Effect of chronic disease on racial difference in COVID-19-associated hospitalization among cancer patients.

BACKGROUND: Research indicates that Black cancer patients have higher rates of COVID-19 hospitalization than their White counterparts. However, the extent to which chronic diseases contribute to racial disparities remains uncertain. We aimed to quantify the effect of chronic diseases on racial disparity in COVID-19-associated hospitalization among cancer patients. METHODS: We linked Louisiana Tumor Registry's data with statewide COVID-19 data and hospital in-patient discharge data to identify patients diagnosed with cancer in 2015-2019 who tested positive for COVID-19 in 2020 and those with COVID-19-associated hospitalization. Multivariable logistic regression and mediation methods based on linear structural equations were employed to assess the effects of the number of chronic diseases (0, 1-2, ≥3) and individual chronic diseases. RESULTS: Of 6381 cancer patients who tested positive for COVID-19, 31.6% were non-Hispanic Black cancer patients. Compared with non-Hispanic White cancer patients, non-Hispanic Black cancer patients had a higher prevalence of chronic diseases (79.5% vs 66.0%) and higher COVID-19-associated hospitalization (27.2% vs 17.2%). The odds of COVID-19-associated hospitalization were 80% higher for non-Hispanic Black cancer patients than non-Hispanic White cancer patients (odds ratio = 1.80, 95% confidence interval = 1.59 to 2.04). After adjusting for age, sex, insurance, poverty, obesity, and cancer type, number of chronic diseases explained 37.8% of the racial disparity in COVID-19-associated hospitalization, and hypertension, diabetes, and chronic renal disease were the top 3 chronic diseases explaining 9.6%, 8.9%, and 7.3% of the racial disparity, respectively. CONCLUSION: Chronic diseases played a substantial role in the racial disparity in COVID-19-associated hospitalization among cancer patients, especially hypertension, diabetes, and renal disease. Understanding and addressing the root causes are crucial for targeted interventions, policies, and health-care strategies to reduce racial disparity.

Electronic Messaging for Gonorrhea and Chlamydia Test Result Notification, Improving Treatment and Patient Satisfaction.

BACKGROUND: Approximately 20% of chlamydia (CT) and gonorrhea (GC) cases in Louisiana are diagnosed at Parish Health Units. Patient notification of CT and GC test results involves nurses' phone calls and letters to positive patients, which is time-consuming and inefficient. METHODS: In December 2018, electronic results notification was implemented in Caddo Parish Health Unit using Chexout software to notify enrolled patients via text or email when test results are ready to view in a patient portal. We compared the timeliness of GC/CT results notification and treatment pre-Chexout (December 2017 to November 2018) and post-Chexout (December 2018 to November 2019) implementation. A random sample of patients was interviewed to assess acceptability. RESULTS: During December 2018 to November 2019, 5432 patients were tested for CT/GC, 3924 (72%) enrolled in Chexout, and notifications were sent to 3884 (99%). Among CT-positives, 472 of 568 (83%) viewed results in the portal compared with 2451 of 3356 (73%) CT-negatives. Among GC-positives, 300 of 353 (85%) viewed results compared with 2657 of 3571 (74%) GC-negatives. Treatment success for CT improved from 493 of 670 (74%) to 506 of 568 (89%), and for GC, from 332 of 409 (81%) to 325 of 353 (92%). Mean time to treatment decreased for CT (13.4-10.7 days) and GC (11.3-9.2 days). Enrolled patients found Chexout notification satisfactory in 168 of 169 (99%) and easy to use in 130 of 141 (92%). Reasons for declining electronic notification included lack of personal cell phone for 55 of 86 (64%) and confidentiality concerns for 42 of 86 (49%). CONCLUSIONS: Electronic messaging decreased time to notification and increased treatment success. Nurses spent less time notifying patients leaving more time for patient care.

The Louisiana Wellness Centers Program for HIV/STD Prevention Among Gay and Bisexual Men and Transgender Persons.

CONTEXT: During the conduct of the described demonstration project (2012-2015), the Centers for Disease Control and Prevention funding standard for HIV testing was 1.0% newly diagnosed positivity in non-health care settings. For linkage to HIV medical care, the National HIV/AIDS Strategy goal was 85%, and the funding standard was 80% (the Centers for Disease Control and Prevention and National HIV/AIDS Strategy had no other quantified goals/standards relevant to the project). OBJECTIVE: To determine aggregate quantitative results of HIV/STD testing and engagement in HIV care. DESIGN: Information sources used for this case study analysis included the Louisiana Department of Health funding application, progress and final reports submitted to the Centers for Disease Control and Prevention, and records of communications between these agencies. SETTING: Six community-based Wellness Centers throughout Louisiana. PARTICIPANTS: Gay and bisexual men and transgender persons. MAIN OUTCOME MEASURES: New HIV/STD diagnoses from testing, linkage to HIV care, and reengagement in HIV medical care. RESULTS: The percentage of persons who were newly diagnosed with HIV was 1.4% (44/3214). Of the newly diagnosed persons, 91% (40/44) were linked to HIV medical care. Of persons who were identified as out of care, 83% (5/6) were reengaged in HIV medical care. STD testing results showed that 9.0% (294/3251) of the syphilis tests were positive, and 8.3% (803/9719) of the chlamydia/gonorrhea tests were positive. The pharyngeal chlamydia/gonorrhea positivity was 7.6% (256/3375); the rectal chlamydia/gonorrhea positivity was 13% (374/2948); and the urine chlamydia/gonorrhea positivity was 5.1% (173/3396). CONCLUSIONS: The demonstration project was successful. The results were used to discontinue funding for a less effective HIV screening program, continue demonstration project activities with other funds, and make policy changes so that extragenital screening for chlamydia/gonorrhea is now the standard at Louisiana clinics that serve gay and bisexual men and transgender persons.

PrEP indicators, social capital and social group memberships among gay, bisexual and other men who have sex with men.

Efforts to reduce HIV among gay, bisexual and other men who have sex with men include increasing awareness and uptake of pre-exposure prophylaxis (PrEP). Social capital may facilitate engagement in HIV prevention. Membership of social groups including chosen families (i.e. friends as family relationships) - one potential indicator of social capital - may be protective against HIV risk and infection. In this cross-sectional quantitative study, we examined social capital items and social group membership in association with PrEP outcomes. In 2014, the New Orleans arm of the National HIV Behavioral Surveillance recruited 353 HIV-negative men, of whom 46% identified as Black, Latino or Other Race and 54% as Non-Hispanic White, using venue-based sampling to complete a structured survey. Multivariable logistic regression models tested the relations between social group membership and social capital with PrEP indicators. Men who reported community group participation were more likely to be aware of PrEP compared to those who did not. Men in chosen families associated with a family name were least likely to be aware of and willing to take PrEP compared to those not in any other social groups. Social group membership is a potential social capital indicator for assessing HIV prevention among men.

Making the Connection: Using Videoconferencing to Increase Linkage to Care for Incarcerated Persons Living with HIV Post-release.

Incarcerated persons living with HIV (PLWH) have relatively high levels of HIV care engagement and antiretroviral therapy adherence during incarceration, but few are able to maintain these levels upon reentry into the community. In Louisiana, PLWH nearing release from prisons were offered video conferences with case managers housed in community based organizations aimed at facilitating linkage to care in the community. Of the 144 persons who received a video conference during the study period, 74.3% had linked to HIV care in the community within 90 days after release. Compared to the comparison group (n = 94), no statistically significant difference in linkage rate was detected (p > 0.05). Nonetheless, the video conference supplement was positively received by clients and case management agencies in the community and the lack of a detectable impact may be due to early difficulties in intervention delivery and study design limitations. Further study is needed to determine the value of the video conferencing supplement in other settings.

"Closing the Loop" Developing State-Level Data Sharing Interventions to Promote Optimum Outcomes Along the HIV Continuum of Care.

This manuscript describes the experiences of three state departments of health (SDoH) that successfully launched data sharing interventions involving surveillance and/or patient data collected in clinics to improve care outcomes among people living with HIV. We examined 58 key informant interviews, gathered at two time points, to describe the development and implementation of data sharing interventions. We identified three common themes across states' experiences: creating standard practices, fostering interoperability, and negotiating the policy environment. Projects were successful when state teams adapted to changing circumstances and were committed to a consistent communication process. Once implemented, the interventions streamlined processes to promote linkage and retention in care among low-income populations living with HIV. Despite using routinely collected data, key informants emphasized the labor-intensive process to develop and sustain the interventions. Lessons learned from these three state experiences can help inform best practices for other SDoH that are considering launching similar interventions.

Using Financial Incentives to Improve Rates of Viral Suppression and Engagement in Care of Patients Receiving HIV Care at 3 Health Clinics in Louisiana: The Health Models Program, 2013-2016.

OBJECTIVES: The Care and Prevention in the United States Demonstration Project aimed to reduce HIV/AIDS-related morbidity and mortality among racial/ethnic minority groups in 8 states. We evaluated Health Models, a pay-for-performance program piloted by the Louisiana Department of Health that used financial incentives to improve rates of engagement in HIV medical care and viral suppression among people with HIV. METHODS: We enrolled 2076 patients of 3 urban HIV specialty clinics in Louisiana in the Health Models pay-for-performance program on a rolling basis from September 2013 through September 2016 and gave patients cash incentives to attend HIV medical appointments, achieve or maintain viral suppression, and link to supportive services. We used laboratory data collected from Louisiana's HIV surveillance database to calculate rates of engagement in care and viral suppression during the first 24 months of enrollment. RESULTS: Of the 2076 patients who enrolled, 1400 (67.4%) were non-Hispanic black, 1480 (71.3%) were male, 1175 (56.6%) were men who have sex with men, and 1371 (66.0%) reported an annual income of <$15 000. At enrollment, 1456 (70.1%) patients were engaged in HIV care, and 1197 (57.7%) patients were virally suppressed. After 12 months of enrollment, 1474 of 1783 (82.7%) patients were virally suppressed. Of enrolled patients with at least 12 or 24 months of follow-up data, 1299 of 1317 (98.6%) patients were engaged in care during their first 12 months of enrollment, and 995 of 1033 (96.3%) patients were engaged in care between 12 and 24 months of enrollment. CONCLUSIONS: During the implementation of Health Models, enrolled patients had increases in rates of viral suppression and achieved rates of engagement in care and viral suppression that were higher than national levels; however, additional supportive services may be needed to further reduce socioeconomic disparities in the rates of viral suppression.

Exploring the Correlates of Linkage to HIV Medical Care Among Persons Living with HIV Infection (PLWH) in the Deep South: Results and Lessons Learned from the Louisiana Positive Charge Initiative.

We explored the correlates of linkage to HIV medical care and barriers to HIV care among PLWH in Louisiana. Of the 998 participants enrolled, 85.8% were successfully linked to HIV care within 3 months. The majority of participants were male (66.2%), African American (81.6%), and had limited education (74.4%). Approximately 22% of participants were Black gay and bisexual men. The most common reported barrier to care was lack of transportation (27.1%). Multivariable analysis revealed that compared with Black gay and bisexual men, White gay and bisexual men were significantly more likely to be linked to HIV care (adjusted prevalence ratio, aPR 1.08, 95% CI 1.02-1.13). Additionally, participants reporting moderate to high levels of stigma at intake (p < 0.05) were significantly more likely to be linked to HIV care compared with those reporting low or no stigma at enrollment. Study findings highlight the continued importance of client-centered interventions and multi-sector collaborations to link PLWH to HIV medical care.

Pathways to Congenital Syphilis Prevention: A Rapid Qualitative Assessment of Barriers, and the Public Health Response, in Caddo Parish, Louisiana.

BACKGROUND: Congenital syphilis (CS) disproportionately affects racial and ethnic minority women, especially in the US South. Although CS is relatively easy and inexpensive to prevent through screening and treatment of pregnant women, CS cases have continued to rise and are concentrated in relatively few US counties and states. In 2010, Louisiana had the highest case rate in the country for primary, secondary, and CS, with the highest number of CS cases in northwest Louisiana, where Shreveport is located. METHODS: We conducted qualitative interviews with community members (women and frontline providers) living in Caddo Parish to obtain their views about factors that negatively impact CS prevention. RESULTS: Participants described impediments in the pathways for prevention of CS. Lack of sexual and reproductive health education, discontinuities and fragmentation in health care insurance coverage, a dearth of referral points for prenatal care, and difficulty finding prenatal care providers who accept Medicaid can delay timely and adequate care for pregnant women. Participants reported that low reimbursement for necessary injections and difficulty obtaining required medication challenged efforts to screen and treat pregnant women according to guidelines. CONCLUSIONS: Although CS is easily prevented, health system and policy obstacles in pathways to CS prevention and care may need remediation at state and local levels.

Preferences for Home-Based HIV Testing Among Heterosexuals at Increased Risk for HIV/AIDS: New Orleans, Louisiana, 2013.

Participants in the New Orleans arm of the National HIV Behavioral Surveillance of Heterosexuals at Increased Risk for HIV were asked about potential utilization of self-administered home-based tests for HIV. The majority (86%) would use a free home-based test if provided by mail and 99% would seek treatment based on a positive result. In addition, more than half of respondents would return test results in some format to the test provider, whereas most of the remaining participants preferred to discuss results only with their doctor. These findings point toward a potential method for advancing the National HIV/AIDS Strategy.

A Low-Cost Partner Notification Strategy for the Control of Sexually Transmitted Diseases: A Case Study From Louisiana.

OBJECTIVES: We estimated the costs and effectiveness of implementing a partner notification (PN) strategy for highly prevalent sexually transmitted diseases (STDs) within the Louisiana STD/HIV Program. METHODS: We carried out a telephone-based PN approach on an experimental basis in 2 public STD clinics in Louisiana from June 2010 to May 2012. We monitored data on the resources used for identifying, tracing, treating, and managing the infected cases and their partners to estimate the intervention costs. RESULTS: Our results indicated that implementation of telephone-based PN should not increase the STD control program's expenses by more than 4.5%. This low-cost PN approach could successfully identify and treat 1 additional infected case at a cost of only $171. We found that the cost per disability-adjusted life year averted (a health outcome measure), because of the adoption of selective screening with partner tracing, was $4499. This was significantly lower than the gross domestic product per capita of the United States, a threshold used for defining highly cost-effective health interventions. CONCLUSIONS: Adoption of PN for gonorrhea and chlamydia should be considered a national strategy for prevention and control of these diseases.

Congenital syphilis investigation processes and timing in Louisiana.

BACKGROUND: Congenital syphilis (CS) is a potentially life-threatening yet preventable infection. State and local public health jurisdictions conduct investigations of possible CS cases to determine case status and to inform public health prevention efforts. These investigations occur when jurisdictions receive positive syphilis test results from pregnant women or from infants. METHODS: We extracted data from Louisiana's electronic case management system for 328 infants investigated as possible CS cases in 2010 to 2011. Using date stamps from the case management system, we described CS investigations in terms of processes and timing. RESULTS: Eighty-seven investigations were prompted by positive test results from women who were known to be pregnant by the health jurisdiction, and 241 investigations were prompted by positive syphilis test results from infants. Overall, investigations required a median of 101 days to complete, although 25% were complete within 36 days. Investigations prompted by positive test results from infants required a median of 135 days to complete, and those prompted by positive test results from pregnant women required a median of 41 days. CONCLUSIONS: Three times as many CS investigations began with reported positive syphilis test results from infants as from pregnant women, and these investigations required more time to complete. When CS investigations begin after an infant's birth, the opportunity to ensure that women are treated during pregnancy is missed, and surveillance data cannot inform prevention efforts on a timely basis. Consistently ascertaining pregnancy status among women whose positive syphilis test results are reported to public health jurisdictions could help to assure timely CS prevention efforts.

The validity of clinic-based samples in approximating out-of-care HIV-infected populations.

Tremendous strides have been made in the diagnosis and treatment of human immunodeficiency virus (HIV); perhaps now the largest barrier to controlling HIV is retaining those diagnosed in care. Data on out-of-care populations are needed to develop effective retention methods, yet obtaining these remains methodologically challenging due to inherent difficulties in sampling. The purpose of this study was to evaluate whether individuals identified by two sampling methods commonly used to approximate out-of-care populations were significantly different from a sample of newly identified out-of-care persons. We compared medical records of 345 out-of-care persons identified by a novel population-based health information exchange who had not received CD4 or viral load monitoring in >1 year with: medical records from a randomly selected, time-matched sample of 488 HIV-infected persons with at least one HIV care visit in the past 5 years, and interviews with 382 participants from a time-matched clinic-based convenience sample. Newly identified out-of-care persons were significantly different from both proxies with respect to demographic, clinical, and utilization characteristics, suggesting that samples of in-care proxy persons are inadequate to describe those not engaged in care. Novel approaches to sampling out-of care populations are urgently needed in order to better understand these populations and ways to improve retention and slow the HIV/AIDS epidemic.

Challenges in congenital syphilis surveillance: how are congenital syphilis investigations classified?

BACKGROUND: Congenital syphilis is a serious, preventable, and nationally notifiable disease. Despite the existence of a surveillance case definition, congenital syphilis is sometimes classified differently using an algorithm on the Centers for Disease Control and Prevention's case reporting form. METHODS: We reviewed Louisiana's congenital syphilis electronic reporting system for investigations of infants born from January 2010 to October 2011, abstracted data required for classification, and applied the surveillance definition and the algorithm. We calculated the sensitivities and specificities of the algorithm and Louisiana's classification using the surveillance definition as the surveillance gold standard. RESULTS: Among 349 congenital syphilis investigations, the surveillance definition identified 62 cases. The algorithm had a sensitivity of 91.9% and a specificity of 64.1%. Louisiana's classification had a sensitivity of 50% and a specificity of 91.3% compared with the surveillance definition. CONCLUSIONS: The differences between the algorithm and the surveillance definition led to misclassification of congenital syphilis cases. The algorithm should match the surveillance definition. Other state and local health departments should assure that their reported cases meet the surveillance definition.

Linking and retaining HIV patients in care: the importance of provider attitudes and behaviors.

Retention in HIV treatment may reduce morbidity and mortality, as well as slow the epidemic. Myriad barriers to retention include stigma, homophobia, structural barriers, transportation, and insurance. The purpose of this study was to evaluate patient perceptions of provider attitudes among HIV-infected persons within a state-wide public hospital system in Louisiana. A convenience sample of patients attending HIV clinics throughout the state participated in an anonymous interview. Factors associated with negative perceptions of care were evaluated in conjunction with a validated stigma measure. Factors associated with having a delayed entry into or break in care were evaluated in conjunction with perceived stigma. Between 2/1/09 and 7/31/11, 479 participants were interviewed and had sufficient data available, of whom 53.4% were male, 79.3% were African American, and 29.4% reported a break or delayed entry into HIV care of >1 year. A break in care was associated with perceiving that the doctor or health professionals do not listen carefully most or all of the time (p<0.01), having an elevated stigma score (p<0.05), and indicating that providers dislike caring for HIV-infected people (p<0.01). Women were more likely to have an elevated stigma score than men (p<0.01), as were participants over 30 (p<0.01); those with a gay/bisexual orientation (p<0.05) were less likely to have an elevated stigma score. Those with a break in care were less likely to have Medicaid (p<0.05). Providers play a key role in the retention of HIV-infected persons in care and are critical to improving outcomes and slowing the epidemic. Development of novel approaches to reduce stigma are imperative in improving retention.

Improved HIV-related outcomes associated with implementation of a novel public health information exchange.

PURPOSE: The purpose of this study was to evaluate HIV-related outcomes associated with use of a novel public health information exchange that was designed to identify out of care HIV-infected individuals seen within a large, integrated delivery network (IDN). METHODS: A novel, secure, bidirectional health care delivery-public health information exchange, the Louisiana Public Health Information Exchange (LaPHIE) was developed between a multi-geographical IDN and the Louisiana public health authority in response to the high proportion of out of care HIV-infected persons. The system provides real-time provider alerts when any HIV-infected person who has not had CD4 or HIV viral load (VL) monitoring in >1 year receives non-HIV care within the IDN, allowing immediate linkage to HIV specialty care. Persons identified over the first 30 months of the system's implementation were characterized using a case-cohort approach to compare out-of-care individuals with randomly sampled, time-matched in-care controls. RESULTS: Between 2/1/09 and 7/31/11, 549 alerts identified 419 unduplicated HIV-infected individuals without a CD4 count or VL in >1 year. Patients were identified at 60 clinics and alerts shown to 223 clinicians in 7 participating facilities. A quarter (24%) of those identified had not had a CD4 count or VL conducted since their initial diagnosis. Of the remaining 76% who had been in care previously, over half (55%) had been out of care for ≥18 months, with a median time of 19.4 months [IQR 15.0-32.5] since their previous visit. Following LaPHIE identification, 42% had CD4 counts<200 cells/mm(3) and 62% had VL>10,000 RNA copies/mL. Of the 344 patients with at least 6 months of follow up, 85% had at least one CD4 and/or VL test after being identified. CONCLUSIONS: The results of this study demonstrate that an information exchange can effectively facilitate engagement, re-engagement, and retention of out-of care HIV-infected persons in HIV specialty care. Within two years, we were able to observe significant improvements in HIV-related utilization and disease progression indices. Future programs should consider adopting this innovative strategy to improve HIV care at both the individual and population levels.

Patient perspectives on tobacco cessation services for persons living with HIV/AIDS.

With the advent of highly active antiretroviral therapy, the survival for HIV-infected individuals has increased, but other health-related behaviors have been largely unaddressed. Tobacco use is of primary concern, given its prevalence and the medical implications of smoking among these patients. Improving responsiveness to the needs, values, and preferences of patients (i.e., patient-centeredness) is a focus for increasing participation in systems of care. To assess the social, cultural, and educational barriers limiting use of smoking cessation services by HIV-positive individuals, two focus groups were conducted at a Louisiana HIV outpatient clinic. Questions addressed smoking history, knowledge of and access to cessation services, and knowledge of effects of smoking on disease progression and medication efficacy. Identified themes included a desire for increased and more specific information on the health effects of smoking as related to the patients' HIV status, difficulty in quitting, motivation, and the increased burden of medication. These results provide recommendations for designing, for HIV-infected smokers, patient-centered treatment of tobacco use, including providing relevant knowledge, access to cessation services, and more effective messages related to the impact of tobacco use on disease progression.

Changes in CD4 count among persons living with HIV/AIDS following Hurricane Katrina.

To examine the effects of Hurricane Katrina on the disease progression of persons living with HIV/AIDS (PLWH/A), CD4 counts during the 18 months immediately prior and subsequent to Katrina were obtained from the Louisiana Office of Public Health. PLWH/A were determined to be either non-residents of the New Orleans area, returning evacuees or evacuees who had returned to the area within 18 months. A mixed model repeated measures ANOVA showed significant effects for race, sex, age, year of diagnosis, and mode of exposure. A significant main effect for residence was found, as well as an interaction of residence by time of CD4 count (pre-Katrina vs. post-Katrina), indicating that, while non-returning evacuees had lower overall CD4 counts, the change in CD4 counts of non-returning evacuees dropped more sharply than those of the returning PLWH/A or non-residents. While these results point to a potential need for the population of PLWH/A who continue to be affected by Katrina, they also provide important data on the effect that large-scale disasters and stressful life events may have on individuals with chronic disease.

Linking recently diagnosed HIV-positive persons to medical care: perspectives of referring providers.

BACKGROUND: quantitative results from clients participating in the Antiretroviral Treatment Access Studies-II (ARTAS-II) intervention have previously been published. The current report provides qualitative data from providers (agency staff who referred clients to ARTAS-II) concerning how the introduction of ARTAS-II case managers affected referrals to HIV care. METHODS: referring providers from agencies that conducted HIV counseling and testing (community organizations, health care clinics, hospitals, and public health agencies) that had been asked to refer recently diagnosed HIV-positive individuals to ARTAS-II participated. Five ARTAS-II sites interviewed a total of 18 providers using a survey instrument of 11 open-ended questions. The questions covered interviewee characteristics (e.g., how long have you been in this position, job title) and questions related to the ARTAS-II project (e.g., before ARTAS-II, how did you link clients? what benefits have come from being part of the ARTAS-II program?) RESULTS: prior to the ARTAS-II project, the referring providers described the referral process as ranging from uncertain to disorganized and chaotic. Referring providers reported the process improved dramatically following implementation of the project, with the transition from HIV testing to medical care becoming less complicated and less prone to delays. Recommendations from the providers for further improvement included increasing the number of ARTAS-II case managers, having the program staff use direct, face-to-face communication with staff at referring agencies, and increasing system integration by having ARTAS-II program staff be co-located in clinic settings. CONCLUSION: the introduction of ARTAS-II case managers to receive referrals from HIV counseling and testing programs was widely viewed as a success by referring providers. ARTAS-II case managers were reported to fill a much needed role that strengthened the HIV service delivery system.