Evolution of a Post-Overdose Outreach Program in King County, Washington: Lessons Learned Through Continuous Quality Improvement.

OBJECTIVES: Emergency Medical Services patients who survive overdose are at high risk for subsequent overdose and death. Programs that seek to link overdose survivors to harm reduction and treatment services are increasingly common, though they vary in design and measured effect. Public Health - Seattle & King County (PHSKC) used a continuous quality improvement (CQI) process to assess and improve a phone-based model for post-overdose outreach in King County, Washington. METHODS: King County Emergency Medical Services (KC-EMS) health records are queried weekly to identify suspected opioid overdose and other drug-related encounters. Patients treated by KC-EMS that met outreach eligibility criteria were contacted by phone and offered referrals to local services. Three Plan-Do-Study-Act (PDSA) cycles were sequentially implemented to iteratively assess program indicators and implement program adaptations. The PDSA cycles varied in terms of eligibility criteria, outreach modality, and level of resources devoted to phone number searches. Program indicators and corresponding costs were measured for each phase and calculated per month, per eligible patient, and per patient referred to services. RESULTS: During the initial call-based outreach pilot, the fewest number of patients met eligibility criteria (monthly average =39) and were referred to services (monthly average =2). In Phase Two, outreach shifted to automated texting and eligibility criteria expanded, resulting in an increase in the monthly average number of eligible patients (monthly average =137) and patients referred to services (monthly average =3). Phase Three adaptations expanded eligibility criteria further but limited outreach to patients with a phone number documented in their KC-EMS record, resulting in an average of 405 eligible patients per month and four patients that were referred to services. The costs per patient referred to services changed from $454 in Phase one to $589 in Phase Two to $279 in Phase Three. CONCLUSIONS: The PDSA process helped PHSKC's post-overdose outreach team identify adaptations to improve the efficiency of the post-overdose outreach program. The number of people referred to services was modest, reflecting the challenges of post-incident phone-based outreach. Our experience highlights the value of incorporating CQI processes in ongoing program operations and the need for a multi-pronged overdose prevention strategy.

Molecular Epidemiology of Individuals Experiencing Unstable Housing or Living Homeless at HIV Diagnosis: Analysis of HIV Surveillance Data in King County, Washington.

We examined patterns of genetic clustering among individuals diagnosed with HIV between 2010 and 2018 using data from King County, Washington's National HIV Surveillance System. Among 2,371 individuals newly diagnosed with HIV, 231 (10%) experienced unstable housing or were living homeless at the time of diagnosis. Among the 1,658 (70%) people with an available HIV-1 pol gene sequence, 1,071 (65%) were identified to be part of 296 genetic clusters. In our analysis, housing status was not associated with genetic clustering (OR 1.02; 95%CI:0.75,1.39). After adjusting for demographic and behavioral factors, people who were living homeless at HIV diagnosis had 35% lower odds of being identified as part of a genetic cluster (AOR 0.65; 95%CI:0.44,0.95) compared to people with stable housing. Our findings highlight that people experiencing unstable housing are disproportionately burdened by HIV, and that within this population in King County, being in a genetic cluster is predominantly associated with substance use.

A Multifaceted Evaluation of a COVID-19 Contact Tracing Program in King County, Washington.

CONTEXT: Despite the massive scale of COVID-19 case investigation and contact tracing (CI/CT) programs operating worldwide, the evidence supporting the intervention's public health impact is limited. OBJECTIVE: To evaluate the Public Health-Seattle & King County (PHSKC) CI/CT program, including its reach, timeliness, effect on isolation and quarantine (I&Q) adherence, and potential to mitigate pandemic-related hardships. DESIGN: This program evaluation used descriptive statistics to analyze surveillance records, case and contact interviews, referral records, and survey data provided by a sample of cases who had recently ended isolation. SETTING: The PHSKC is one of the largest governmental local health departments in the United States. It serves more than 2.2 million people who reside in Seattle and 38 other municipalities. PARTICIPANTS: King County residents who were diagnosed with COVID-19 between July 2020 and June 2021. INTERVENTION: The PHSKC integrated COVID-19 CI/CT with prevention education and service provision. RESULTS: The PHSKC CI/CT team interviewed 42 900 cases (82% of cases eligible for CI/CT), a mean of 6.1 days after symptom onset and 3.4 days after SARS-CoV-2 testing. Cases disclosed the names and addresses of 10 817 unique worksites (mean = 0.8/interview) and 11 432 other recently visited locations (mean = 0.5/interview) and provided contact information for 62 987 household members (mean = 2.7/interview) and 14 398 nonhousehold contacts (mean = 0.3/interview). The CI/CT team helped arrange COVID-19 testing for 5650 contacts, facilitated grocery delivery for 7253 households, and referred 9127 households for financial assistance. End of I&Q Survey participants (n = 304, 54% of sampled) reported self-notifying an average of 4 nonhousehold contacts and 69% agreed that the information and referrals provided by the CI/CT team helped them stay in isolation. CONCLUSIONS: In the 12-month evaluation period, CI/CT reached 42 611 households and identified thousands of exposure venues. The timing of CI/CT relative to infectiousness and difficulty eliciting nonhousehold contacts may have attenuated the intervention's effect. Through promotion of I&Q guidance and services, CI/CT can help mitigate pandemic-related hardships.

COVID-19 Surveillance and Investigations in Workplaces - Seattle & King County, Washington, June 15-November 15, 2020.

Workplace activities involving close contact with coworkers and customers can lead to transmission of SARS-CoV-2, the virus that causes COVID-19 (1,2). Information on the approach to and effectiveness of COVID-19 workplace investigations is limited. In May 2020, Public Health - Seattle & King County (PHSKC), King County, Washington established a COVID-19 workplace surveillance and response system to enhance COVID-19 contact tracing and identify outbreaks in workplaces. During June 15-November 15, 2020, a total of 2,881 workplaces in King County reported at least one case of COVID-19. Among 1,305 (45.3%) investigated workplaces,* 524 (40.3%) met the definition of a workplace outbreak.† Among 306 (58.4%) workplaces with complete data,§ an average of 4.4 employee COVID-19 cases¶ (median = three; range = 1-65) were identified per outbreak, with an average attack rate among employees of 17.5%. PHSKC and the Washington State Department of Health optimized resources by establishing a classification scheme to prioritize workplace investigations as high, medium, or low priority based on workplace features observed to be associated with increased COVID-19 spread and workforce features associated with severe disease outcomes. High-priority investigations were significantly more likely than medium- and low-priority investigations to have two or more cases among employees (p<0.001), two or more cases not previously linked to the workplace (p<0.001), or two or more exposed workplace contacts not previously identified during case interviews (p = 0.002). Prioritization of workplace investigations allowed for the allocation of limited resources to effectively conduct workplace investigations to limit the potential workplace spread of COVID-19. Workplace investigations can also serve as an opportunity to provide guidance on preventing workplace exposures to SARS-CoV-2, facilitate access to vaccines, and strengthen collaborations between public health and businesses.

Engaging an unstably housed population with low-barrier buprenorphine treatment at a syringe services program: Lessons learned from Seattle, Washington.

Background: Clinic-imposed barriers can impede access to medication for opioid use disorder (MOUD). We evaluated a low-barrier buprenorphine program that is co-located with a syringe services program (SSP) in Seattle, Washington, USA. Methods: We analyzed medical record data corresponding to patients who enrolled into the buprenorphine program in its first year of operation. We used descriptive statistics and tests of association to longitudinally evaluate retention, cumulative number of days buprenorphine was prescribed, and toxicology results. Results: Demand for buprenorphine among SSP clients initially surpassed programmatic capacity. Of the 146 enrolled patients, the majority (82%) were unstably housed. Patients were prescribed buprenorphine for a median of 47 days (interquartile range [IQR] = 8-147) in the 180 days following enrollment. Between the first and sixth visits, the percentage of toxicology tests that was positive for buprenorphine significantly increased (33% to 96%, P < .0001) and other opioids significantly decreased (90% to 41%, P < .0001) and plateaued thereafter. Toxicology test results for stimulants, benzodiazepines, and barbiturates did not significantly change. Conclusions: SSP served as an effective point of entry for a low-barrier MOUD program. A large proportion of enrolled patients demonstrated sustained retention and reductions in opioid use, despite housing instability and polysubstance use.

Monitoring HIV Preexposure Prophylaxis Use Among Men Who Have Sex With Men in Washington State: Findings From an Internet-Based Survey.

BACKGROUND: Many state and local health departments now promote and support the use of HIV preexposure prophylaxis (PrEP), yet monitoring use of the intervention at the population level remains challenging. METHODS: We report the results of an online survey designed to measure PrEP use among men who have sex with men (MSM) in Washington State. Data on the proportion of men with indications for PrEP based on state guidelines and levels of awareness, interest, and use of PrEP are presented for 1080 cisgender male respondents who completed the survey between January 1 and February 28, 2017. We conducted bivariate and multivariable logistic regression to identify factors associated with current PrEP use. To examine patterns of discontinuation, we conducted Cox proportional hazards regression and fit a Kaplan-Meier curve to reported data on time on PrEP. RESULTS: Eighty percent of respondents had heard of PrEP, 19% reported current use, and 36% of men who had never used PrEP wanted to start taking it. Among MSM for whom state guidelines recommend PrEP, 31% were taking it. In multivariable analysis, current PrEP use was associated with older age, higher education, and meeting indications for PrEP use. Our data suggest that 20% of PrEP users discontinue within 12 months, and men with lower educational attainment were more likely to discontinue. CONCLUSIONS: Despite high levels of use, there is significant unmet need for PrEP in Washington. Our experience indicates that Internet surveys are feasible and informative for monitoring PrEP use in MSM.

Reconciling the evaluation of co-morbidities among HIV care patients in two large data systems: the Medical Monitoring Project and CFAR Network of Integrated Clinical Systems.

The estimated burden of chronic disease among people living with HIV (PLWH) varies considerably by data source, due to differences in case definitions, analytic approaches, and underlying patient populations. We evaluated the burden of diabetes (DM) and chronic kidney disease (CKD) in two large data systems that are commonly queried to evaluate health issues affecting HIV care patients: the Medical Monitoring Project (MMP), a nationally representative sample, and the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS), a clinical cohort. In order to reconcile these two data sources, we addressed issues common to observational data, including selection bias, missing data, and development of case definitions. The overall adjusted estimated prevalence of DM and CKD in MMP was 12.7% and 7.6%, respectively, and the overall prevalence of DM and CKD in CNICS was 9.9% and 8.3%, respectively; prevalence estimates increased with age in both data sources. After reconciling the approach to analyzing MMP and CNICS data, sub-group specific prevalence estimates of DM and CKD was generally similar in both data sources. Both data sources suggest a considerable burden of disease among older adults in HIV care. MMP and CNICS can provide reliable data to monitor HIV co-morbidities in the US.

Integrating HIV Surveillance and Field Services: Data Quality and Care Continuum in King County, Washington, 2010-2015.

OBJECTIVES: To assess how integration of HIV surveillance and field services might influence surveillance data and linkage to care metrics. METHODS: We used HIV surveillance and field services data from King County, Washington, to assess potential impact of misclassification of prior diagnoses on numbers of new diagnoses. The relationship between partner services and linkage to care was evaluated with multivariable log-binomial regression models. RESULTS: Of the 2842 people who entered the King County HIV Surveillance System in 2010 to 2015, 52% were newly diagnosed, 41% had a confirmed prior diagnosis in another state, and 7% had an unconfirmed prior diagnosis. Twelve percent of those classified as newly diagnosed for purposes of national HIV surveillance self-reported a prior HIV diagnosis that was unconfirmed. Partner services recipients were more likely than nonrecipients to link to care within 30 days (adjusted risk ratio [RR] = 1.10; 95% confidence interval [CI] = 1.03, 1.18) and 90 days (adjusted RR = 1.07; 95% CI = 1.01, 1.14) of diagnosis. CONCLUSIONS: Integration of HIV surveillance, partner services, and care linkage efforts may improve the accuracy of HIV surveillance data and facilitate timely linkage to care.

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

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

Projected demographic composition of the United States population of people living with diagnosed HIV.

The transformation of HIV from a fatal disease to lifelong disease has resulted in an HIV-infected population that is growing and aging, placing new and increasing demands on public programs and health services. We used National HIV Surveillance System and US census data to project the demographic composition of the population of people living with diagnosed HIV (PLWDH) in the United States through 2045. The input parameters for the projections include: (1) census projections, (2) number of people with an existing HIV diagnosis in 2013, (3) number of new HIV diagnoses in 2013, and (4) death rate within the PLWDH population in 2013. Sex-, risk group-, and race-specific projections were estimated through an adapted Leslie Matrix Model for age-structured populations. Projections for 2013-2045 suggest that the number of PLWDH in the U.S. will consistently grow, from 917,294 to 1,232,054, though the annual growth rate will slow from 1.8% to 0.8%. The number of PLWDH aged 55 years and older will increase from 232,113 to 470,221. The number of non-Hispanic (NH) African Americans/Blacks and Hispanics is projected to consistently grow, shifting the racial/ethnic composition of the US PLWDH population from 32 to 23% NH-White, 42 to 38% NH-Black, and 20-32% Hispanic between 2013 and 2045. Given current trends, the composition of the PLWDH population is projected to change considerably. Public health practitioners should anticipate large shifts in the age and racial/ethnic structure of the PLWDH population in the United States.