Characteristics of Adults Aged ≥18 Years Evaluated for Substance Use and Treatment Planning - United States, 2019.

In 2019, 65.8 million U.S. adults reported past-month binge drinking and 35.8 million reported illicit drug use or prescription pain reliever misuse during the past month; 20.4 million met diagnostic criteria for a substance use disorder during the past year (1). Approximately 81,000 persons died of a drug overdose* during May 2019-May 2020; excessive alcohol use contributes to an estimated 95,000 deaths per year (2). Persons with a substance use disorder are at elevated risk for overdose and associated harms (3). To examine the prevalence of past 30-day substance use patterns and the severity of problems experienced across seven biopsychosocial domains (alcohol, drug, employment, family, legal, medical, and psychiatric), CDC used 2019 data from the National Addictions Vigilance Intervention and Prevention Program (NAVIPPRO) Addiction Severity Index-Multimedia Version (ASI-MV) tool (4); these data are collected from adults aged ≥18 years who seek substance use treatment in the United States. Alcohol was the most commonly reported substance used during the past 30 days (35.8%), followed by cannabis (24.9%), prescription opioids (misuse) (18.5%), illicit stimulants (14.0%), heroin (10.2%), prescription sedatives or tranquilizers (misuse) (8.5%), cocaine (7.4%), illicit fentanyl (4.9%), and prescription stimulants (misuse) (1.8%).† Polysubstance use (use of two or more substances) during the past 30 days was reported by 32.6% of respondents. Among the biopsychosocial domains measured, 45.4% of assessments reported more severe problems with drugs; others reported psychiatric (35.2%), legal (28.8%), medical (27.4%), employment (25.0%), alcohol (24.2%), and family problems (22.8%). These findings highlight the complex nature of substance use in the United States, the interplay between substance use and mental illness, and the complex challenges that persons with substance use disorder face when seeking treatment. Actions to enhance comprehensive substance use programs that incorporate polysubstance use and co-occurring mental health problems into strategies for prevention, treatment, and response are needed, as is expanded linkage to services. CDC provides data and resources to equip and inform states, territories, and local jurisdictions to help improve opioid prescribing practices, improve linkage to care for the treatment of opioid use disorder, and prevent and reverse overdoses.§.

Using Registry Data to Construct a Comparison Group for Programmatic Effectiveness Evaluation: The New York City HIV Care Coordination Program.

Many nonrandomized interventions rely upon a pre-post design to evaluate effectiveness. Such designs cannot account for events external to the intervention that may produce the outcome. We describe a method to construct a surveillance registry-based comparison group, which allows for estimating the effectiveness of the intervention while controlling for secular trends in the outcome of interest. Using data from the population-based, human immunodeficiency virus Surveillance Registry in New York City, we created a contemporaneous comparison group for persons enrolled in the New York City human immunodeficiency virus Care Coordination Program (CCP) from December 2009 to March 2013. Inclusion in the Registry-based (non-CCP) comparison group required meeting CCP eligibility criteria. To control for secular trends in the outcome, we randomly assigned persons in the non-CCP, Registry-based comparison group a pseudoenrollment date such that the distribution of pseudoenrollment dates matched the distribution of enrollment dates among CCP enrollees. We then matched CCP to non-CCP persons on propensity for enrollment in the CCP, enrollment dates, and baseline viral load. Registry-based comparison group estimates were attenuated relative to pre-post estimates of program effectiveness. These methods have broad applicability for observational intervention effectiveness studies and programmatic evaluations for conditions with surveillance registries.

Persons living with diagnosed HIV in New York City: over 50% over 50 years old.

Using NYC HIV surveillance data, we estimated the annual median age of persons living with diagnosed HIV (PLWDH) and the proportion of PLWDH over 50 years old in NYC between 2008 and 2015, and described the characteristics, retention in care and viral suppression status among PLWDH in NYC in 2015, by age (<50 vs. ≥50 years old). The median age of PLWDH in NYC increased from 46.4 years (interquartile range [IQR]: 39.4, 53.2) in 2008 to 50.2 years (IQR: 39.8, 57.5) in 2015, and the proportion of PLWDH over 50 years old increased from 35.9% in 2008 to 50.6% in 2015. In 2015, by race/ethnicity, whites had the highest proportion over 50 years old (57.0%) and Asian/Pacific Islanders had the lowest (36.2%); by transmission risk, men who have sex with men were the lowest (40.0%) and injection drug users were the highest (76.1%). A large and increasing proportion of PLWDH over 50 years old presents challenges for HIV-infected individuals and healthcare system. Better social support services for HIV-infected individuals and additional training for medical and public health staff are needed.

Come as You Are: Improving Care Engagement and Viral Load Suppression Among HIV Care Coordination Clients with Lower Mental Health Functioning, Unstable Housing, and Hard Drug Use.

Lower mental health functioning, unstable housing, and drug use can complicate HIV clinical management. Merging programmatic and surveillance data, we examined characteristics and outcomes for HIV Care Coordination clients enrolled between December 2009 and March 2013. For clients diagnosed over 12 months before enrollment, we calculated post- versus pre-enrollment relative risks for short-term (12-month) care engagement and viral suppression. Both outcomes significantly improved in all subgroups, including those with lower mental health functioning, unstable housing, or hard drug use. Analyses further stratified within barrier-affected groups showed a tendency toward greater improvement when that barrier was reduced during the follow-up year.

Validation of Retention in HIV Care Status Using the New York City HIV Surveillance Registry and Clinical Care Data From a Large HIV Care Center.

CONTEXT: Improving retention in care is a key element of the National HIV/AIDS Strategy (NHAS). However, definitions for measuring retention in care are not standardized. OBJECTIVE: To compare measures of retention based on both clinic visit data and HIV laboratory surveillance data. DESIGN: Retrospective cohort study. SETTING: New York City (NYC), New York. PARTICIPANTS: We matched adult patients with HIV infection seen at the Spencer Cox Center for Health (SCC) in 2010 or 2011 with the NYC HIV Surveillance Registry. MAIN OUTCOME MEASURES: Retention in care was measured on the basis of SCC electronic medical record (EMR) data (≥1 medical visits in 2012) and Surveillance Registry data (≥2 CD4/viral load [VL] tests ≥90 days apart in 2012). RESULTS: There were 5746 adult HIV-infected patients seen at SCC between 2010 and 2011 who matched with the Surveillance Registry. Seventy-eight percent (n = 4469) had 1 or more medical visits at SCC in 2012 and were considered retained on the basis of the EMR definition, among which 3831 (86%) met the surveillance definition for retention in care. Patients who did not have a medical visit at SCC in 2012 (n = 1277) were lost to care in NYC (n = 485; 36%), engaged in care at an alternate provider (n = 622; 49%), or died after their last SCC visit (n = 197; 15%). IMPLICATIONS: This study is an important comparison of laboratory surveillance versus clinic visit-based measures of retention in care in an urban setting with the largest HIV epidemic in the country. Collaborative projects between local health departments and clinical care providers can help validate the care status of patients and inform the allocation of resources to reengage patients who are lost to care. CONCLUSION: The combined use of laboratory and clinic visit-based data to measure retention in care provides a more accurate representation of the care status of HIV-infected patients than use of a single data source alone. Routine sharing of data by public health institutions and clinical care providers would help target resources toward reengaging patients who are lost to care in jurisdictions with universal HIV-related laboratory reporting.

Improvements in HIV care engagement and viral load suppression following enrollment in a comprehensive HIV care coordination program.

BACKGROUND: Substantial evidence gaps remain regarding human immunodeficiency virus (HIV) intervention strategies that improve engagement in care (EiC) and viral load suppression (VLS). We assessed EiC and VLS before and after enrollment in a comprehensive intervention for persons at risk of poor HIV care outcomes. METHODS: New York City's Ryan White Part A HIV Care Coordination Program (CCP), launched at 28 agencies in 2009, applies multiple strategies to promote optimal utilization of medical and social services. Using laboratory test records from an HIV surveillance registry, we examined pre-post outcomes among 3641 CCP clients enrolled before April 2011. For the year before and after enrollment, we assessed EiC (defined as ≥2 tests, ≥90 days apart, with ≥1 in each half-year) and VLS (defined as viral load [VL] ≤200 copies/mL on latest VL test in the second half of the year). We estimated relative risks (RRs), comparing pre- and postenrollment proportions achieving EiC and VLS. RESULTS: Among newly diagnosed clients, 90.5% (95% confidence interval [CI], 87.9%-93.2%) and 66.2% (95% CI, 61.9%-70.6%) achieved EiC and VLS, respectively. Among previously diagnosed clients, EiC increased from 73.7% to 91.3% (RR = 1.24; 95% CI, 1.21-1.27) and VLS increased from 32.3% to 50.9% (RR = 1.58; 95% CI, 1.50-1.66). Clients without evidence of HIV care during the 6 months preenrollment contributed most to overall improvements. Pre-post improvements were robust, retaining statistical significance within most sociodemographic and clinical subgroups, and in 89% (EiC) and 75% (VLS) of CCP agencies. CONCLUSIONS: Clients in comprehensive HIV care coordination for persons with evident barriers to care showed substantial and consistent improvement in short-term outcomes.

Protein inactivation in mycobacteria by controlled proteolysis and its application to deplete the beta subunit of RNA polymerase.

Using a component of the Escherichia coli protein degradation machinery, we have established a system to regulate protein stability in mycobacteria. A protein tag derived from the E. coli SsrA degradation signal did not affect several reporter proteins in wild-type Mycobacterium smegmatis or Mycobacterium tuberculosis. Expression of the adaptor protein SspB, which recognizes this modified tag and helps deliver tagged proteins to the protease ClpXP, strongly decreased the activities and protein levels of different reporters. This inactivation did not occur when the function of ClpX was inhibited. Using this system, we constructed a conditional M. smegmatis knockdown mutant in which addition of anhydrotetracycline (atc) caused depletion of the beta subunit of RNA polymerase, RpoB. The impact of atc on this mutant was dose-dependent. Very low amounts of atc did not prevent growth but increased sensitivity to an antibiotic that inactivates RpoB. Intermediate amounts of RpoB knockdown resulted in bacteriostasis and a more substantial depletion led to a decrease in viability by up to 99%. These studies identify SspB-mediated proteolysis as an efficient approach to conditionally inactivate essential proteins in mycobacteria. They further demonstrate that depletion of RpoB by ∼ 93% is sufficient to cause death of M. smegmatis.

Brief Report: Drug Overdose Deaths Among People With HIV in New York City, 2007-2017.

BACKGROUND: Preventable deaths, including those because of drug overdose (OD), are a significant public health concern in New York City (NYC). Trends in drug OD death among people with HIV (PWH) in NYC have not been described. METHODS: We selected PWH from the NYC HIV Registry who died during 2007-2017, resided in NYC at death, and died because of drug OD. We characterized PWH who died of drug OD and analyzed CD4 and viral load tests from surveillance to evaluate retention in care and viral suppression (viral load < 200 cc/mL) in the 12 months before death as markers of care-seeking. RESULTS: From 2007 to 2017, 870 NYC PWH died of drug OD. Of the total OD deaths, 821 (94.4%) were classified as accidental and 49 (5.6%) as intentional. Although the rate of OD deaths among PWH declined during the full period, from 58.5 per 100,000 in 2007 to 47.9 per 100,000 in 2017, it increased from 2014 (30.9/100,000) to 2016 (53.3/100,000) and stayed high through 2017 (47.9/100,000). Decedents during 2007-2017 were predominantly men (70.8%), Black (38.0%) or Latino/Hispanic (38.7%), aged 40-59 years (73.2%), and had a history of injection drug use (43.0%). Over 3-quarters (80.1%) of decedents were retained in HIV care in the 12 months preceding death; 45.4% were viral suppression. CONCLUSIONS: A sizeable number of PWH died of OD during 2007-2017, and OD death rates in recent years increased. Predeath care patterns reveal frequent interaction with the health care system, underscoring missed opportunities for harm-reduction and suicide prevention interventions for PWH.

Nonmedical Use of Xtampza® ER and Other Oxycodone Medications in Adults Evaluated for Substance Abuse Treatment: Real-World Data from the Addiction Severity Index-Multimedia Version (ASI-MV®).

PURPOSE: The purpose of this study was to evaluate real-world data related to past 30-day nonmedical use (NMU) and routes of administration of Xtampza® ER and comparator oxycodone medications in the US as captured within the Addiction Severity Index-Multimedia Version® (ASI-MV®). METHODS: Data were collected from July 2016 through December 2019 from 647 centers located in 44 states using the ASI-MV, a clinical instrument used to evaluate substance use and treatment planning. Demographic characteristics were assessed using Pearson's chi-square test for categorical data and quarterly NMU rates were calculated. Distribution of route of administration was studied using a proportional reporting ratio (PRR) analysis. RESULTS: Of 192,810 assessments, 42,279 (21.9%) indicated past 30-day NMU of at least one prescription opioid, including Xtampza ER (N=73, 0.2%), other oxycodone ER (n=3802, 9.0%) and oxycodone IR (n=14,579, 34.5%). All quarterly Xtampza ER NMU rates per 100 ASI-MV assessments were significantly lower than those for other oxycodone ER and oxycodone IR. Overall, quarterly Xtampza ER NMU drug utilization adjusted rates were significantly lower than quarterly rates observed for other oxycodone ER NMU but not consistently significantly lower than oxycodone IR NMU. Although not all statistically significant, all ratios from the PRR analysis were less than 1.0, indicating that rates of use of any alternate route, any non-oral route, snorting, and injecting were higher for other oxycodone ER and oxycodone IR than for Xtampza ER. CONCLUSION: Xtampza ER had significantly lower rates of NMU than other oxycodone ER products and oxycodone IR products, as well as significantly lower rates of non-oral NMU than oxycodone IR products, in a population of individuals seeking substance abuse treatment. Understanding risks associated with different opioid medications is important for prescribers as they manage risks of opioid misuse and abuse with effective pain therapy.

Characterizing prescription stimulant nonmedical use (NMU) among adults recruited from Reddit.

OBJECTIVE: Increased prescription stimulant nonmedical use (NMU) is part of a growing polysubstance use landscape. The purpose of the present study was to characterize prescription stimulant NMU among adults reporting past 5-year non-oral prescription stimulant NMU. METHODS: Adults who reported non-oral prescription stimulant NMU within the last 5 years were recruited by banner ads placed on the Reddit website between February and September 2019. Types of prescription stimulants used, routes of administration, preferred routes of administration, motivations for prescription stimulant NMU, concurrent substances used simultaneously during prescription stimulant NMU, illicit substances used and factors impacting prescription stimulant NMU were queried. RESULTS: Respondents (n = 225) were male (86.2%), non-Hispanic (92.4%), white (78.2%), between 18 and 24 (48.0%) or 25-34 (43.1%) years with some amount of college education (81.3%). Most reported lifetime intranasal (93.8%) or oral use (85.2%). Prescription stimulants were diverted: 64.5% reported the prescription stimulants were given to them by a family or a friend and 10.5% reported that they had stolen these medications from a family or friend. Preferred route of administration was oral use (70.2%). Motivations to use were stratified by route of administration: intranasal (55.6%) or oral (63.0%) use was primarily endorsed as an attempt to enhance performance at work or at school; use by injection (57.1%) or smoking (62.5%) was primarily endorsed to get high. Most of the sample reported concurrent drug use (79.1%) including tobacco (57.3%), marijuana (52.0%), caffeine (47.6%) or alcohol (41.8%), among others. When excluding licit substances, 30.7% reported using 1 illicit substance concurrently with prescription stimulants and 25.3% reported using 2 or more illicit substances concurrently with prescription stimulants. Whether participants would undertake prescription stimulant NMU was determined by their work/school schedules or the location of the NMU (48.9%) whereas the route of administration employed was primarily influenced by the desired feeling or effect (56.9%). CONCLUSIONS: Adults reporting lifetime non-oral prescription stimulant NMU engage in substantial risky behaviors that in addition to alternate routes of administration include polysubstance use, diversion and concurrent substance use.

Non-medical Use of Prescription Stimulants Among College Students: Non-oral Routes of Administration, Risk Factors, Motivations, and Pathways.

Introduction: Non-medical use (NMU) of prescription stimulant medications is a continuing public health concern. Stimulant medications prescribed for attention-deficit/hyperactivity disorder (ADHD) are widely available on college campuses, and, as a consequence, college students may have multiple opportunities to engage in prescription stimulant NMU. This online self-report survey examined prescription stimulant NMU among college students, including: (1) patterns of non-oral route of administration (ROA); (2) motivations for non-oral ROAs; and (3) retrospectively recalled pathways of initiation. Method: The survey sample was created from a pool of 3,379 respondents, who were matched to a sampling frame constructed from the 18-26-year-old, college student sample of the 2016 American Community Survey (ACS). About 14% (n = 486) from the overall pool were identified as college students with self-reported prescription stimulant NMU, all of whom completed the survey. The survey covered user characteristics, prescription and illicit substance use, age of first NMU, motivations for NMU, sources of procurement, and ROAs used. Results: Among 486 students reporting prescription stimulant NMU, 43% had a lifetime diagnosis of ADHD. More than 90% reported polysubstance use, with 55% using illicit substances other than marijuana. Slightly more than 2 in 5 (43.3%) reported using illicit substances prior to prescription stimulant NMU, 24.6% used both at the same age, and 32.0% engaged in NMU of prescription stimulants prior to using illicit substances. Prescription stimulant NMU preceded prescription opioid NMU 45% of the time. More than a quarter of those engaged in prescription stimulant NMU (27.9%) initiated prescription stimulants alone or at the same age as other drugs. Most prescription stimulant NMU was oral, however 23.0% reported any non-oral use: snorting (20.4%), smoking (6.0%)and/or injection (3.5%). Non-oral use was associated with being male, obtaining medication from a dealer, use to get high, and/or a substance use disorder diagnosis. Conclusions: Prescription stimulant NMU often occurs in the larger context of other substance use among college students. Injection, an under-researched route for prescription stimulants, was associated with male gender, history of substance use and higher likelihood of illicit substance use. Nearly a quarter of college student survey respondents reported use with non-oral routes, which is associated with other high-risk behaviors. Efforts to reduce non-oral prescription stimulant NMU in college students are warranted.

Characterizing Pathways of Non-oral Prescription Stimulant Non-medical Use Among Adults Recruited From Reddit.

Objective: Prescription stimulant non-medical use (NMU) is a national predicament. While the risks of prescription stimulant NMU have been considered, less is known about non-oral use. To focus on this gap, a sample of adults with non-oral prescription stimulant NMU within the last 5-years was recruited. The purpose of the present study was to characterize the pathways and substance transitions associated with prescription stimulant NMU and non-oral prescription stimulant NMU in this unique sample of adults. Methods: Adults (n = 225) reporting non-oral prescription stimulant NMU within the last 5 years were recruited to complete an online survey by banner ads placed on the Reddit website between February and September 2019. After completion of the survey, a second study consisting of an in-depth telephone interview was conducted with 23 participants: interviews took place between July and September 2019. Data reported here include substance, route of administration and class transitions, as well as qualitative data from the interviews. Results: Approximately 1 in 5 began their substance use trajectory with prescription stimulants (19.1%). Other than marijuana, most exposures to illicit substances occurred after both initial prescription stimulant NMU and initial non-oral prescription stimulant NMU. The most frequently reported route of administration transition was from oral use to snorting (n = 158, 70.2%), however, other route of administration transitions included oral use to injection drug use (n = 14, 6%). In-depth interviews elaborated upon these transitions and indicated that prescription stimulant NMU was consequential to substance use pathways. Conclusions: Oral prescription stimulant NMU was a precursor to non-oral prescription stimulant NMU. Non-oral prescription stimulant NMU was a precursor to illicit substance use, suggesting that prescription stimulant NMU impacts substance use pathways and revealing opportunities for intervention.

New York City HIV Care Continuum Dashboards: Using Surveillance Data to Improve HIV Care Among People Living With HIV in New York City.

BACKGROUND: HIV surveillance data can be used to improve patient outcomes. OBJECTIVE: This study aimed to describe and present findings from the HIV care continuum dashboards (CCDs) initiative, which uses surveillance data to quantify and track outcomes for HIV patients at major clinical institutions in New York City. METHODS: HIV surveillance data collected since 2011 were used to provide high-volume New York City clinical facilities with their performance on two key outcomes: linkage to care (LTC), among patients newly diagnosed with HIV and viral load suppression (VLS), among patients in HIV care. RESULTS: The initiative included 21 facilities covering 33.78% (1135/3360) of new HIV diagnoses and 46.34% (28,405/61,298) of patients in HIV care in New York City in 2011 and was extended to a total of 47 sites covering 44.23% (1008/2279) of new diagnoses and 69.59% (43,897/63,083) of New York City patients in care in 2016. Since feedback of outcomes to providers began, aggregate LTC has improved by 1 percentage point and VLS by 16 percentage points. CONCLUSIONS: Disseminating information on key facility-level HIV outcomes promotes collaboration between public health and the clinical community to end the HIV epidemic. Similar initiatives can be adopted by other jurisdictions with mature surveillance systems and supportive laws and policies.

Impact of an HIV Care Coordination Program on Durable Viral Suppression.

BACKGROUND: To assess long-term effectiveness of an intensive and comprehensive Ryan White Part A-funded HIV Care Coordination Program recruiting people living with HIV with a history of suboptimal HIV care outcomes. METHODS: We merged programmatic data on CCP clients with surveillance data on all adults diagnosed with HIV. Using propensity score matching, we identified a contemporaneous, non-CCP-exposed comparison group. Durable viral suppression (DVS) was defined as regular viral load (VL) monitoring and all VLs ≤200 copies per milliliter in months 13-36 of follow-up. RESULTS: Ninety percent of the combined cohort (N = 12,414) had ≥1 VL ≤200 during the follow-up period (December 1, 2009-March 31, 2016), and nearly all had routine VL monitoring, but only 36.8% had DVS. Although DVS did not differ overall (relative risk: 0.99, 95% confidence interval: 0.95 to 1.03), CCP clients without any VL suppression (VLS) in the 12-month pre-enrollment showed higher DVS versus "usual care" recipients (21.3% versus 18.4%; relative risk: 1.16, 95% confidence interval: 1.04 to 1.29). CONCLUSIONS: Enrollment in an intensive intervention modestly improved DVS among those unsuppressed before CCP enrollment. This program shows promise for meeting treatment-as-prevention goals and advancing progress along the HIV care continuum, if people without evidence of VLS are prioritized for CCP enrollment over those with recent evidence of VLS. Low overall DVS (<40%) levels underscore a need for focused adherence maintenance interventions, in a context of high treatment access.

Short-term effectiveness of HIV care coordination among persons with recent HIV diagnosis or history of poor HIV outcomes.

The New York City HIV Care Coordination Program (CCP) combines multiple evidence-based strategies to support persons living with HIV (PLWH) at risk for, or with a recent history of, poor HIV outcomes. We assessed the comparative effectiveness of the CCP by merging programmatic data on CCP clients with population-based surveillance data on all New York City PLWH. A non-CCP comparison group of similar PLWH who met CCP eligibility criteria was identified using surveillance data. The CCP and non-CCP groups were matched on propensity for CCP enrollment within four baseline treatment status groups (newly diagnosed or previously diagnosed and either consistently unsuppressed, inconsistently suppressed or consistently suppressed). We compared CCP to non-CCP proportions with viral load suppression at 12-month follow-up. Among the 13,624 persons included, 15∙3% were newly diagnosed; among the 84∙7% previously diagnosed, 14∙2% were consistently suppressed, 28∙9% were inconsistently suppressed, and 41∙6% were consistently unsuppressed in the year prior to baseline. At 12-month follow-up, 59∙9% of CCP and 53∙9% of non-CCP participants had viral load suppression (Relative Risk = 1.11, 95%CI:1.08-1.14). Among those newly diagnosed and those consistently unsuppressed at baseline, the relative risk of viral load suppression in the CCP versus non-CCP participants was 1.15 (95%CI:1.09-1.23) and 1.32 (95%CI:1.23-1.42), respectively. CCP exposure shows benefits over no CCP exposure for persons newly diagnosed or consistently unsuppressed, but not for persons suppressed in the year prior to baseline. We recommend more targeted case finding for CCP enrollment and increased attention to viral load suppression maintenance.

Missed Opportunities: Adapting the HIV Care Continuum to Reduce HIV-Related Deaths.

INTRODUCTION: With advances in HIV care, persons with HIV/AIDS (PWHA) can lead healthy lives, but avoidable HIV-related deaths continue to occur in New York City (NYC). METHODS: We selected PWHA from our surveillance registry who died between 2007 and 2013, resided in NYC, and survived ≥15 months after diagnosis to generate an HIV Mortality Reduction Continuum of Care (HMRCC) describing predeath care patterns among PWHA. We used HIV laboratory test reports to measure care outcomes during an "intervenable period" during which deaths may have been avoided. The continuum was stratified by the underlying cause of death (HIV-related vs. other), and the HIV-related HMRCC was stratified by demographic characteristics. RESULTS: Eleven thousand one hundred eighty-seven analysis-eligible PWHA died during 2007-2013. Ninety-eight percent linked to care; 80% were retained in care during the intervenable period; 66% were prescribed antiretroviral therapy; 47% had viral load ≤1500 copies/mL; and 40% achieved viral suppression (VS). Half (47%) of the deaths were HIV-related. Retention was higher among HIV-related cause of death (83% vs. 78%) but VS was lower (34% vs. 46%). The HIV-related HMRCC revealed disparities in VS. Despite comparable retention rates, whites had the highest VS (42%, vs. 32% blacks and 33% Latinos/Hispanics). In addition, retention and VS increased with increasing age. People with a history of injection drug use had relatively high rates of retention (88%) and VS (37%). DISCUSSION: The HMRCC is a novel framework for evaluating predeath care patterns among PWHA and identifying opportunities to reduce preventable deaths. In NYC, reducing mortality will require increasing VS among those already in care, particularly for blacks and Latinos/Hispanics.

Racial and socioeconomic disparities in viral suppression among persons living with HIV in New York City.

PURPOSE: To examine differences in racial disparities across levels of neighborhood poverty and differences in socioeconomic disparities by race/ethnicity in viral suppression among persons living with HIV (PLWH). METHODS: Using HIV surveillance data, we categorized and geocoded PLWH who were in care in New York City (NYC). Multilevel binomial regression techniques were used to model viral suppression with a two-level hierarchical structure, by including age, transmission risk, year of diagnosis, race/ethnicity, census tract poverty, and an interaction term of race/ethnicity and census tract poverty in the model. RESULTS: There were 30,638 Blacks, 22,921 Hispanics, and 11,695 Whites living with HIV and retained in care in NYC, 2014. Compared with Blacks living in the most impoverished neighborhoods (≥30% residents living below the federal poverty level) who had the lowest proportion of viral suppression, with 75% in males and 76% in females, Whites living in the least impoverished neighborhoods (<10% residents living below the federal poverty level) had the highest, with 92% in males (prevalence ratio = 1.16; 95% confidence interval: 1.13, 1.18) and 90% in females (PR = 1.14; 95% CI: 1.09, 1.19). CONCLUSIONS: By examining racial and socioeconomic disparities simultaneously, we were able to detect both disparities in viral suppression among PLWH in NYC.

Optimizing the use of surveillance data for monitoring the care status of persons recently diagnosed with HIV in NYC.

BACKGROUND: Comprehensive laboratory reporting of CD4 and viral load (VL) tests to surveillance has been used to assess HIV care-related outcomes at the population level, but their validity for this purpose has not been comprehensively evaluated. OBJECTIVE: Assess performance characteristics and validity of surveillance-based measures of linkage to and establishment of HIV primary care among HIV-infected persons in the first 12 months after diagnosis using medical record (MR) data on outpatient HIV primary care visits as the gold standard. METHODS: All patients diagnosed with HIV in 2009 at 24 New York City high-volume, HIV diagnostic and treatment facilities who linked to care within 12 months at the same site as defined by the presence of ≥1 CD4/VL report received by surveillance were selected for MR review to confirm linkage to outpatient HIV primary care within the first year. All HIV care visit dates were abstracted and considered associated with a surveillance laboratory report, if within 14 days of a care visit. The proportion linking to care according to the MR was compared with the proportion linking per CD4/VL tests reported to surveillance. Four measures of the establishment of outpatient HIV primary care in the first year were assessed: (1) sustained care (first visit within 3 months; second visit, 3-9 months later), (2) continuous care (2 visits at least 90 days apart), (3) trimester visits (visit in each 4-month period), and (4) visit constancy (visit in each 3-month period). The validity of surveillance data for measuring this outcome was assessed by comparing results for each of the 4 measures calculated using surveillance data to those calculated using MR data. RESULTS: Of the 782 patients selected, 20% (N = 157) of patients did not link to outpatient HIV primary care at the co-located care facility within 12 months of diagnosis. Half (48.5%) of patients' care visits after linkage did not have an associated CD4/VL reported to surveillance. Of the 4 establishment measures, sustained and continuous care had the highest agreement with MR (86.6% and 88.8%, respectively) as compared with the trimester visits and visit constancy (77.8% and 72.8%, respectively). CONCLUSIONS: Surveillance data overestimated linkage rates but underestimated the frequency of HIV care in the first year after HIV diagnosis. Of the 4 measures of establishment of HIV care evaluated, "sustained care" is best suited for measurement using surveillance data because of its high level of agreement with MR data and close alignment with national standards for timely linkage and flexible follow-up.