1.01, 1.14) 1.04 (0.98, 1.11)
Note. ARR = adjusted risk ratio; CI = confidence interval; PS = partner services. Relative risk ratios were adjusted
for age, gender, race/ethnicity, year of diagnosis, facility of diagnosis, HIV transmission category, and nativity
status.
FIGURE 2—Time From Diagnosis to Linkage to HIV Care, by Partner Services Status, Among
1474 People Newly Diagnosed with HIV: King County, WA, 2010–2015
of new HIV diagnoses in our jurisdiction. It has
also allowed us to achieve nearly universal
linkage to HIV care through a process that
relies primarily on disease intervention specialists to coordinate, monitor, and ensure
individuals’ entry into medical care.
Our findings suggest that integrating surveillance and field services improves HIV
surveillance but also highlight the challenges
facing local and national surveillance efforts.
We observed an increase in the number of
in-migrants with previously diagnosed HIV
infection and a concurrent decline in new
HIV diagnoses.
The growing number of in-migrants with
prior diagnoses (“imported cases”) likely reflects a true increase in in-migration of people living with diagnosed HIV infection
(PLWDH) into King County, an area with
a growing population.12,13 However, it may
also be a consequence of increased ascertainment of in-migration resulting from
greater efforts by local surveillance and
partner services staff to identify and confirm
prior HIV diagnoses, along with improvements in national HIV surveillance data. As
the number of PLWDH increases, newly
diagnosed HIV individuals will represent
a small and decreasing percentage of the
PLWDH population.14 If the rate of annual
interstate migration in the PLWDH population remains relatively constant, the ratio
Published online ahead of print October 19, 2017
of imported cases to newly diagnosed cases
would likely increase in many jurisdictions.
Migration has the potential to distort
surveillance data, and ongoing changes in
surveillance data quality complicate the interpretation of observed trends. Prevalent
cases that move across state lines are at risk for
being erroneously reported as new diagnoses.
The CDC attempts to de-duplicate HIV cases
through a process called the “Routine Interstate Duplicate Review” or “RIDR,” but
this process probably misses an unknown
proportion of duplicate case reports.5,15 We
observed a decline in newly diagnosed cases
alongside an increase in imported cases, which
raises the possibility that ascertainment of
in-migration has improved over time and that
some unknown proportion of the observed
decline in new diagnoses may be an artifact
of changing surveillance processes and data
quality. Recognition of this possibility should
prompt caution when interpreting trends in
new diagnoses. Additional efforts are needed
to understand how changes in the surveillance
system affect epidemiologic monitoring.
Migration of individuals from outside the
United States poses a separate but related
problem. For surveillance purposes, individuals with an HIV diagnosis predating
their entry into the United States are generally
classified as being newly diagnosed. As we
have reported previously,16 classification of
AJPH
such cases as new has led to an almost 12%
overestimate of new diagnoses and inflated
estimates of the proportions of new diagnoses
occurring among non-Hispanic Blacks and
Asians, women, and heterosexuals.16 Although imported cases of HIV need to be
included in surveillance data to provide an
accurate estimate of prevalent cases, efforts to
evaluate local transmission patterns would
ideally exclude such cases as they are not
avertable through local prevention activities.
From a practical perspective, we have
identified a number of strategies that can
improve a surveillance program’s ability to
distinguish imported cases from new diagnoses. These strategies include establishing
dedicated staffing, negotiating electronic access to medical record systems, establishing
routine calls with jurisdictions that have large
PLWDH populations to determine individuals’ place of diagnosis and residence,
and integrating surveillance into HIV partner
services. Ensuring that the relevant health
departments are notified about cases found to
be duplicates through RIDR will also help
improve the quality of local surveillance data.
Our findings highlight the feasibility and
potential value of integrating linkage to care
into HIV partner services and public health
clinical services. In many areas of the United
States, people newly diagnosed with HIV
must interact with multiple individuals from
different agencies before seeing an HIV
medical provider, a trying process that contributes to delays in linkage to care. PHSKC
strives to streamline this process. The disease
intervention specialists discuss both partner
services and linkage to care topics when they
meet with newly diagnosed individuals, and
the One-on-One program enables such individuals to receive immediate clinical evaluations. These activities occur at the PHSKC
STD Clinic, illustrating how clinics of this
kind can facilitate an integrated approach to
managing newly diagnosed HIV patients.
Time to linkage to care improved after
PHSKC integrated surveillance into partner
services and began providing those services to
all individuals with newly diagnosed HIV.
The association we observed between
linkage to care and receipt of partner services is
consistent with a prior report from New York
City17 and suggests that partner services can
improve linkage to care. That association,
which was based on an analysis of observational
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program data, could reflect confounding rather
than a true intervention effect. At present, the
only linkage to care intervention that CDC
regards as “evidenced based” is the Antiretroviral Treatment Access Study, a multisession18 behavioral intervention.19 Although
our findings related to partner services do not
rise to that level, we believe that partner services
should be regarded as an “evidenced-informed”
intervention. This intervention has helped
King County achieve nearly universal linkage
to care, and it is consistent with ongoing
efforts in other areas to rapidly initiate antiretroviral therapy among people with newly
diagnosed HIV.20
diagnosis, nativity, timing of immigration)
that improve our program’s understanding of
the local epidemic and resulted in nearly
universal linkage to HIV care. Our system of
integration depends on an interdisciplinary
team that uses diverse public health resources
and operates within the STD Clinic to efficiently respond to new HIV cases.
The CDC is now encouraging state and
local public health HIV/STD programs to
better integrate their surveillance and prevention activities. Our experience supports
such a direction, and some of the aspects of
this experience may be helpful to other jurisdictions as they modify the interaction of
surveillance and field services teams.
partner notification. J Acquir Immune Defic Syndr. 2003;
32(2):196–202.
Limitations
CONTRIBUTORS
There are limitations to the surveillance
data included in our analyses and perhaps to the
generalizability of our experience. Many of our
analyses relied on reported date of HIV diagnosis, a field in eHARS that may align
imperfectly with actual diagnosis date. Similarly, date of first reported CD4 or viral load
result may imperfectly align with date of care
initiation.21 For example, incomplete laboratory reporting and care visits without laboratory orders may cause the time from diagnosis
to linkage to care to be overestimated, or,
conversely, laboratory tests ordered through
the One-on-One program may underestimate
time to linkage to care. We cannot conclude
definitively that partner services improved
time to linkage to care, as our analysis of observational data may not have controlled for all
sources of confounding. For example, there
might be unobserved factors that would influence both the likelihood of receiving
partner services and time to linkage to care.
Also, some of the aspects of our approach in
King County may be less feasible in areas with
more limited resources or larger epidemics.
Finally, 19% of the PLWDH population in
King County is not suppressed despite high
levels of care linkage, highlighting the need to
address each step on the HIV care continuum.
J. E. Hood conducted the analyses and managed the
preparation and writing of the article. The original design
and scope of the study was conceptualized by D. A. Katz
and M. R. Golden. A. B. Bennett and S. E. Buskin
managed the programs that collected the data analyzed in
the article. J. C. Dombrowski and S. E. Hawes provided
guidance on the goals and approach of the analysis. All
of the authors contributed to interpreting results and to
writing and reviewing the article.
12. King County. King County experiences strong
population growth according to 2010 census results.
Available at: http://www.kingcounty.gov/elected/
executive/constantine/News/release/2011/February/
24Census.aspx. Accessed September 12, 2017.
Conclusions
We found that integrating surveillance
and field staff into a team responsible for
investigating new cases of HIV, providing
partner services, and ensuring care linkage was
feasible. This approach allowed staff members
to collect new data elements (prior HIV
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ACKNOWLEDGMENTS
We thank and acknowledge the King County disease
intervention specialists for their thorough case investigations, detailed recordkeeping, and commitment to HIV
care and prevention.
HUMAN PARTICIPANT PROTECTION
The analyses described in this article were undertaken as
a public health surveillance activity and therefore did not
require institutional review board review.
REFERENCES
1. Cohen MS, Chen YQ, McCauley M, et al. Prevention
of HIV-1 infection with early antiretroviral therapy. N
Engl J Med. 2011;365(6):493–505.
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AJPH
Published online ahead of print October 19, 2017
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