Cost Analysis of Implementing a 12-Month Recertification Criterion for Ryan White HIV/AIDS Program's AIDS Drug Assistance Program in Washington State.

OBJECTIVE: AIDS Drug Assistance Programs (ADAPs) are state-administered programs that pay for medical care and medication for people living with HIV (PLWH) in the United States. In October 2021, the federal policy requiring that clients recertify for the program every 6 months was repealed, giving states the authority to set their own recertification policies. However, little data exist on the costs and health effects of alternative recertification schedules. We assessed the cost of changing the legacy 6-month recertification to a 12-month schedule in Washington State to inform policy decisions on recertification. METHODS: We used a Markov model to simulate the population of PLWH in Washington State who are eligible or enrolled in ADAP. We obtained model inputs and validation data from the Washington State Ryan White database. We estimated the cost of 12-month and 6-month criteria over a 5-year time horizon. Model outputs included annual program costs, population sizes, and number of people virally suppressed, by scenario. RESULTS: Under a continuation of the legacy 6-month recertification criteria, the annual cost of Washington ADAP would be $37 663 000 (95% CI, $34 570 000-$41 686 000) during the next 5 years, with a per-client cost of $7966 (95% CI, $7478-$8494). Under 12-month criteria, the annual cost would be $40 217 000 (95% CI, $36 243 000-$44 401 000) and the per-client cost would be $7543 (95% CI, $7084-$8042). Under the 12-month scenario, 245 more people will have been virally suppressed by the end of 2025. CONCLUSIONS: Switching to a less frequent recertification process may improve health outcomes at a modest increase in cost in Washington State.

Evaluating surveillance definitions of HIV viral suppression 2015-2019: Which definition best detected barriers to care?

Background: People living with HIV (PLWH) who have not achieved or maintained viral suppression post-diagnosis likely face multiple barriers to HIV care. To identify these barriers a universally accepted definition of viral suppression is needed. The most common definition, the Center for Disease Control and Prevention (CDC) definition, contains simplifying assumptions that may misclassify individuals and attenuate associations. In this study, we evaluated alternative definitions of viral suppression on their ability to identify barriers to care. Design and methods: We used HIV surveillance data to classify participants of the 2015-2019 Washington Medical Monitoring Project (MMP) as virally suppressed or not using the CDC definition and two definitions that assess viral suppression over a longer period ("Enriched" and "Durable"). We identified barriers to suppression from literature (unstable housing, illicit drug use, poor mental health, heavy drinking, recent incarceration, racism, and poverty) and measured them using interview questions from MMP. We compared the rate ratios (RR) of being not virally suppressed using each definition for each barrier. Results: There were 858 PLWH in our study. All viral suppression definitions classified a similar proportion of people as suppressed (85%-89%). The durable viral suppression definition consistently yielded the largest rate ratios (e.g. unstable housing: CDC RR = 1.3, 95% CI 0.9-1.8; Enriched 1.5, 95% CI 1.0-2.2; Durable 2.2, 95% CI 1.6-3.1) and reclassified 10% of the population relative to the CDC definition. Conclusions: Longitudinal definitions for viral suppression may yield less misclassification and serve as superior tools for identifying and curtailing barriers to HIV care.

AIDS Drug Assistance Program disenrollment is associated with loss of viral suppression beyond differences in homelessness, mental health, and substance use disorders: An evaluation in Washington state 2017-2019.

AIDS Drug Assistance Programs (ADAPs) are state-administered programs that pay for medical care for people living with HIV in the US. Maintaining enrollment in the programs is challenging, and a large proportion of clients in Washington state (WA) fail to recertify and are disenrolled. In this study we sought to quantify the impact of disenrollment from ADAPs on viral suppression. We conducted a retrospective cohort study of the 5238 clients in WA ADAP from 2017 to 2019 and estimated the risk difference (RD) of viral suppression before and after disenrollment. We performed a quantitative bias analysis (QBA) to assess the effect of unmeasured confounders, as the factors that contribute to disenrollment and medication discontinuation may overlap. Of the 1336 ADAP clients who disenrolled ≥1 time, 83% were virally suppressed before disenrollment versus 69% after (RD 12%, 95%CI 9-15%). The RD was highest among clients with dual Medicaid-Medicare insurance (RD 22%, 95%CI 9-35%) and lowest among privately insured individuals (RD 8%, 95%CI 5-12%). The results of the QBA suggest that unmeasured confounders do not negate the overall RD. The ADAP recertification procedures negatively impact the care of clients who struggle to stay in the program; alternative procedures may reduce this impact.

Direct and Indirect Effects of a Project ECHO Longitudinal Clinical Tele-Mentoring Program on Viral Suppression for Persons With HIV: A Population-Based Analysis.

BACKGROUND: Project Extension for Community Health Outcomes (ECHO) aims to connect community providers to academic specialists, deliver longitudinal clinical mentorship and case consultations, plus encourage dissemination of knowledge and resources. The impact on outcomes for persons with HIV (PWH) is uncertain. SETTING: PWH in Washington and Oregon outside of the Seattle and Portland metro areas, January 2011 to March 2018. METHODS: Using viral load (VL) surveillance data, we assessed difference in the percentage of PWH who were virally suppressed among PWH whose providers participated versus did not participate in Project ECHO. Analyses included multiple mixed-effects regression models, adjusting for time and for patient, provider, and clinic characteristics. RESULTS: Based on 65,623 VL results, Project ECHO participation was associated with an increase in the percentage of patients with VL suppression (13.7 percentage points greater; P < 0.0001), although the effect varied by estimated provider PWH patient volume. The difference was 14.7 percentage points ( P < 0.0001) among patients of providers who order <20 VL's/quarter and 2.3 and -0.6 percentage points among patients of providers who order 20-40 or >40 VL's/quarter, respectively ( P > 0.5). The magnitude of difference in VL suppression was associated with the number of sessions attended. Among patients of lower-volume providers who did not participate, VL suppression was 6.2 percentage points higher if providers worked in a clinic where another provider did participate ( P < 0.0001). CONCLUSION: Project ECHO is associated with improvement in VL suppression for PWH whose providers participate or work in the same clinic system as a provider who participates, primarily because of benefits for patients of lower-volume providers.

Predictive Value of Time-Space Clusters for HIV Transmission in Washington State, 2017-2019.

BACKGROUND: Pillar 4 of the United States' End the HIV Epidemic plan is to respond quickly to HIV outbreaks, but the utility of CDC's tool for identifying HIV outbreaks through time-space cluster detection has not been evaluated. The objective of this evaluation is to quantify the ability of the CDC time-space cluster criterion to predict future HIV diagnoses and to compare it to a space-time permutation statistic implemented in SaTScan software. SETTING: Washington State from 2017 to 2019. METHODS: We applied both cluster criteria to incident HIV cases in Washington State to identify clusters. Using a repeated-measures Poisson model, we calculated a rate ratio comparing the 6 months after cluster detection with a baseline rate from 24 to 12 months before the cluster was detected. We also compared the demographics of cases within clusters with all other incident cases. RESULTS: The CDC criteria identified 17 clusters containing 192 cases in the 6 months after cluster detection, corresponding to a rate ratio of 1.25 (95% confidence interval: 0.95 to 1.65) relative to baseline. The time-space permutation statistic identified 5 clusters containing 25 cases with a rate ratio of 2.27 (95% confidence interval: 1.28 to 4.03). Individuals in clusters identified by the new criteria were more likely to be of Hispanic origin (61% vs 20%) and in rural areas (51% vs 12%). CONCLUSIONS: The space-time permutation cluster analysis is a promising tool for identification of clusters with the largest growth potential for whom interruption may prove most beneficial.

Characterization of Molecular Cluster Detection and Evaluation of Cluster Investigation Criteria Using Machine Learning Methods and Statewide Surveillance Data in Washington State.

Molecular cluster detection can be used to interrupt HIV transmission but is dependent on identifying clusters where transmission is likely. We characterized molecular cluster detection in Washington State, evaluated the current cluster investigation criteria, and developed a criterion using machine learning. The population living with HIV (PLWH) in Washington State, those with an analyzable genotype sequences, and those in clusters were described across demographic characteristics from 2015 to2018. The relationship between 3- and 12-month cluster growth and demographic, clinical, and temporal predictors were described, and a random forest model was fit using data from 2016 to 2017. The ability of this model to identify clusters with future transmission was compared to Centers for Disease Control and Prevention (CDC) and the Washington state criteria in 2018. The population with a genotype was similar to all PLWH, but people in a cluster were disproportionately white, male, and men who have sex with men. The clusters selected for investigation by the random forest model grew on average 2.3 cases (95% CI 1.1-1.4) in 3 months, which was not significantly larger than the CDC criteria (2.0 cases, 95% CI 0.5-3.4). Disparities in the cases analyzed suggest that molecular cluster detection may not benefit all populations. Jurisdictions should use auxiliary data sources for prediction or continue using established investigation criteria.

Outbreak of Human Immunodeficiency Virus Infection Among Heterosexual Persons Who Are Living Homeless and Inject Drugs - Seattle, Washington, 2018.

Although diagnoses of human immunodeficiency virus (HIV) infection among persons who inject drugs in the United States are declining, an HIV outbreak among such persons in rural Indiana demonstrated that population's vulnerability to HIV infection (1). In August 2018, Public Health-Seattle and King County (PHSKC) identified a cluster of cases of HIV infection among persons living homeless, most of whom injected drugs. Investigation identified 14 related cases diagnosed from February to mid-November 2018 among women who inject drugs and men who have sex with women (MSW) who inject drugs and their sex partners. All 14 persons were living homeless in an approximately 3-square-mile area and were part of a cluster of 23 cases diagnosed since 2008. Twenty-seven cases of HIV infection were diagnosed among women and MSW who inject drugs in King County during January 1-November 15, 2018, a 286% increase over the seven cases diagnosed in 2017. PHSKC has alerted medical and social service providers and the public about the outbreak, expanded HIV testing among persons who inject drugs or who are living homeless, and is working to increase the availability of clinical and prevention services in the geographic area of the outbreak. This outbreak highlights the vulnerability of persons who inject drugs, particularly those who also are living homeless, to outbreaks of HIV infection, even in areas with high levels of viral suppression and large syringe services programs (SSPs).

Estimating Effects of HIV Sequencing Data Completeness on Transmission Network Patterns and Detection of Growing HIV Transmission Clusters.

HIV nucleotide sequence data can identify clusters of persons with genetically similar strains suggesting transmission. We simulated the effect of lowered data completeness, defined by the percent of persons with diagnosed HIV with a reported sequence, on transmission patterns and detection of growing HIV transmission clusters. We analyzed HIV surveillance data for persons with HIV diagnosed during 2008-2014 who resided in Michigan or Washington. We calculated genetic distances, constructed the inferred transmission network for each jurisdiction, and compared transmission network characteristics and detection of growing transmission clusters in the full dataset with artificially reduced datasets. Simulating lower levels of completeness resulted in decreased percentages of persons linked to a cluster from high completeness (full dataset) to low completeness (5%) (Michigan: 54%-18%; Washington, 46%-16%). Patterns of transmission between certain populations remained robust as data completeness level was reduced. As data completeness was artificially decreased, sensitivity of cluster detection substantially diminished in both states. In Michigan, sensitivity decreased from 100% with the full dataset, to 62% at 50% completeness and 21% at 25% completeness. In Washington, sensitivity decreased from 100% with the full dataset, to 71% at 50% completeness and 29% at 25% completeness. Lower sequence data completeness limits the ability to detect clusters that may benefit from investigation; however, inferences can be made about transmission patterns even with low data completeness, given sufficient numbers. Data completeness should be prioritized, as lack of or delays in detection of transmission clusters could result in additional infections.

A cross-jurisdictional evaluation of insurance coverage among HIV care patients following the Affordable Care Act.

The impact of the Affordable Care Act (ACA) on HIV care patients, aged 18-64, was evaluated in three jurisdictions with Medicaid expansion (Chicago, New York State, and Washington) and three jurisdictions without Medicaid expansion (Georgia, Texas, and Virginia) using data from the Medical Monitoring Project. Multivariate regression models were used to evaluate insurance status that was reported pre- and post-ACA; self-reported impact of ACA on HIV care was explored with descriptive statistics. The likelihood of having insurance was significantly greater post-ACA compared to pre-ACA in Chicago (aRR = 1.33, 95%CI = 1.20, 1.47), Washington (aRR = 1.15, 95%CI = 1.08, 1.22), and Virginia (aRR = 1.14, 95%CI = 1.00, 1.29). In Washington and Chicago, the likelihood of being Medicaid-insured was greater post-ACA compared to pre-ACA implementation (Chicago: aRR = 1.25, 95%CI = 1.03,1.53; Washington: aRR = 1.66 95% CI = 1.30, 2.13). No other significant differences were observed. Only a subset of HIV care patients (range: 15-35%) reported a change in insurance that would have coincided with the implementation of ACA; and within this subset, a change in medical care costs was the most commonly noted issue. In conclusion, the influence of ACA on insurance coverage and other factors affecting HIV care likely varies by jurisdiction.

Duration of Shedding and Secondary Household Transmission of Shiga Toxin-Producing Escherichia coli O26 During an Outbreak in a Childcare Center, Oregon, October-December 2010.

We assessed shedding duration and secondary household transmission of Shiga toxin 1-positive Escherichia coli O26 during a childcare-associated outbreak. No severe illness was noted. Shedding duration was 15-46 days (median, 29). No secondary transmission to household members was identified. Value of isolating asymptomatic infected children with this low-virulence infection remains uncertain.

From making pamphlets to making policies: results from a collaborative training to increase knowledge, motivation, and self-efficacy for achieving public health policy and systems change.

Steps to a Healthier Washington, in collaboration with other programs in the Washington State Department of Health and external partners, has implemented training to improve public health practice and create greater organizational and staff capacity for promoting effective policy and systems changes, including reducing disparities. The training is grounded in behavior change and adult learning theories. A comprehensive post training evaluation found long-term improvements in self-efficacy, reported changes in work, and attribution of those changes to the training. Organizations working to refocus public health work on policy and systems change should consider providing skills-based policy training to their staff. This study suggests that an integrated training, using adult learning theory, has led to long-term improvements in capacity among public health staff and partners.

The role of horizontal gene transfer in the spread of trimethoprim-sulfamethoxazole resistance among uropathogenic Escherichia coli in Europe and Canada.

OBJECTIVES: To describe the distribution of trimethoprim-sulfamethoxazole resistance genes and the role of horizontal gene transfer and clonal expansion in recent increases of antibiotic resistance rates among uropathogenic Escherichia coli in Europe and Canada. METHODS: We identified antibiotic resistance alleles sul1, sul2, sul3 and dfr along with type 1 and type 2 integrons among 350 uropathogenic E. coli isolates from a cross-sectional study of acute, uncomplicated, community-acquired urinary tract infections in 16 western European countries and Canada (ECOSENS). RESULTS: Trimethoprim resistance gene distributions showed no regional dependency (P = 0.84). The most common trimethoprim resistance gene was dfrA1, which occurred in 37.9% of dfr containing isolates. Similarly, the sulfamethoxazole resistance gene distributions did not vary significantly by region (P = 0.20). sul2, the most common sulfamethoxazole resistance gene, was found in 77.9% of sulfamethoxazole-resistant isolates. The distribution of type 1 and type 2 integrons varied slightly by region (P = 0.04) with type 1 integrons being the more common (85.9%). We observed 34 combinations of the sul genes, dfr genes and integron types; the most common combinations were broadly disseminated across every region examined. CONCLUSIONS: Horizontal gene transfer plays a larger role than clonal expansion in the increase of trimethoprim-sulfamethoxazole resistance levels in Europe and Canada.