Using Data-To-Care Strategies to Optimize the HIV Care Continuum in Connecticut: Results From a Randomized Controlled Trial.

BACKGROUND: Re-engaging people with HIV who are newly out-of-care remains challenging. Data-to-care (D2C) is a potential strategy to re-engage such individuals. METHODS: A prospective randomized controlled trial compared a D2C strategy using a disease intervention specialist (DIS) vs standard of care where 23 HIV clinics in 3 counties in Connecticut could re-engage clients using existing methods. Using a data reconciliation process to confirm being newly out-of-care, 655 participants were randomized to DIS (N = 333) or standard of care (N = 322). HIV care continuum outcomes included re-engagement at 90 days, retention in care, and viral suppression by 12 months. Multivariable regression models were used to assess factors predictive of attaining HIV care continuum outcomes. RESULTS: Participants randomized to DIS were more likely to be re-engaged at 90 days (adjusted odds ratios [aOR] = 1.42, P = 0.045). Independent predictors of re-engagement at 90 days were age older than 40 years (aOR = 1.84, P = 0.012) and perinatal HIV risk category (aOR = 3.19, P = 0.030). Predictors of retention at 12 months included re-engagement at 90 days (aOR = 10.31, P < 0.001), drug injection HIV risk category (aOR = 1.83, P = 0.032), detectable HIV-1 RNA before randomization (aOR = 0.40, P = 0.003), and county (Hartford aOR = 1.74, P = 0.049; New Haven aOR = 1.80, P = 0.030). Predictors of viral suppression included re-engagement at 90 days (aOR = 2.85, P < 0.001), retention in HIV care (aOR = 7.07, P < 0.001), and detectable HIV-1 RNA prerandomization (aOR = 0.23, P < 0.001). CONCLUSIONS: A D2C strategy significantly improved re-engagement at 90 days. Early re-engagement improved downstream benefits along the HIV care continuum like retention in care and viral suppression at 12 months. Moreover, other factors predictive of care continuum outcomes can be used to improve D2C strategies.

The Cooperative Re-Engagement Controlled Trial (CoRECT): Durable Viral Suppression Assessment.

BACKGROUND: A collaborative, data-to-care strategy to identify persons with HIV (PWH) newly out-of-care, combined with an active public health intervention, significantly increases the proportion of PWH re-engaged in HIV care. We assessed this strategy's impact on durable viral suppression (DVS). METHODS: A multisite, prospective randomized controlled trial for out-of-care individuals using a data-to-care strategy and comparing public health field services to locate, contact, and facilitate access to care versus the standard of care. DVS was defined as the last viral load, the viral load at least 3 months before, and any viral load between the 2 were all <200 copies/mL during the 18-month postrandomization. Alternative definitions of DVS were also analyzed. RESULTS: Between August 1, 2016-July 31, 2018, 1893 participants were randomized from Connecticut (n = 654), Massachusetts (n = 630), and Philadelphia (n = 609). Rates of achieving DVS were similar in the intervention and standard-of-care arms in all jurisdictions (all sites: 43.4% vs 42.4%, P = 0.67; Connecticut: 46.7% vs 45.0%, P = 0.67; Massachusetts: 40.7 vs 44.4%, P = 0.35; Philadelphia: 42.4% vs 37.3%, P = 0.20). There was no association between DVS and the intervention (RR: 1.01, CI: 0.91-1.12; P = 0.85) adjusting for site, age categories, race/ethnicity, birth sex, CD4 categories, and exposure categories. CONCLUSION: A collaborative, data-to-care strategy, and active public health intervention did not increase the proportion of PWH achieving DVS, suggesting additional support to promote retention in care and antiretroviral adherence may be needed. Initial linkage and engagement services, through data-to-care or other means, are likely necessary but insufficient for achieving DVS for all PWH.

Costs and cost-effectiveness of a collaborative data-to-care intervention for HIV treatment and care in the United States.

INTRODUCTION: Data-to-care programmes utilize surveillance data to identify persons who are out of HIV care, re-engage them in care and improve HIV care outcomes. We assess the costs and cost-effectiveness of re-engagement in an HIV care intervention in the United States. METHODS: The Cooperative Re-engagement Control Trial (CoRECT) employed a data-to-care collaborative model between health departments and HIV care providers, August 2016-July 2018. The health departments in Connecticut (CT), Massachusetts (MA) and Philadelphia (PHL) collaborated with HIV clinics to identify newly out-of-care patients and randomize them to receive usual linkage and engagement in care services (standard-of-care control arm) or health department-initiated active re-engagement services (intervention arm). We used a microcosting approach to identify the activities and resources involved in the CoRECT intervention, separate from the standard-of-care, and quantified the costs. The cost data were collected at the start-up and recurrent phases of the trial to incorporate potential variation in the intervention costs. The costs were estimated from the healthcare provider perspective. RESULTS: The CoRECT trial in CT, MA and PHL randomly assigned on average 327, 316 and 305 participants per year either to the intervention arm (n = 166, 159 and 155) or the standard-of-care arm (n = 161, 157 and 150), respectively. Of those randomized, the number of participants re-engaged in care within 90 days in the intervention and standard-of-care arms was 85 and 70 in CT, 84 and 70 in MA, and 98 and 67 in PHL. The additional number of participants re-engaged in care in the intervention arm compared with those in the standard-of-care arm was 15 (CT), 14 (MA) and 31 (PHL). We estimated the annual total cost of the CoRECT intervention at $490,040 in CT, $473,297 in MA and $439,237 in PHL. The average cost per participant enrolled was $2952, $2977 and $2834 and the average cost per participant re-engaged in care was $5765, $5634 and $4482. We estimated an incremental cost per participant re-engaged in care at $32,669 (CT), $33,807 (MA) and $14,169 (PHL). CONCLUSIONS: The costs of the CoRECT intervention that identified newly out-of-care patients and re-engaged them in HIV care are comparable with other similar interventions, suggesting a potential for its cost-effectiveness in the US context.

Advancing data to care strategies for persons with HIV using an innovative reconciliation process.

BACKGROUND: UN AIDS has set ambitious 95-95-95 HIV care continuum targets for global HIV elimination by 2030. The U.S. HIV Care Continuum in 2018 showed that 65% of persons with HIV(PWH) are virally suppressed and 58% retained in care. Incomplete care-engagement not only affects individual health but drives ongoing HIV transmission. Data to Care (D2C) is a strategy using public health surveillance data to identify and re-engage out-of-care (OOC) PWH. Optimization of this strategy is needed. SETTING: Statewide partnership with Connecticut Department of Public Health (CT DPH), 23 HIV clinics and Yale University School of Medicine (YSM). Our site was one of 3 participants in the CDC-sponsored RCT evaluating the efficacy of DPH-employed Disease Intervention Specialists (DIS) for re-engagement in care. METHODS: From 11/2016-7/2018, a data reconciliation process using public health surveillance and clinic visit data was used to identify patients eligible for randomization (defined as in-Care for 12 months and OOC for subsequent 6-months) to receive DIS intervention. Clinic staff further reviewed this list and designated those who would not be randomized based on established criteria. RESULTS: 2958 patients were eligible for randomization; 655 (22.1%) were randomized. Reasons for non-randomizing included: well patient [499 (16.9%)]; recent visit [946 (32.0%)]; upcoming visit [398 (13.5%)]. Compared to non-randomized patients, those who were randomized were likely to be younger (mean age 46.1 vs. 51.6, p < .001), Black (40% vs 35%)/Hispanic (37% vs 32.8%) [(p < .001)], have CD4<200 cells/ul (15.9% vs 8.5%, p < .001) and viral load >20 copies/ml (43.8% vs. 24.1%, 0<0.001). Extrapolating these estimates to a statewide HIV care continuum suggests that only 8.3% of prevalent PWH are truly OOC. CONCLUSIONS: A D2C process that integrated DPH surveillance and clinic data successfully refined the selection of newly OOC PWH eligible for DIS intervention. This approach more accurately reflects real world care engagement and can help prioritize DPH resources.

The Cooperative Re-Engagement Controlled trial (CoRECT): A randomised trial to assess a collaborative data to care model to improve HIV care continuum outcomes.

Background: Persons with HIV (PWH), aware of their HIV infection but not in care account for an estimated 42.6% of HIV transmissions in the United States. Health departments and clinics implemented a collaborative data-to-care strategy to identify persons newly out-of-care with the objective of increasing re-engagement, retention in medical care, and viral load suppression. Methods: A multi-site, prospective randomised trial was conducted to identify newly out-of-care PWH using surveillance and clinic data in Connecticut (CT), Massachusetts (MA) and Philadelphia (PHL). All out-of-care participants were randomised to receive standard of care or an active public health intervention. Re-engagement in care was defined as having a documented CD4 count and/or HIV viral load within 90 days of randomization. Retention was defined as having at least two CD4 count and/or HIV viral load results ≥ 3 months apart within 12 months of randomization, and viral load suppression as having a viral load < 200 copies/ml within 12 months of randomization. Findings: Between August 2016 and July 2018, 1893 out-of-care participants were randomised from CT (N = 654), MA (N = 630), and PHL (N = 609). Participants were male (69.5%), non-Hispanic Black (48.3%) and men who have sex with men (38.8%). Re-engagement within 90 days was significantly higher for the intervention group overall and in all three jurisdictions (All sites: 54.9% vs 42.1%, p < 0.0001; CT: 51.2% vs 41.9%, p = 0.02; MA: 52.7% vs 44.1%, p = 0.03; PHL 61.2% vs 40.3%, p < 0.0001). Retention in care over 12 months improved overall (p = 0.04). Median time to viral suppression was reduced overall (p = 0.0006); CT (p = 0.32), MA (p = 0.02) and PHL (p < 0.0001). Interpretation: This trial showed that a collaborative, data-to-care strategy, and active public health intervention led by health departments significantly increases the proportion of PWH re-engaged in HIV care and may improve retention in care and decrease time to viral suppression.

Implementing Data to Care-What Are the Costs for the Health Department?

BACKGROUND: The Cooperative Re-Engagement Controlled Trial (CoRECT) is a randomized controlled trial that uses a combined health department-provider data to care (D2C) model to identify out-of-care HIV-infected persons. We present cost data for programmatic aspects of the trial during the start-up period (first 30 days of the study). METHODS: We used microcosting methods to estimate health department start-up costs. We collected start-up cost data between September 2016 and December 2016; 3 health departments completed a form to capture expenses for the initial 30 days of study implementation; the start date varied by health department. All costs are expressed in 2016 US dollars. RESULTS: Among the 3 health departments, the total start-up costs ranged from $14,145 to $26,058. Total start-up labor hours ranged from 224 to 640 hours. CONCLUSIONS: As D2C expands nationally with cooperative agreement, PS 18-1802 health departments may be able to use a similar analysis to consider the labor, time, and resources needed to implement D2C within their jurisdiction.

Public health opportunities and challenges in the provision of partner notification services: the New England experience.

BACKGROUND: Partner notification services (PNS) are recommended by the Centers for Disease Control and Prevention as a public health intervention for addressing the spread of HIV and other sexually transmitted diseases (STDs). Barriers and facilitators to the partner notification process from a public health perspective have not been well described. METHODS: In 2015, a coalition of New England public health STD directors and investigators formed to address the increasing STD prevalence across the region (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) and to promote communication between state STD programs. To evaluate barriers and facilitators of PNS programs, a survey was administered to representatives from each state to describe PNS processes and approaches. RESULTS: Of the six PNS programs, Connecticut, Maine, Massachusetts, Vermont, and New Hampshire had combined HIV and STD PNS programs; Rhode Island's programs were integrated but employed separate disease intervention specialists (DIS). All states performed PNS for HIV and syphilis. Maine, New Hampshire and Vermont performed services for all gonorrhea cases. Rhode Island, Connecticut, and Massachusetts performed limited partner notification for gonorrhea due to lack of resources. None of the six states routinely provided services for chlamydia, though Maine and Vermont did so for high-priority populations such as HIV co-infected or pregnant individuals. Across all programs, clients received risk reduction counseling and general STD education as a component of PNS, in addition to referrals for HIV/STD care at locations ranging from Planned Parenthood to community- or hospital-based clinics. Notable barriers to successful partner notification across all states included anonymous partners and index cases who did not feel comfortable sharing partners' names with DIS. Other common barriers included insufficient staff, inability of DIS to identify and contact partners, and index cases declining to speak with DIS staff. CONCLUSIONS: In New England, state health departments use different strategies to implement PNS programs and referral to STD care. Despite this, similar challenges exist across settings, including difficulty with anonymous partners and limited state resources.

Stigma, substance use and sexual risk behaviors among HIV-infected men who have sex with men: A qualitative study.

BACKGROUND: Public health HIV-service providers, including Medical Case Managers (case managers) and Disease Intervention Specialists (DIS) have a key role to play in identifying and addressing clients' complex mental health needs and substance use which contribute to sexual risk behaviors, yet their understanding and its consensus with HIV-infected men who have sex with men (MSM) have not been well characterized. METHODS: Together with an AIDS Service Organization and the Connecticut State Department of Public Health in 2011-2012, we conducted a focus group of case managers (n = 14) and interviewed DIS (n = 7) and HIV-infected MSM (n = 17) in Connecticut. We used the constant comparison method, grounded theory, and a community-based participatory approach to guide analysis. RESULTS: We identified three themes characterizing public health HIV-service providers' and MSM's perspectives regarding factors contributing to substance use and sexual risk behaviors in the context of HIV infection: 1) While both MSM and providers described a co-occurrence of HIV, stigma, substance use, and sexual risk behaviors, only MSM identified a causal relationship between these factors; 2) MSM and providers both described varying levels of self-efficacy in readiness to decrease substance use and sexual risk behaviors among MSM; both identified the social network as the key barrier to overcome; 3) Providers described how the co-occurrence of HIV, stigma and sexual risk behaviors leads to multi-faceted client needs for which they lacked sufficient training and collaboration. CONCLUSIONS: Provider education, skills-based training, and interventions targeting social networks may decrease sexual risk behaviors among HIV-infected MSM.

Opportunities for improving partner notification for HIV: results from a community-based participatory research study.

To identify actionable opportunities for improving Partner Notification (PN) for HIV among men who have sex with men (MSM), we characterized the perspectives and experiences of PN among Medical Case Managers (case managers), Disease Intervention Specialists (DIS), and MSM. In partnership with an AIDS service organization and the Connecticut State Health Department, we conducted a focus group of case managers (n = 14) and in-depth interviews with DIS (n = 7) and MSM (n = 24). We found differences between MSM's and providers' (case managers and DIS) perspectives regarding (1) determinants of sexual risk behaviors; (2) considerations impacting HIV disclosure; and (3) barriers to trusting relationships between MSM and providers. Factors impacting MSM perspectives on PN were incompletely appreciated by both case managers and DIS. PN may be improved through improving provider understanding of the complexities for MSM regarding sexual risk behaviors and disclosure and transcending barriers to trusting relationships between MSM and providers.

Time, dual roles, and departments of public health: lessons learned in CBPR by an AIDS service organization.

Community-based participatory research (CBPR) is an important approach to inform the development and implementation of HIV/AIDS prevention and treatment strategies. However, there is a paucity of literature describing CBPR from the perspective of community-based organizations (CBOs), specifically AIDS service organizations (ASO). Focusing on the perspective of the executive director (ED) from the partnering ASO, we describe in this paper lessons learned during Project Counseling Others About Contacts and Exposures with HIV (COACH), a CBPR, qualitative study intended to examine perspectives and experiences of professionals and clients regarding partner notification (PN) for HIV. Specifically, we describe opportunities and challenges associated with the time investment, balancing a dual role of service provider and researcher, and partnering with the department of public health. This description of the perspective of the ED from the ASO and the associated lessons learned may inform the actions of other CBOs, including ASOs, considering partnering with academic institutions for CBPR.

HPV vaccine implementation in STD clinics--STD Surveillance Network.

We surveyed selected public sexually transmitted disease clinics in the United States regarding human papillomavirus vaccine availability, target populations, funding sources, and barriers. Although nearly all had experience offering other vaccines, only 7 of 42 clinics (17%) offered human papillomavirus vaccine. Vaccine cost, staff time, and follow-up issues were commonly reported barriers.

Diagnosis of acute HIV infection in Connecticut.

Acute HIV infection (AHI) is the earliest stage of HIV disease, when plasma HIV viremia, but not HIV antibodies, can be detected. Acute HIV infection often presents as a nonspecific viral syndrome. However, its diagnosis, which enables linkage to early medical care and limits further HIV transmission, is seldom made. We describe the experience of Yale's Center for Interdisciplinary Research on AIDS with AHI diagnosis in Connecticut, as a participating center in the National Institute of Mental Health Multisite AHI Study. We sought to identify AHI cases by clinical referrals and by screening for AHI at two substance abuse care facilities and an STD clinic. We identified one case by referral and one through screening of 590 persons. Screening for AHI is feasible and probably cost effective. Primary care providers should include AHI in the differential diagnosis when patients present with a nonspecific viral syndrome.

Sex partner meeting venues and out-of-state sex partners among men who have sex with men with early syphilis in Connecticut.

OBJECTIVES: To examine sex partner meeting venues and out-of-state sex partners among men who have sex with men (MSM) with syphilis in Connecticut, a state with moderate syphilis prevalence. GOAL: To better understand transmission dynamics in the current syphilis epidemic. STUDY DESIGN: Review of health department records. RESULTS: A total of 185 MSM were diagnosed with early syphilis in Connecticut from 2000 to 2005 (mean age, 36 years; 56% white, 37% HIV-positive). Fifty-two percent of cases reported meeting sex partners at venues that facilitate multiple and/or anonymous sexual encounters including gay clubs or bars (22%), Internet (18%), and adult bookstores (12%). Meeting sex partners in venues increased over time and was associated with nonmetropolitan residence of the case. Forty-three percent of cases had an out-of-state sex partner during the time in which they likely acquired their infection. Having out-of-state sex partners decreased during the study period. Throughout 2000-2005, having out-of-state sex partners was positively associated with bathhouse use and negatively associated with use of adult bookstores. CONCLUSIONS: The observed pattern of increased meeting sex partners in venues located within the state and decreased out-of-state sex partners over time is suggestive of increasing transmission within the state of Connecticut.

Early syphilis among men in Connecticut: epidemiologic and spatial patterns.

OBJECTIVE: The objective of this study was to describe the epidemiology of early syphilis among men in Connecticut, a moderate-prevalence region, in 2004. STUDY DESIGN: The authors conducted a cross-sectional analysis of health department data. RESULTS: Fifty-five cases were reported from 25 different towns. A majority of cases (82%) were reported among men who have sex with men, and 22% reported coinfection with HIV. Spatial analysis indicated moderate clustering of cases. Approximately half of 197 reported sex partners were not from Connecticut, including 28% from New York City and 20% from other states/countries. The median distance between partners was 48 km (30 miles). Twenty-three percent of syphilis cases had both local and nonlocal partners. CONCLUSIONS: The current epidemiology of early syphilis in Connecticut is consistent with national trends. However, the dispersal of cases throughout the state and the high proportion of reported sex partners residing outside of Connecticut suggest that this state is not a core area of endemic transmission.