Defining Care Patterns and Outcomes Among Persons Living with HIV in Washington, DC: Linkage of Clinical Cohort and Surveillance Data

Castel, Amanda D.; Terzian, Arpi; Opoku, Jenevieve; Happ, Lindsey Powers; Younes, Naji; Kharfen, Michael; Greenberg, Alan E.

doi:10.2196/publichealth.9221

Cited by 26 publications

(17 citation statements)

References 29 publications

(28 reference statements)

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“…The role of surveillance data in demonstration state programs was of particular interest in this analysis. Findings from prior city- and state-sized studies support the use of surveillance data to identify PLWH most in need of targeted outreach and services and to promote efficient use of resources [ 37 , 38 ]. Surveillance data were found to be particularly helpful when states used them in planning.…”

Section: Discussionmentioning

confidence: 94%

Outcomes and costs of publicly funded patient navigation interventions to enhance HIV care continuum outcomes in the United States: A before-and-after study

et al. 2021

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Background In the United States, patients with HIV face significant barriers to linkage to and retention in care which impede the necessary steps toward achieving the desired clinical outcome of viral suppression. Individual-level interventions, such as patient navigation, are evidence based, effective strategies for improving care engagement. In addition, use of surveillance and clinical data to identify patients who are not fully engaged in care may improve the effectiveness and cost-effectiveness of these programs. Methods and findings We employed a pre-post design to estimate the outcomes and costs, from the program perspective, of 5 state-level demonstration programs funded under the Health Resources and Services Administration’s Special Projects of National Significance Program (HRSA/SPNS) Systems Linkages Initiative that employed existing surveillance and/or clinical data to identify individuals who had never entered HIV care, had fallen out of care, or were at risk of falling out of care and navigation strategies to engage patients in HIV care. Outcomes and costs were measured relative to standard of care during the first year of implementation of the interventions (2013 to 2014). We followed patients to estimate the number and proportion of additional patients linked, reengaged, retained, and virally suppressed by 12 months after enrollment in the interventions. We employed inverse probability weighting to adjust for differences in patient characteristics across programs, missing data, and loss to follow-up. We estimated the additional costs expended during the first year of each intervention and the cost per outcome of each intervention as the additional cost per HIV additional care continuum target achieved (cost per patient linked, reengaged, retained, and virally suppressed) 12 months after enrollment in each intervention. In this study, 3,443 patients were enrolled in Louisiana (LA), Massachusetts (MA), North Carolina (NC), Virginia (VA), and Wisconsin (WI) (147, 151, 2,491, 321, and 333, respectively). Patients were a mean of 40 years old, 75% male, and African American (69%) or Caucasian (22%). At baseline, 24% were newly diagnosed, 2% had never been in HIV care, 45% had fallen out of care, and 29% were at risk of falling out of care. All 5 interventions were associated with increases in the number and proportion of patients with viral suppression [percent increase: LA = 90.9%, 95% confidence interval (CI) = 88.4 to 93.4; MA = 78.1%, 95% CI = 72.4 to 83.8; NC = 47.5%, 95% CI = 45.2 to 49.8; VA = 54.6, 95% CI = 49.4 to 59.9; WI = 58.4, 95% CI = 53.4 to 63.4]. Overall, interventions cost an additional $4,415 (range = $3,746 to $5,619), $2,009 (range = $1,516 to $2,274), $920 (range = $627 to $941), $2,212 (range = $1,789 to $2,683), and $3,700 ($2,734 to $4,101), respectively per additional patient virally suppressed. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess patients against themselves at baseline and not against standard of care during the same time period. Conclusions Patient navigation programs were associated with improvements in engagement of patients in HIV care and viral suppression. Cost per outcome was minimized in states that utilized surveillance data to identify individuals who were out of care and/or those that were able to identify a larger number of patients in need of improvement at baseline. These results have the potential to inform the targeting and design of future navigation-type interventions.

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Section: Discussionmentioning

confidence: 94%

Outcomes and costs of publicly funded patient navigation interventions to enhance HIV care continuum outcomes in the United States: A before-and-after study

et al. 2021

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“…A recent systematic review found that while viral load and adherence improved during jail or prison, post-release HIV-related outcomes were even worse than before incarceration (Iroh et al, 2015). However, recent developments in community-based HIV surveillance methods show promise for improving HIV care linkage, retention, and reengagement in care (Castel et al, 2018;Enns et al, 2016;Mulatu et al, 2018).…”

Section: Introductionmentioning

confidence: 99%

Expert stakeholders’ perspectives on a Data-to-Care strategy for improving care among HIV-positive individuals incarcerated in jails

et al. 2020

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Data-to-Care (D2C) uses surveillance data (e.g., laboratory, Medicaid billing) to identify out-of-care HIV-positive persons to re-link them to care. Most US states are implementing D2C, yet few studies have explored stakeholders' perspectives on D2C, and none have addressed these perspectives in the context of D2C in jail. This article reports findings from qualitative, semi-structured interviews conducted with expert stakeholders regarding their perspectives on the ethical challenges of utilizing D2C to understand and improve continuity of care among individuals incarcerated in jails. Participants included 47 professionals with expertise in ethics and privacy, public health and HIV care, the criminal justice system, and community advocacy. While participants expressed a great deal of support for extending D2C to jails, they also identified many possible risks. Stakeholders discussed many issues specific to D2C in jails, such as heightened stigma in the jail setting, the need for training of jail staff and additional non-medical community-based resources, and the high priority of this vulnerable population. Many experts suggested that the actual likelihood of benefits and harms would depend on contextual details. Implementation of D2C in jails may require novel strategies to minimize risk of disclosing out-of-care patients' HIV status.

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“…From 2011 to 2014, publicly-insured PWH were less likely to achieve VS; privately-insured PWH had an earlier time to VS; and public insurance was associated with earlier time to virologic failure [9]. Further, PWH concurrently receiving care at three or more clinics were more likely to have public insurance and detectable VL, as well as hypertension, cardiovascular disease, and mental health issues [12]. To further probe these findings, we first analyzed demographic characteristics of DC Cohort participants by insurance type.…”

Section: Introductionmentioning

confidence: 99%

Despite early Medicaid expansion, decreased durable virologic suppression among publicly insured people with HIV in Washington, DC: a retrospective analysis

et al. 2020

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Background: Despite widely available access to HIV care in Washington, DC, inequities in HIV outcomes persist. We hypothesized that laboratory monitoring and virologic outcomes would not differ significantly based on insurance type. Methods: We compared HIV monitoring with outcomes among people with HIV (PWH) with private (commercial payer) versus public (Medicare, Medicaid) insurance receiving care at community and hospital clinics. The DC Cohort follows over 8000 PWH from 14 clinics. We included those ≥18 years old enrolled between 2011 and 2015 with stable insurance. Outcomes included frequency of CD4 count and HIV RNA monitoring (> 2 lab measures/year, > 30 days apart) and durable viral suppression (VS; HIV RNA < 50 copies/mL at last visit and receiving antiretroviral therapy (ART) for ≥12 months). Multivariable logistic regression models examined impact of demographic and clinical factors. Results: Among 3908 PWH, 67.9% were publicly-insured and 58.9% attended community clinics. Compared with privately insured participants, a higher proportion of publicly insured participants had the following characteristics: female sex, Black race, heterosexual, unemployed, and attending community clinics. Despite less lab monitoring, privately-insured PWH had greater durable VS than publicly-insured PWH (ART-naïve: private 70.0% vs public 53.1%, p = 0.03; ART-experienced: private 80.2% vs public 69.4%, p < 0.0001). Privately-insured PWH had greater durable VS than publicly-insured PWH at hospital clinics (AOR = 1.59, 95% CI: 1.20, 2.12; p = 0.001). Conclusions: Paradoxical differences between HIV monitoring and durable VS exist among publicly and privatelyinsured PWH in Washington, DC. Programs serving PWH must improve efforts to address barriers creating inequity in HIV outcomes.

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Defining Care Patterns and Outcomes Among Persons Living with HIV in Washington, DC: Linkage of Clinical Cohort and Surveillance Data

Cited by 26 publications

References 29 publications

Outcomes and costs of publicly funded patient navigation interventions to enhance HIV care continuum outcomes in the United States: A before-and-after study

Outcomes and costs of publicly funded patient navigation interventions to enhance HIV care continuum outcomes in the United States: A before-and-after study

Expert stakeholders’ perspectives on a Data-to-Care strategy for improving care among HIV-positive individuals incarcerated in jails

Despite early Medicaid expansion, decreased durable virologic suppression among publicly insured people with HIV in Washington, DC: a retrospective analysis

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