Estimates of Prenatal HIV, Hepatitis B Virus, and Hepatitis C Virus Testing Among Pregnant People Enrolled in Wisconsin Medicaid, 2011-2015.

BACKGROUND: The opioid epidemic and rising rates of injection drug use are increasing the risk of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections among pregnant people. According to national clinical guidelines, pregnant people should be universally tested for HIV and HBV, and risk-based tested for HCV. The aim of this study was to determine the proportion and characteristics of prenatal HIV, HBV, and HCV testing and diagnosis among pregnant people with Wisconsin Medicaid coverage between 2011 and 2015. METHODS: Wisconsin birth certificates and Medicaid enrollment data were used to identify the sample. Standard billing and diagnosis codes were used to assess study variables. Data for each pregnancy were analyzed to describe the proportion of pregnancies that had evidence of testing, diagnoses, and yearly trends. RESULTS: Of the 78,917 pregnancies, prenatal testing estimates were 67% for HIV, 73% for HBV, and 6% for HCV. The estimated rate of infections during the study period was 1.82 for HIV, 2.09 for HBV, and 3.52 for HCV per 1000 pregnancies. Compared to the other race/ethnicity groups, pregnant people who were Black were most likely to be tested for HIV (78%) and HBV (80%), and pregnant people who were White were most likely to be tested for HCV (7%). CONCLUSIONS: Clinical testing guidelines have not been effectively translated to practice. Additionally, compared to HIV and HBV, HCV infections during pregnancy are becoming more prevalent, yet current national HCV screening guidelines are the least comprehensive.

"Don't Deny Yourself a Seat at the Table": Supporting the Leadership Development of MSM of Color in HIV Services.

AIDS service organizations have played a vital role in responding to the HIV epidemic, yet many are plagued by an underrepresentation of racial, ethnic, and sexual minorities in leadership positions. In response, the Wisconsin Department of Health Services, HIV Division, created the Wisconsin Health Leaders Fellowship program to provide training and skills to gay and bisexual men of color in HIV service organizations in Milwaukee, Wisconsin. The program was evaluated using in-depth pre- and post-Fellowship interviews with fellows, their agency preceptors, and Fellowship staff (n = 23 interviews). Results indicate that the Fellowship was successful at developing leadership skills and increasing the confidence of the fellows. However, findings revealed the need to address larger social and structural issues alongside supporting individuals in order to create effective, sustainable change. There is a need for cultural diversity trainings for organizational leaders, changes to organizational hiring and promotion practices, and improving opportunities for formal education for racial and ethnic minority men.

Transmission Patterns in a Low HIV-Morbidity State - Wisconsin, 2014-2017.

Public health interviews (i.e., partner services), during which persons with diagnosed human immunodeficiency virus (HIV) infection name their sexual or needle-sharing partners (named partners), are used to identify HIV transmission networks to guide and prioritize HIV prevention activities. HIV sequence data, generated from provider-ordered drug resistance testing, can be used to understand characteristics of molecular clusters, a group of sequences for which each sequence is highly similar (linked) to all other sequences, and assess whether named partners are plausible HIV transmission partners. Although molecular data in higher HIV-morbidity states have been analyzed (1-3), few analyses exist for lower morbidity states (4), such as Wisconsin, which reported 4.6 HIV diagnoses per 100,000 persons aged ≥13 years in 2016 (5). The Wisconsin Division of Public Health (DPH) analyzed HIV sequence data generated from provider-ordered drug resistance testing and collected through routine HIV surveillance to identify molecular clusters and describe demographic and transmission risk characteristics among pairs of persons whose sequences were highly genetically similar (i.e., molecular linkages). In addition, overlap between partner linkages identified during public health interviews and molecular linkages was assessed. Overall, characteristics of molecular clusters in Wisconsin mirrored those from states with more HIV diagnoses, particularly in that most molecular linkages were observed among persons of the same race (78.2% of non-Hispanic blacks [blacks] linked to other blacks), the same transmission risk (90.2% of men who have sex with men [MSM] linked to other MSM), and the same age group (59.2% of persons aged 20-29 years linked to other persons aged 20-29 years). Among named partner linkages identified during interviews in which both persons also had a reported sequence, overlap of named partner and molecular linkages was moderate: 33.8% of named partners were plausible transmission partners according to available molecular data. Analysis of HIV sequence data is a useful tool for characterizing transmission patterns not immediately apparent using traditional public health interview data, even in a state with lower HIV morbidity. Prevention recommendations generated from national data (e.g., targeting preexposure prophylaxis for HIV-negative persons at high risk and implementing measures to maintain viral suppression among persons with HIV infection) also are relevant in a lower HIV-morbidity state.

Developing a Patient Navigation Program to Improve Engagement in HIV Medical Care and Viral Suppression: A Demonstration Project Protocol.

Individuals diagnosed and living with HIV who are out of care or who have persistent viremia are at risk for poor health outcomes and are estimated to account for two-thirds of all new HIV infections. As part of a six-state demonstration project to improve access to care for hard-to-reach populations, Wisconsin developed an HIV-specific patient navigation program to improve engagement in HIV care and viral suppression for populations at risk for poor HIV care outcomes. Patient navigators worked with individuals who were out of HIV medical care or were at risk of falling out of care over nine months to identify and address barriers to care. This manuscript describes the patient navigation program and rationale, and lessons learned that should be considered by sites developing similar programs.

Implementing a Standardized Social Networks Testing Strategy in a Low HIV Prevalence Jurisdiction.

Alternative HIV testing strategies are needed to engage individuals not reached by traditional clinical or non-clinical testing programs. A social networks recruitment strategy, in which people at risk for or living with HIV are enlisted and trained by community-based agencies to recruit individuals from their social, sexual, or drug-using networks for HIV testing, demonstrates higher positivity rates compared to other non-clinical recruitment strategies in some jurisdictions. During 2013-2015, a social networks testing protocol was implemented in Wisconsin to standardize an existing social networks testing program. Six community-based, non-clinical agencies with multiple sites throughout the state implemented the protocol over the 2-year period. Both quantitative and qualitative data were collected. The new positivity rate (0.49%) through social networks testing did not differ from that of traditional counseling, testing, and referral recruitment methods (0.48%). Although social networks testing did not yield a higher new positivity rate compared to other testing strategies, it proved to be successful at reaching high risk individuals who may not otherwise engage in HIV testing.

Increased Risk for Mother-to-Infant Transmission of Hepatitis C Virus Among Medicaid Recipients - Wisconsin, 2011-2015.

State surveillance during the last 10 years reveals a nationwide increase in hepatitis C virus (HCV) infection among young adults (1). The proportion of infants born to HCV-infected women is also increasing nationally (2). To estimate the proportion of infants born to HCV-infected women and the frequency of confirmed HCV infection in their infants, maternal name and date of birth from HCV reports in the Wisconsin Electronic Disease Surveillance System (WEDSS) were linked to Wisconsin Medicaid data for 2011-2015 births. During this period, in the Wisconsin Medicaid population, the proportion of women who had evidence of HCV infection during pregnancy increased 93%, from 1 in 368 pregnancies to 1 in 192. Among 183 infants born to women with evidence of HCV viremia during pregnancy, 34% received recommended HCV testing (3). Mother-to-infant (vertical) transmission was documented in 4% of infants. Improvements in HCV screening practices among pregnant women and infants could enhance identification of infants at risk for vertical transmission of HCV.

Rapid hepatitis C testing among persons at increased risk for infection--Wisconsin, 2012-2013.

An estimated 3.2 million persons in the United States have chronic infection with hepatitis C virus (HCV). Most new HCV transmissions occur among persons who inject drugs, often within the first few years of their injection drug use. During 2003-2012, reports of HCV infection increased from 15 to 54 cases per 100,000 among persons aged <30 years in Wisconsin, and 58% of persons in this age group with acute HCV infection reported injecting drugs (Wisconsin Division of Public Health, unpublished data, 2013). To increase detection of HCV infection, the Wisconsin Division of Public Health (WDPH) piloted a program during October 2012-October 2013 that offered rapid HCV testing to clients of four agencies providing outreach testing for HCV and human immunodeficiency virus infection, syringe exchange, counseling, and other harm reduction services to persons with drug dependence. During that period, 1,255 persons were tested using a rapid HCV test, and 246 (20%) of the results were positive. Most (72%) of the infections had not been reported to WDPH. A blood specimen for further testing was collected from 192 (78%) participants with positive HCV test results; among these participants, 183 were tested for HCV RNA using reverse transcription-polymerase chain reaction (RT-PCR), and these results were positive for 128 (70%) participants, indicating active infection. Use of the rapid HCV test detected previously unreported HCV infections and raised awareness of HCV. Persons identified with active HCV infection should be referred to medical care and counseled on ways to prevent HCV transmission to others.

Academic health departments as training sites for future public health leaders: a partnership model in Wisconsin.

BACKGROUND: In 2004, 2 Wisconsin academic health departments partnered with the School of Medicine and Public Health, University of Wisconsin-Madison to strengthen the public health workforce through a service-learning program that prepares the next generation of leaders while addressing local public health needs. The Wisconsin Population Health Service Fellowship annually provides 4 to 6 master's or doctorally trained fellows with 2-year service-learning placements in health departments and community-based organizations. PROGRAM BENEFITS: Placement communities benefit from fellows' contributions to a broad range of public health issues, including chronic and communicable disease prevention, health equity, community practice, and policy and systems change. Academic health departments and the UW School of Medicine and Public Health enjoy additional program benefits, along with the advantages that accrue to the fellows themselves. For the academic health departments, this includes increased organizational capacity, generation of resources for public health, and a stronger and more diverse public health workforce. LESSONS LEARNED: The success of the partnership depends upon shared decision making and management, written agreements to clarify partner expectations, shared financial and in-kind contributions, and collaboration on program evaluation and dissemination. CONCLUSIONS: By building upon their respective organizational strengths, Wisconsin's academic health departments and the UW School of Medicine and Public Health have developed a successful model for transforming talented, highly motivated young professionals into confident, emerging public health leaders with the cutting-edge skills and connections necessary to improve population health outcomes and advance health equity.

Hepatitis A and Hepatitis B Vaccination Coverage Among Persons Who Inject Drugs and Have Evidence of Hepatitis C Infection.

OBJECTIVES: Despite recommendations for vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV) for all adults at increased risk of infection, several US states have reported increases in HAV and HBV infections among persons who inject drugs. We investigated hepatitis A and hepatitis B vaccination coverage among a sample of persons who reported injecting drugs and had evidence of hepatitis C virus (HCV) infection. METHODS: We searched the Wisconsin Immunization Registry for the vaccination records of persons who underwent HCV testing at syringe services programs from January 1 through August 31, 2018, and were reported to the Wisconsin Division of Public Health as having positive HCV antibody test results and a history of injection drug use. We calculated the percentage of persons who were vaccinated according to national recommendations. RESULTS: Of 215 persons reported, 204 (94.9%) had a client record in the Wisconsin Immunization Registry. Of these 204 persons, 66 (32.4%) had received ≥1 dose of hepatitis A vaccine, 46 (22.5%) had received 2 doses of hepatitis A vaccine, and 115 (56.4%) had received 3 doses of hepatitis B vaccine. Hepatitis B vaccine coverage decreased with increasing age, from 88.0% (22 of 25) among adults aged 20-24 to 30.3% (10 of 33) among adults aged 35-39. CONCLUSIONS: These findings suggest that most persons who inject drugs in Wisconsin are susceptible to HAV infection and that most persons aged ≥35 who inject drugs are susceptible to HBV infection. In addition to routine vaccination of children, targeted hepatitis vaccination programs should focus on adults who inject drugs to help prevent future infections.

Incorporating rapid HIV testing into partner counseling and referral services.

OBJECTIVES: Partner counseling and referral services (PCRS) provide a unique opportunity to decrease transmission of human immunodeficiency virus (HIV) by notifying sex and drug-injection partners of HIV-infected individuals of their exposure to HIV. We incorporated rapid HIV testing into PCRS to reduce barriers associated with conventional HIV testing and identify undiagnosed HIV infection within this high-risk population. METHODS: From April 2004 through June 2006, HIV-infected people (index clients) were interviewed, and their partners were notified of their potential exposure to HIV and offered rapid HIV testing at six sites in the United States. The numbers of index clients participating and the numbers of partners interviewed and tested were compared by site. Descriptive and bivariate analyses were performed. RESULTS: A total of 2,678 index clients were identified, of whom 779 (29%) provided partner locating information. A total of 1,048 partners were elicited, of whom 463 (44%) were both interviewed and tested for HIV. Thirty-seven partners (8%) were newly diagnosed with HIV. The number of index clients interviewed to identify one partner with newly diagnosed HIV infection ranged from 10 to 137 at the participating sites. CONCLUSIONS: PCRS provides testing and prevention services to people at high risk for HIV infection. Incorporating rapid HIV testing into PCRS and identifying previously undiagnosed infections likely confer individual and public health benefits. Further evaluation is needed to determine the best methods of identifying partners with previously unrecognized HIV infection.

Hepatitis C virus infection: an overview of Wisconsin's public health resources.

Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States, with an estimated 3.9 million infected persons nationally and 85,000 persons infected in Wisconsin. HCV infection results in significant morbidity and mortality and contributes to high health care costs associated with specialized medical care, medications, and hospitalization. This report is an overview of HCV-related resources for consumers and clinicians caring for persons with HCV infection in Wisconsin.

Wisconsin trends in pneumonia and influenza mortality, 1980-2003.

INTRODUCTION: Mortality due to pneumonia and influenza continues to be a serious public health threat, especially among those aged > or = 65. Continued monitoring of these high-risk populations is necessary for evaluating the impact of public health prevention activities, determining vaccine distribution policies, and ensuring that existing guidelines reflect the populations at risk. OBJECTIVES: We characterized pneumonia and influenza mortality in Wisconsin from 1980 to 2003, including trend analysis, identification of high risk populations, and assessment of Wisconsin's progress toward state and national goals for vaccination. METHODS: We examined mortality trends for pneumonia and influenza as underlying causes of death among all Wisconsin residents who died in the state from 1980 to 2003. RESULTS: The pneumonia and influenza (P&I) mortality rate increased from 27/100,000 to 38/100,000 during 1980 through 1988, and then decreased to 26/100,000 through 2003. The decline in the mortality rate after 1988 was temporally associated with improving pneumococcal and influenza vaccination among those > or = 65. By 2003, all age groups except those aged > or = 85 had lower P&I mortality than in 1980. CONCLUSIONS: In Wisconsin, the increase in pneumonia and influenza mortality demonstrated during the 1980s was reversed. However, there was relatively little change in mortality among those aged 65-84 and rates among those > or = 85 years have increased. Novel improvements in public health interventions are needed to improve the focus on the elderly, including efforts to increase vaccination, prevent pneumococcal disease, and explore other evidence-based strategies to reduce pneumonia and influenza mortality.

Epidemiologic trends in infection, mortality, and transplants related to hepatitis C in Wisconsin.

Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the United States. An estimated 3.9 million persons nationally and 85,000 persons in Wisconsin are currently infected. The disease is responsible for approximately 8000 to 10,000 deaths nationally each year. This article summarizes epidemiologic trends in infection, mortality and transplants related to HCV in Wisconsin. It presents surveillance data collected during 1997-2004; HCV-related deaths during 1995-2002, with HCV as an underlying or contributing cause of death; and data for liver transplants related to HCV between 1993 and 2004. During the time periods reviewed, there were 16,668 cases of HCV infection reported, 1186 HCV-related deaths, and 356 HCV-related liver transplants involving HCV in Wisconsin. Infection rates and related adverse health outcomes related to HCV are highest in males, persons ages 35-64, Milwaukee residents, and inmates in the state correctional system. African Americans have high rates of morbidity (24% of cases) and mortality (16% of decedents), but are under-represented among recipients of HCV-related transplants (6% of recipients).

Prenatal HIV testing in Wisconsin: results of a survey among women who gave birth in 2003.

Since 1995 the United States Public Health Service has recommended voluntary prenatal human immunodeficiency virus (HIV) testing for all pregnant women in the United States. To better understand how well this goal is being met in Wisconsin, the Wisconsin Division of Public Health facilitated a review of hospital medical records for a random sample of women who gave birth in Wisconsin in 2003. Of the 968 maternal medical records reviewed, 68% (95% CI: 65%-71%) showed evidence that the mother had a completed HIV antibody test during pregnancy. Rates of prenatal HIV testing were higher in Milwaukee County. After controlling for residence, prenatal HIV testing rates were higher among Hispanic mothers compared to white mothers; African American and white mothers had similar testing rates. These data suggest that the goal of voluntary HIV testing for all pregnant women is not currently being met in Wisconsin.

Performance of Risk-Based and Birth-Cohort Strategies for Identifying Hepatitis C Virus Infection Among People Entering Prison, Wisconsin, 2014.

OBJECTIVES: The prevalence of hepatitis C virus (HCV) infection among young adults is rising in Wisconsin. We examined the prevalence of HCV infection among male and female inmates entering two Wisconsin prisons and evaluated existing and alternate risk-based strategies for identifying HCV infection at intake. METHODS: We added HCV testing to the intake procedures for all 1,239 adults prison entrants at the Wisconsin Department of Corrections (WDOC) from November 3, 2014, to January 31, 2015. We identified risk factors associated with HCV infection during the routine intake examination and calculated the sensitivity and specificity of risk-based testing strategies for identifying HCV infection. RESULTS: The prevalence of HCV antibody among prison entrants was 12.5% (95% confidence interval [CI] 10.7, 14.4) overall and was almost two times higher at the women's facility (21.3%, 95% CI 15.4, 27.2) than at the men's facility (11.0%, 95% CI 0.0, 12.9) (p<0.001). The sensitivity and specificity of the WDOC risk-based criteria were 88% (95% CI 83, 93) and 80% (95% CI 78, 83), respectively. Adding a new criterion, the 1945-1965 birth cohort, to the risk-based criteria improved the sensitivity to 92% (95% CI 88, 96) and lowered the specificity to 71% (95% CI 68, 74). Compared with entrants without these risk factors, HCV antibody prevalence was significantly higher among prison entrants who had the following risk factors: injection drug use (prevalence ratio [PR] = 9.9, 95% CI 7.4, 13.2), liver disease (PR=9.7, 95% CI 7.8, 12.0), and elevated levels of alanine transaminase (PR=3.6, 95% CI 2.7, 4.9). CONCLUSION: The WDOC risk criteria for HCV testing identified 88% of HCV infections among prison entrants. Including the 1945-1965 birth cohort as a criterion along with the other WDOC risk criteria increased the sensitivity of targeted testing to 92%. These findings may be informative to jurisdictions where universal HCV testing is not feasible because of resource limitations.

Reductions in transmission risk behaviors in HIV-positive clients receiving prevention case management services: findings from a community demonstration project.

Prevention case management (PCM) for HIV-infected persons is an HIV risk reduction intervention designed to assist clients who are aware of their HIV infection and who continue to engage in risk transmission behaviors. PCM combines individual risk reduction counseling with case management to address the psychosocial factors affecting HIV transmission. More than 350 HIV-positive clients participated in PCM in Wisconsin between 2000 and 2003, and 109 completed both baseline and follow-up risk assessments. The percentage of clients reporting risk transmission behaviors, specifically unprotected vaginal intercourse, insertive anal intercourse, or needle sharing with partners of negative or unknown HIV status, declined from 41.3% at baseline to 29.4% at follow-up (p = 0.04). Furthermore, clients showed progression (p < or =.05) through stages of change using Prochaska and DiClemente's transtheoretical model on seven domains related to HIV transmission risk, including personalizing risk of HIV transmission and sexual risk behavior.

Provider Workforce Assessment in a Rural Hepatitis C Epidemic: Implications for Scale-up of Antiviral Therapy.

New recommendations for birth cohort screening for hepatitis C virus (HCV) infection and the development of new, highly effective antiviral medications are expected to increase the demand for HCV treatment. In the past, antiviral therapy for HCV was almost exclusively prescribed by specialists in the field of gastroenterology and infectious diseases, meaning that people living in rural areas that are underserved by specialists may have poor access to treatment. We investigated the number and geographic distribution of medical providers who actively prescribed direct acting antiviral drugs for hepatitis C in Wisconsin during 2012. Using public health surveillance data and a state-wide prescription drug database, we found that there was 1 treatment provider for every 340 residents known to be living with HCV. However, 51 of 72 Wisconsin counties had no providers who provided HCV treatment in 2012.Scaling up antiviral treatment to address the epidemic of hepatitis C efficiently and equitably will require strategies to increase the number of treatment providers in rural communities. Providing education, training, and support to the primary care workforce serving rural communities should be considered a potentially effective and efficient approach to preventing future HCV-related illness.

Partner Referral by HIV-Infected Persons to Partner Counseling and Referral Services (PCRS) - Results from a Demonstration Project.

OBJECTIVE: The objectives of this article are to determine factors associated with refusal and agreement to provide partner information, and evaluate the effectiveness of referral approaches in offering PCRS. METHODS: Index clients from 5 sites that used 3 different PCRS approaches were interviewed to obtain demographic and risk characteristics and choice of partner referral method for PCRS. Logistic regression was used to assess factors associated with providing partner information. RESULTS: The percentage of index clients who refused to provide partner information varied by site (7% to 88%). Controlling for PCRS approach, index clients who were older than 25 years, male, or reported having male-male sex in the past 12 months were more likely (p <0.01) to refuse to provide partner information. Overall, 72% of named partners referred by index clients were located and offered PCRS. The proportion of partners who were located and offered PCRS differed by referral approach used, ranging from 38% using contract referral (index clients agree to notify their partners within a certain timeframe, else a disease intervention specialist or health care provider will notify them) to 98% using dual referral (index clients notify their partners with a disease intervention specialist or provider present). CONCLUSION: Success in obtaining partner information varied by the PCRS approach used and effectiveness in locating and notifying partners varied by the referral approach selected. These results provide valuable insights for enhancing partner services.