1. Poster WP41; Contact: David A. Katz, dkatz7@u.washington.edu
Using Sexually Transmitted Disease Partner Services to Promote Engagement in HIV Care among Persons Living with HIV
David A. Katz1,2, Matthew R. Golden1,2, Teal R. Bell3, Roxanne P. Kerani1,2, Mark R. Aubin3, Zandt Bryan3, David A. Kern4, David D. Heal3, Julia C. Dombrowski1,2
University of Washington1, Seattle, WA; Public Health – Seattle & King County2, Seattle, WA; Washington State Department of Health3, Olympia, WA; Chicago Department of Public Health4, Chicago, IL
Revised Abstract
BACKGROUND: Persons living with HIV (PLWH) are at elevated risk for other sexually transmitted diseases (STDs). STD partner services (PS) provide an opportunity to identify PLWH who are inadequately engaged in HIV care and link or relink them to care.
METHODS: In May 2012, disease intervention specialists (DIS) in Washington State began routinely assessing HIV care and antiretroviral therapy (ART) status during PS interviews. DIS provide or refer PS recipients identified as inadequately engaged in care to re-linkage services. Among STD cases receiving PS, we identified the proportion of PLWH who reported inadequate engagement and who, of those, were virally suppressed within 6 months following interview. Inadequate engagement was defined by 3 hierarchical criteria based on self-report: 1) not having an HIV care provider, 2) no completed appointment in the prior six months and none scheduled in the next two months, or 3) not taking ART. We used HIV surveillance to assess viral suppression, defined as an HIV RNA <200 copies/mL.
RESULTS: From May 2012-December 2015, 2087 PLWH were diagnosed with a total of 3905 bacterial STDs in Washington State; 2521 (65%) of the total cases received PS. Among PS recipients, 448 (18%) reported inadequate engagement: 86 (3.4%) reported no provider, 92 (4.2%) no recent or upcoming provider visit, and 257 (10%) not taking ART. Thirteen percent of syphilis, 22% of gonorrhea, and 16% of chlamydia cases reported inadequate engagement (p<0.0001). Of 437 reporting inadequate engagement who matched to HIV surveillance, viral suppression increased from 25% in the year prior to interview to 45% in the subsequent 6 months (p<0.001).
CONCLUSIONS: Approximately 1 in 5 PLWH interviewed for STD PS reported inadequate engagement in HIV care. In this group, a moderate increase in viral suppression occurred following DIS relinkage efforts; however, the effectiveness of this approach is uncertain without comparison against a control group.
Background
U.S. CDC estimated that, in 2011, only 40% of persons living with HIV (PLWH) were engaged in HIV care and 30% were virally suppressed
PLWH are at elevated risk for other sexually transmitted diseases (STDs)
STD partner services (PS) present an opportunity to:
Identify PLWH who are inadequately engaged in HIV care and
Link or re-link these persons to care
Yet, few health departments:
Provide PS for STDs other than syphilis and HIV or
Integrate engagement in HIV care as an objective of PS
Objective
We instituted and evaluated a program promoting engagement in HIV care through public health STD partner services in Washington State.
Methods
Partner Services Intervention
In May 2012, health departments in WA State revised PS programs to:
Assess HIV care status, CD4 count, and antiretroviral therapy (ART) use for all PLWH interviewed for STD PS
For PLWH inadequately engaged in HIV care, directly provide or refer to relinkage services
Provide PS to all MSM with early syphilis, gonorrhea (GC), or chlamydial infection (CT)
Data Sources
HIV and STD surveillance data from Washington State, 5/1/ /31/2015
STD surveillance and partner services data are matched with HIV surveillance data (eHARS) as follows:
Weekly automated probabilistic matching algorithm based on legal and alias names, date of birth, and sex
Bimonthly manual review of STI cases without eHARS match but with indication of HIV infection in STD surveillance data
HIV surveillance data include viral loads:
Washington State law requires that laboratories report all viral loads
Outcomes & Analyses
Described proportion of PLWH interviewed for STD PS who reported inadequate engagement in HIV care
Among PS recipients, assessed correlates of being identified as inadequately engaged using logistic regression (inadequately engaged v engaged/missing)
Assessed viral suppression within 6 months following receipt of STD PS
Among cases inadequately engaged in care who matched to HIV surveillance, compared proportion virally suppressed in year prior to vs. in 6 months following PS interview using McNemar’s tests
Results
STD cases, partner services delivery, and engagement in HIV care among PLWH in Washington State, May 2012-Dec 2015
Engagement in HIV care among PLWH receiving STD PS in Washington State, May 2012-Dec 2015
65% of STD cases living with HIV were interviewed for partner services
2452 (67%) of 3654 MSM cases vs. 69 (27%) of 251 non-MSM
18% of cases receiving PS were identified as inadequately engaged in care
57% of whom had a recent or upcoming visit to their provider but were not taking ART
HIV care status could be not be determined for 17% of cases receiving PS
20% of whom had a recent or upcoming visit to their provider but had no information recorded regarding ART use
If adequate engagement were defined as having had a completed appointment with a provider in the prior 6 months or scheduled for the next 2 months, 79% of PLWH receiving PS would have been adequately engaged (vs. 66%)
Characteristics of PLWH receiving STD partner services by self-reported HIV care status
STDs are presented in hierarchical order: early syphilis, gonorrhea, and chlamydial infection. MSM = men who have sex with men. MSW = men who have sex with women only. Moderate morbidity jurisdictions = Clark, Pierce, Snohomish, and Spokane Counties.
Correlates of reporting inadequate engagement in HIV care among PLWH receiving STD partner services
Race/ethnicity and sex/gender of sex partners were not significantly associated with inadequate engagement in bivariable or multivariable analyses, but were included in multivariable analyses due to a priori assumptions.
Viral suppression in year before PS interview vs. 6 months after interview among PS recipients inadequately engaged in HIV care
437 (98%) of 448 inadequately engaged cases were matched to HIV surveillance
Viral suppression was significantly greater in the 6 months following PS than in the prior year among cases reporting inadequate engagement at PS interview, specifically those reporting no provider or not taking ART
Limitations
Missing data re: care status for large proportion of cases (35% not interviewed, 11% not adequate information)
Relied on self-reported HIV care and ART status
Absence of a control group for comparison
Summary & Conclusions
Approximately 1 in 5 PLWH interviewed for STD PS reported inadequate engagement in HIV care.
A moderate increase in viral suppression occurred following DIS relinkage efforts with PLWH inadequately engaged in care.
STD PS can be used to identify PLWH who are inadequately engaged in HIV care and relink them to care.
The population-level effectiveness of this approach is uncertain without comparison against a control group.
Assessment of and relinkage to HIV care should be considered as explicit outcomes of STD PS.
Acknowledgments
This program and its evaluation were supported by the U.S. Centers for Disease Control and Prevention (CDC PS and 3H25PS004364), the Washington State Department of Health, and Public Health – Seattle & King County. This evaluation was also supported by the the University of Washington Center for AIDS Research, a National Institutes of Health-funded program (P30 AI027757).
Characteristic
Inadequately Engaged
In Care & On ART
Unknown Care Status
N = 448
N = 1656
N = 417 N %
STD
Early syphilis 88
13%
407
60%
183
27%
Gonorrhea
235
22%
692
65%
139
Chlamydial infection
125
16%
557
72%
Sex/Gender of Partners
MSM
436
18%
1624
66%
392
MSW 11
20% 27
50% 16
30%
Women 1
11% 7
78%
Age
<24 53
28%
107
56% 32
17%
25-34
519
63%
118
14%
35-44
109
15%
477
144
45+
103
553
71%
123
Race/Ethnicity
Non-Hispanic White
262
1041
280
Non-Hispanic Black 45
174 43
Hispanic/Latino 99
21%
299
64% 66
Other 42
142
67% 28
County of Diagnosis
King County
337
1275
68%
275
Moderate Morbidity 76
302
62%
106
Low Morbidity 35
23% 79
53% 36
24%
2087 unique persons living with HIV
p>.9999
3905 cases of early syphilis, GC, or CT
p<.0001
p=.0015
p<.0001
2521 (65%) cases interviewed for PS
1656 (66%) in care and taking ART
448 (18%) inadequately engaged in care
417 (17%) unable to determine care status
Inadequate engagement in HIV care
Viral suppression
Definition
Based on 3 hierarchical criteria:
1) not having an HIV care provider,
2) no completed appointment in the prior 6 months and none scheduled in the next 2 months, or
3) not taking ART.
HIV RNA viral load <200 copies/ml
Ascertainment
Self-report by case
Laboratory reporting
Denominator
PLWH interviewed for STD PS
PLWH inadequately engaged in HIV care
Characteristic
Unadjusted
Adjusted OR
95%CI p
STD (vs. Chlamydial infection)
<0.001
Early syphilis
0.78
0.81
Gonorrhea
1.48
1.45
Age (vs. <24)
25-34
0.75
35-44
0.46
0.50
45+
0.40
0.45
County of Diagnosis (vs. King)
0.10
0.07
Moderate Morbidity
0.86
0.80
Low Morbidity
1.40
1.35