20th International AIDS Conference in Melbourne, Australia: Re-Linking HIV-Positive Patients to Care: Utilizing Existing Data Systems

1.  In 2010, only 51% of HIV-diagnosed individuals were retained in HIV care across the United States, and viral
suppression was only achieved in 43% of HIV-positive patients.[1] Out-of-care patients lack access to
antiretroviral therapy, often resulting in increased HIV-associated morbidity and mortality in addition to a higher
probability of virus transmission.
 Within the Harris County (Houston) area of the state of Texas, there are 4.3 million residents.[2] There were
almost 23,000 people living with HIV (PLWH) in the Houston area in 2012, with 49% of
HIV-diagnosed residents lost to HIV care.[3]
 In 2013, the Houston Department of Health and Human Services (HDHHS) initiated a project that employs HIV
surveillance records to identify and confirm the care status of HIV-positive residents in the Houston/Harris
County area in order to provide targeted re-linkage services.
 Implement a program that uses multiple referral mechanisms to identify previously in-care HIV-positive patients
that might be lost to care.
 Utilize multiple surveillance and care data systems to confirm the current care status of potentially out-of-care
individuals to determine their eligibility for re-linkage services.
 Three program referral methods identified potentially out-of-care patients: medical providers, surveillance
laboratory records, and health department field (Disease Intervention Specialists or “DIS”) staff.
 Minimum standards of care in the United States suggest that viral load (VL) testing should occur every 3-6
months as a part of routine medical visits.[4] Texas law mandates that VL and CD4 counts must be reported to
the jurisdiction’s local or state health department.
 Patients were considered out-of-care if they lacked a CD4 or viral load laboratory result and/or HIV-care appointment
within the previous six months of the referral date
 Two laboratory systems yielded information about CD4 and viral load results (Figure 1):
 eHARS—a national HIV surveillance system; the HDHHS accesses information on all Texas residents
 Maven—a repository for electronic laboratory reports from Houston area providers and laboratories
 Two care systems yielded information about HIV-related medical appointments (Figure 1):
 CPCDMS—data system used in Houston by the local administrative agency of the Ryan White HIV/AIDS Program; the
Ryan White HIV/AIDS Program is a federally-funded program that provides HIV-related care and services to those with
insufficient health care coverage or financial resources
 Epic—electronic medical record system for the Harris Health System, a Ryan White-funded provider of HIV medical care
in Houston
 Five additional data systems solely provided data about patients’ current location and contact information
(Figure 1). All systems assessed ineligibility, such as those individuals that were incarcerated,
out-of-jurisdiction (OOJ), deceased, underage, newly diagnosed, pregnant, or never in-care.
 If patients lacked a medical care appointment and/or CD4 or viral load laboratory results within the previous six
months, they were classified as potentially out-of-care and assigned to Service Linkage Workers (SLW),
specialized case managers, for re-linkage intervention.
Re-Linking HIV-Positive Patients to Care: Utilizing Existing Data Systems
 From June 2013 through January 2014, 124 referrals were received.
 Fifty-five clients were not assigned to re-linkage services. Surveillance records indicated that 37 of these
individuals (67.3%) returned to care without HDHHS re-linkage intervention, 13 (23.6%) were OOJ, 3 (5.5%) were
ineligible, and 2 (3.6%) were incarcerated.
 Of the individuals that did not qualify for re-linkage services because of recent evidence of care, 61.8% percent
were identified through electronic laboratory reports while 45.5% had evidence of at least one medical
appointment among electronic care data systems (not mutually exclusive).
 The care data systems produced a total of 25 appointments that qualified as evidence of care: 13 in CPCDMS
and 12 in Epic. The laboratory data systems produced a total of 36 laboratory results that qualified as evidence
of care: 33 in eHARS and 3 in Maven (Figure 1).
 The eHARS data system produced the most recent evidence of care within the six month period with 54% (n=20),
followed by CPCDMS with 24% (n=9) and Epic with 22% (n=8) (Figure 2).
 69 persons (55.6%) were potentially out-of-care and assigned to SLWs (Figure 3).
 Characteristics of re-linkage clients were 46 (66.7%) African-American, 47 (68.1%) male, and had an average age
of 36.9 (+ 11.0) years. Clients were diagnosed with HIV an average of 9.9 years (Table 1).
 Existing laboratory and medical care records are useful tools that can confirm the care status of referrals.
 Coupled with record searches among other data systems to determine locating information, these methods can
reduce resource expenditure by targeting services to HIV-positive patients most likely to be truly out-of-care.
 The majority of referrals that were already in-care had evidence of at least one laboratory result in a surveillance
database, which also accounted for the majority of the most recent evidence of care. This suggests that
laboratory records, which are subject to mandatory reporting laws, might have the greatest potential to
distinguish patients that qualify for re-linkage.
 Potential Limitations:
 Completeness of laboratory and medical records and timeliness of reporting is dependent upon local or national laws,
thoroughness of public health follow-up activities, medical record extraction, and provider cooperation
 Next Steps:
 Evaluate whether service linkage workers improve the rate at which HIV-positive patients return to care
 Measure the length of time clients are lost to care and the impact on CD4 and viral load counts while out-of-care
Table 1. Characteristics of SLW Assigned Cases
Kellie L Watkins MS1, Camden J Hallmark MPH2, Richard Grimes PhD³, Biru Yang PhD1, Marcia Wolverton MPH1, Marlene McNeese2
1 Houston Department of Health and Human Services, Bureau of Epidemiology,
2 Houston Department of Health and Human Services, Bureau of HIV/STD and Viral Hepatitis Prevention, 3 The University of Texas Health Science Center, Division of General Internal Medicine
Figure 1. Data Systems for Record Searches and Evidence of Care
1. Gray KM, Cohen SM, Hu X, et al. Jurisdiction Level Differences in HIV Diagnosis, Retention in Care, and Viral Suppression in the United States. Journal of
Acquired Immune Deficiency Syndrome 2014; 65:129-132.
2. Harris (county), Texas. 2013 Population Estimate. United States Census Bureau. Available at: http://quickfacts.census.gov/qfd/states/48/48201.html. Accessed
June 30, 2014.
3. Houston Area Ryan White Planning. “OVERALL EMA: Number and Percentage of People with HIV in Selected Stages of the Continuum of HIV Care, 2012
(Version 2, as of 12-17-13)” Available at http://www.rwpchouston.org/Publications/2012_Comp_Plan/Treatment_Cascade.htm. Section accessed 27 May 2014.
4.Panel on Antiretroviral Guidelines for Adults and Adolescents. “Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department
of Health and Human Services.” Available at http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Section accessed 21 May 2014.
Characteristics (n=69) n (%)
Years HIV+
Mean 9.9
Range 1-29
Age (Years) 36.9
<20 2 (2.9)
20-29 19 (27.5)
30-39 21 (30.4)
40-49 15 (21.7)
50-59 12 (17.4)
>60 0 (0.0)
Sex
Male 47 (68.1)
Female 20 (29.0)
Transgender 2 (2.9)
Race
African-American 46 (66.7)
White 21 (30.4)
Other 2 (2.9)
Ethnicity
Hispanic 11 (15.9)
Non-Hispanic 58 (84.1)
Background
This study was supported by cooperative agreements from the Merck Foundation and the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the sponsoring organizations. Special thanks to Saroochi Agarwal and Dr. Jeffrey Meyer (HDHHS), Texas Department of State Health Services, the Houston Area Ryan White Planning Council, and the Houston HIV Prevention Community Planning Group. Further gratitude for the Ryan White Grant Administration of Harris County Department of Health and Environmental Services and to the following Ryan White Care providers: Harris Health
System, Houston Area Community Services, and St. Hope Foundation. This presentation was made possible with support from the Baylor-UTHouston Center for AIDS Research (CFAR), an NIH-funded program (AI036211). The authors appreciate the contributions of all research and support staff at the affiliated institutions.
Objectives
Description
Lessons Learned
Conclusions and Next Steps
References
Presented at the 20th International AIDS Conference ● July 20-25, 2014 ● Melbourne, Australia
Figure 3. Record Search Outcomes (N=124)