HIV Care Status Research Articles

"I was still very young": agency, stigma and HIV care strategies at school, baseline results of a qualitative study among youth in rural Kenya and Uganda.

IntroductionAdolescents and young adults living with HIV (AYAH) have the lowest rates of retention in HIV care and antiretroviral therapy (ART) adherence, partly due to the demands of school associated with this life stage, to HIV‐related stigma and to fears of serostatus disclosure. We explore the implications of school‐based stigma and disclosure on the development of agency during a critical life stage in rural Kenya and Uganda.MethodsWe conducted a qualitative study in the baseline year of the SEARCH Youth study, a combination intervention using a life‐stage approach among youth (15–24 years old) living with HIV in western Kenya and southwestern Uganda to improve viral load suppression and health outcomes. We conducted in‐depth, semi‐structured interviews in 2019 with three cohorts of purposively selected study participants (youth [n = 83], balanced for sex, life stage and HIV care status; recommended family members of youth [n = 33]; and providers [n = 20]). Inductive analysis exploring contextual factors affecting HIV care engagement revealed the high salience of schooling environments.ResultsStigma within school settings, elicited by non‐consensual serostatus disclosure, medication schedules and clinic appointments, exerts a constraining factor around which AYAH must navigate to identify and pursue opportunities available to them as young people. HIV status can affect cross‐generational support and cohort formation, as AYAH differ from non‐AYAH peers because of care‐related demands affecting schooling, exams and graduation. However, adolescents demonstrate a capacity to overcome anticipated stigma and protect themselves by selectively disclosing HIV status to trusted peers and caregivers, as they develop a sense of agency concomitant with this life stage. Older adolescents showed greater ability to seek out supportive relationships than younger ones who relied on adult caregivers to facilitate this support.ConclusionsSchool is a potential site of HIV stigma and also a setting for learning how to resist such stigma. School‐going adolescents should be supported to identify helpful peers and selectively disclose serostatus as they master decision making about when and where to take medications, and who should know. Stigma is avoided by fewer visits to the clinic; providers should consider longer refills, discreet packaging and long‐acting, injectable ART for students.

Application of machine-learning techniques in classification of HIV medical care status for people living with HIV in South Carolina.

Ending the HIV epidemic requires innovative use of data for intelligent decision-making from surveillance through treatment. This study sought to examine the usefulness of using linked integrated PLWH health data to predict PLWH's future HIV care status and compare the performance of machine-learning methods for predicting future HIV care status for SC PLWH. We employed supervised machine learning for its ability to predict PLWH's future care status by synthesizing and learning from PLWH's existing health data. This method is appropriate for the nature of integrated PLWH data because of its high volume and dimensionality. A data set of 8888 distinct PLWH's health records were retrieved from an integrated PLWH data repository. We experimented and scored seven representative machine-learning models including Bayesian Network, Automated Neural Network, Support Vector Machine, Logistic Regression, LASSO, Decision Trees and Random Forest to best predict PLWH's care status. We further identified principal factors that can predict the retention-in-care based on the champion model. Bayesian Network (F = 0.87, AUC = 0.94, precision = 0.87, recall = 0.86) was the best predictive model, followed by Random Forest (F = 0.78, AUC = 0.81, precision = 0.72, recall = 0.85), Decision Tree (F = 0.76, AUC = 0.75, precision = 0.70, recall = 0.82) and Neural Network (cluster) (F = 0.75, AUC = 0.71, precision = 0.69, recall = 0.81). These algorithmic applications of Bayesian Networks and other machine-learning algorithms hold promise for predicting future HIV care status at the individual level. Prediction of future care patterns for SC PLWH can help optimize health service resources for effective interventions. Predictions can also help improve retention across the HIV continuum.

The usefulness of HIV partner services in the age of treatment as prevention: a registry-based study

Partner services are effective tools to identify new cases among sex or needle-sharing partners of people with a new HIV diagnosis. Little is known about partners previously diagnosed with HIV who are not in care or are in care with unsuppressed HIV viral load. We aimed to quantify the previously diagnosed partners of people with a new HIV infection and examine their HIV care status and viral suppression in the 12 months before elicitation. We did a registry-based study. We used the New York City HIV Surveillance Registry to determine HIV care status and viral load of partners elicited from newly diagnosed people between Jan 1, 2007, and Dec 31, 2018. Previously diagnosed partners with no report of CD4 count or viral load in the preceding 12 months were presumed not to be in care, viral load suppression (<200 copies per mL) was based on the last viral load in the year preceding elicitation, and viraemia was defined as a viral load of 200 copies per mL or more. We used multinomial logistic regression to generate covariates of care and viral load status and their marginal effects. 11 964 partners were elicited; 2603 (33%) were previously diagnosed and 485 (20%) were not in care. 1153 (49%) of 2343 with a viral load report were in care and viraemic at elicitation. The odds of being not in care were higher in non-Hispanic black than non-Hispanic white or other partners (adjusted odds ratio 1·89, 95% CI 1·09-3·27) and lower in partners with male-to-male sex transmission risk (0·37, 0·26-0·51) and country of birth other than the USA (0·57, 0·39-0·85). The odds of being viraemic were higher in partners younger than 30 years than in those aged 30 years or older (1·68, 1·35-2·09) and lower among people with male-to-male sex transmission risk (0·36, 0·29-0·44) and country of birth other than the USA (0·78, 0·66-0·97). People with HIV should receive ongoing HIV prevention counselling and partner services data should inform engagement in care for previously diagnosed partners. None.

Temporal trends of population viral suppression in the context of Universal Test and Treat: the ANRS 12249 TasP trial in rural South Africa.

IntroductionThe universal test‐and‐treat (UTT) strategy aims to maximize population viral suppression (PVS), that is, the proportion of all people living with HIV (PLHIV) on antiretroviral treatment (ART) and virally suppressed, with the goal of reducing HIV transmission at the population level. This article explores the extent to which temporal changes in PVS explain the observed lack of association between universal treatment and cumulative HIV incidence seen in the ANRS 12249 TasP trial conducted in rural South Africa.MethodsThe TasP cluster‐randomized trial (2012 to 2016) implemented six‐monthly repeat home‐based HIV counselling and testing (RHBCT) and referral of PLHIV to local HIV clinics in 2 × 11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters and regardless of CD4 count in intervention clusters. We measured residency status, HIV status, and HIV care status for each participant on a daily basis. PVS was computed per cluster among all resident PLHIV (≥16, including those not in care) at cluster opening and daily thereafter. We used a mixed linear model to explore time patterns in PVS, adjusting for sociodemographic changes at the cluster level.Results8563 PLHIV were followed. During the course of the trial, PVS increased significantly in both arms (23.5% to 46.2% in intervention, +22.8, p < 0.001; 26.0% to 44.6% in control, +18.6, p < 0.001). That increase was similar in both arms (p = 0.514). In the final adjusted model, PVS increase was most associated with increased RHBCT and the implementation of local trial clinics (measured by time since cluster opening). Contextual changes (measured by calendar time) also contributed slightly. The effect of universal ART (trial arm) was positive but limited.ConclusionsPVS was improved significantly but similarly in both trial arms, explaining partly the null effect observed in terms of cumulative HIV incidence between arms. The PVS gains due to changes in ART‐initiation guidelines alone are relatively small compared to gains obtained by strategies to maximize testing and linkage to care. The achievement of the 90‐90‐90 targets will not be met if the operational and implementational challenges limiting access to care and treatment, often context‐specific, are not properly addressed. Clinical trial number: NCT01509508 (clinicalTrials.gov)/DOH‐27‐0512‐3974 (South African National Clinical Trials Register).

Temporal Trends of Population Viral Suppression in the Context of Universal Test and Treat: The ANRS 12249 TasP Trial in Rural South Africa

Background: The universal test-and-treat strategy (UTT) aims to maximize population viral suppression (PVS), i.e. the proportion of all people living with HIV (PLHIV) on antiretroviral treatment (ART) and virally suppressed in a community. We investigated whether PVS improved during the course of the ANRS 12249 TasP trial conducted in rural South Africa and investigating UTT impact on HIV incidence. Methods: The TasP cluster-randomized trial (2012-2016) implemented six-monthly repeat home-based HIV counselling and testing (RHBCT) and referral of PLHIV to local HIV clinics in 2×11 clusters opened sequentially. ART was initiated according to national guidelines in control clusters and regardless of CD 4 count in intervention clusters. We measured residency status, HIV status and HIV care status for each participant. PVS was computed per cluster among all resident PLHIV (≥16, including those not in care) at cluster opening and daily thereafter. We used a mixed linear model to explore time patterns in PVS, adjusting for sociodemographic changes at cluster level. Findings: 8 563 PLHIV were followed. Between cluster opening and January 1, 2016, PVS increased significantly in both arms (intervention: 23·5% to 46·2%, +22·8, p<0·001; control: 26·0% to 44·6%, +18·6, p < 0·001), but not differently by arm (p=0·514). In the final adjusted model, PVS increase was most associated with increased RHBCT (measured by time since cluster opening). Contextual changes (measured by calendar time) also contributed slightly. The effect of universal ART was positive but not significant. Conclusions: Changes in ART initiation guidelines alone are not enough to significantly increase PVS. Trial Registration Number: The trial was also registered on ClinicalTrials.gov: NCT01509508 and South African National Clinical Trials Register: DOH-27-0512-3974. Funding Statement: This trial was sponsored by the French National Agency for AIDS and Viral Hepatitis Research (ANRS; grant number, 2011-375), and funded by the AN S, the Deutsche esellschaft f r Internationale Zusammenarbeit (GIZ; grant number, 81151938), and the International Initiative for Impact Evaluation, Inc. (3ie) with support from the Bill & Melinda Gates Foundation. The content is solely the responsibility of the authors and does not represent the official views of 3ie or the Bill & Melinda Gates Foundation. This trial was done with the support of Merck and Gilead Sciences, which provided the Atripla drug supply. The Africa Health Research Institute, (previously Africa Centre for Population Health, University of KwaZulu-Natal, South Africa) receives core funding from the Wellcome Trust, which provides the platform for the population-based and clinic-based research at the centre. Declaration of Interests: CI received honoraria for consulting services rendered to Gilead Sciences. All other authors declare that they have no conflicts of interest. Ethics Approval Statement: The Biomedical Research Ethics Committee (BREC), University of KwaZulu-Natal, South Africa (BFC 104/11) and the Medicines Control Council of South Africa approved the trial.

HIV Care and Viral Load Suppression After Sexual Health Clinic Visits by Out-of-Care HIV-Positive Persons.

Outcomes among people living with HIV (PLWH) in New York City (NYC) remain suboptimal. To assess the potential role of the city's sexual health clinics (SHCs) in improving HIV outcomes and reducing HIV transmission, we examined HIV care status and its correlates among HIV-positive SHC patients in NYC. Clinic electronic medical records were merged with longitudinal NYC HIV surveillance data to identify HIV-positive patients and derive their retrospective and prospective HIV care status. Evidence of HIV care and viral load suppression (VLS) after clinic visit were considered outcomes. Logistic regression models were used to assess their correlates. A third of the 1045 PLWH who visited NYC SHCs in 2012 were out of HIV care (OOC) in the 12 months preceding the clinic visit, and were less likely than those previously in HIV care (IC) to have subsequent evidence of HIV care (42% vs. 72%) or VLS in the 12 months after the visit (39% vs. 76%). VLS was particularly low among patients diagnosed with ≥2 sexually transmitted infections (46%). The odds of VLS were lowest among those OOC before the clinic visit [versus those IC, adjusted odds ratio (aOR): 0.21, 95% confidence interval (CI): 0.16-0.29], non-Hispanic blacks (versus non-Hispanic whites, aOR: 0.58, 95% CI: 0.37-0.90), and residents of high-poverty neighborhoods (>30% vs. <10%, aOR: 0.51, 95% CI: 0.29-0.89). Our findings suggest that SHCs could serve as an intervention point to (re-)link PLWH to HIV care. Real-time provider alerts about patients' OOC status could help achieve that goal.

Gaps Along the HIV Care Continuum: Findings Among a Population Seeking Sexual Health Care Services in New York City.

Linkage/relinkage to HIV care for virally unsuppressed people with new sexually transmitted infections is critical for ending the HIV epidemic. We quantified HIV care continuum gaps and viral suppression among HIV-positive patients attending New York City (NYC) sexual health clinics (SHCs). One thousand six hundred forty-nine HIV-positive patients and a 10% sample of 11,954 patients with unknown HIV status on clinic visit date (DOV) were matched against the NYC HIV registry. Using registry diagnosis dates, we categorized matched HIV-positive patients as "new-positives" (newly diagnosed on DOV), "recent-positives (diagnosed ≤90 days before DOV), "prevalent-positives" (diagnosed >90 days before DOV), and "unknown-positives" (previously diagnosed but status unknown to clinic on DOV). We assessed HIV care continuum outcomes before and after DOV for new-positives, prevalent-positives, and unknown-positives using registry laboratory data. In addition to 1626 known HIV-positive patients, 5% of the unknown sample (63/1196) matched to the registry, signifying that approximately 630 additional HIV-positive patients attended SHCs. Of new-positives, 65% were linked to care after DOV. Of prevalent-positives, 66% were in care on DOV; 43% of the out-of-care patients were relinked after DOV. Of unknown-positives, 40% were in care on DOV; 21% of the out-of-care patients relinked after DOV. Viral suppression was achieved by 88% of in-care unknown-positives, 76% in-care prevalent-positives, 50% new-positives, 42% out-of-care prevalent-positives, and 16% out-of-care unknown-positives. Many HIV-positive people, including those with uncontrolled HIV infection, attend SHCs and potentially contribute to HIV spread. However, HIV status often is not known to staff, resulting in missed linkage/relinkage to care opportunities. Better outcomes could be facilitated by real-time ascertainment of HIV status and HIV care status.

The impact of population dynamics on the population HIV care cascade: results from the ANRS 12249 Treatment as Prevention trial in rural KwaZulu-Natal (South Africa).

IntroductionThe universal test and treat strategy (UTT) was developed to maximize the proportion of all HIV‐positive individuals on antiretroviral treatment (ART) and virally suppressed, assuming that it will lead to a reduction in HIV incidence at the population level. The evolution over time of the cross‐sectional HIV care cascade is determined by individual longitudinal trajectories through the HIV care continuum and underlying population dynamics. The purpose of this paper is to quantify the contribution of each component of population change (in‐ and out‐migration, HIV seroconversion, ageing into the cohort and definitive exit such as death) on the HIV care cascade in the context of the ANRS 12249 Treatment as Prevention (TasP) cluster‐randomized trial, investigating UTT in rural KwaZulu‐Natal, South Africa, between 2012 and 2016.Methods HIV test results and information on clinic visits, ART prescriptions, viral load and CD4 count, migration and deaths were used to calculate residency status, HIV status and HIV care status for each individual on a daily basis. Position within the HIV care continuum was considered as a score ranging from 0 (undiagnosed) to 4 (virally suppressed). We compared the cascade score of each individual joining or leaving the population of resident adults living with HIV with the average score of their cluster at the time of entry or exit. Then, we computed the contribution of each entry or exit on the average cascade score and their annualized total contribution, by component of change.ResultsWhile the average cascade score increased over time in all clusters, that increase was constrained by population dynamics. Permanent exits and ageing into the people living with HIV cohort had a marginal effect. Both in‐migrants and out‐migrants were less likely to be retained at each step of the HIV care continuum. However, their overall impact on the cross‐sectional cascade was limited as the effect of in‐ and out‐migration balanced each other. The contribution of HIV seroconversions was negative in all clusters.ConclusionsIn a context of high HIV incidence, the continuous flow of newly infected individuals slows down the efforts to increase ART coverage and population viral suppression, ultimately attenuating any population‐level impact on HIV incidence.Clinical Trial Number NCT01509508 (clinicalTrials.gov)/DOH‐27‐0512‐3974 (South African National Clinical Trials Register).

Validation of Retention in HIV Care Status Using the New York City HIV Surveillance Registry and Clinical Care Data From a Large HIV Care Center.

Improving retention in care is a key element of the National HIV/AIDS Strategy (NHAS). However, definitions for measuring retention in care are not standardized. To compare measures of retention based on both clinic visit data and HIV laboratory surveillance data. Retrospective cohort study. New York City (NYC), New York. We matched adult patients with HIV infection seen at the Spencer Cox Center for Health (SCC) in 2010 or 2011 with the NYC HIV Surveillance Registry. Retention in care was measured on the basis of SCC electronic medical record (EMR) data (≥1 medical visits in 2012) and Surveillance Registry data (≥2 CD4/viral load [VL] tests ≥90 days apart in 2012). There were 5746 adult HIV-infected patients seen at SCC between 2010 and 2011 who matched with the Surveillance Registry. Seventy-eight percent (n = 4469) had 1 or more medical visits at SCC in 2012 and were considered retained on the basis of the EMR definition, among which 3831 (86%) met the surveillance definition for retention in care. Patients who did not have a medical visit at SCC in 2012 (n = 1277) were lost to care in NYC (n = 485; 36%), engaged in care at an alternate provider (n = 622; 49%), or died after their last SCC visit (n = 197; 15%). This study is an important comparison of laboratory surveillance versus clinic visit-based measures of retention in care in an urban setting with the largest HIV epidemic in the country. Collaborative projects between local health departments and clinical care providers can help validate the care status of patients and inform the allocation of resources to reengage patients who are lost to care. The combined use of laboratory and clinic visit-based data to measure retention in care provides a more accurate representation of the care status of HIV-infected patients than use of a single data source alone. Routine sharing of data by public health institutions and clinical care providers would help target resources toward reengaging patients who are lost to care in jurisdictions with universal HIV-related laboratory reporting.

IMPACT OF COMMUNITY TRACING ON HIV COHORT OUTCOMES IN URBAN ZAMBIA

BackgroundWe investigated the impact of community tracing as recommended in national guidelines on outcomes within a prospective HIV cohort in Zambia.MethodsHIV-positive, antiretroviral therapy-naïve adults were enrolled at 2 Lusaka clinics....

Perinatal HIV Exposure Surveillance and Reporting in the United States, 2014.

We sought to describe the current status of perinatal HIV exposure surveillance (PHES) activities and regulations in the United States and to make recommendations to strengthen PHES. In 2014, we sent an online survey to health departments in the 50 states, District of Columbia, Puerto Rico, Virgin Islands, and 6 cities and counties (Chicago, Illinois; Houston, Texas; Los Angeles, California; New York, New York; Philadelphia, Pennsylvania; and San Francisco, California). We analyzed responses from 56 of the 59 (95%) jurisdictions. Thirty-three of 56 jurisdictions (59%) reported conducting PHES and following infants to determine their infection status. Of the 33 jurisdictions performing PHES, 28 (85%) linked maternal and infant data, but only 12 (36%) determined the HIV care status of postpartum women. Themes of respondents' recommendations for strengthening PHES centered on updating laws and regulations to support PHES, reporting all HIV test results and linking vital records with PHES data to identify and follow HIV-exposed infants, communicating with health care providers to improve reporting, training staff, and getting help from experienced jurisdictions to implement PHES. Our findings indicate that data on perinatal exposure collected through the current system are inadequate to comprehensively monitor and prevent perinatal HIV exposure and transmission. Comprehensive PHES data collection and reporting are needed to sustain the progress that has been made toward lowering perinatal HIV transmission rates. We propose that minimum standards be established for perinatal HIV exposure reporting to improve the completeness, quality, and efficiency of PHES in the United States.

Examining clinic-based and public health approaches to ascertainment of HIV care status.

Clinic-based tracing efforts and public health surveillance data can provide different information about HIV care status for the same patients. The relative yield and how best to use these sources to identify and reengage out-of-care patients is unknown. At a large public HIV clinic in San Francisco, we selected a 10% random sample of active patients who were at least 210 days "late" for an HIV primary care visit as of April 1, 2013, for clinic-based outreach. Patients were considered out of care if they did not have an HIV primary care visit in the 210 days before April 1, 2013. We then matched the sample with the San Francisco Department of Public Health HIV surveillance registry. Patients with a CD4 or viral load result in the 210-day period were classified as in care. We compared results from both sources and estimated the cumulative incidence of disengagement from care for the full cohort of clinic patients. Of 940 patients lost to follow-up, 95 were sampled. Clinic tracing found 60 (63%) in care, 23 (24%) not located, 9 (10%) out of care, 2 (2%) incarcerated, and 1 (1%) had died. Of 42 individuals surveillance classified as out of care, tracing found 22 (52%) were in care. Of 52 patients found to be in care by surveillance, 12 (23%) were out of care by clinic tracing or unable to be located. The naive estimate of the cumulative incidence of disengagement from care at 3 years for the active clinic cohort was 41.1% [95% confidence interval (CI): 37.6 to 44.5]. The use of surveillance data reduced this estimate to 12.7% (95% CI: 18.2 to 25.4), and when further corrected using tracing outcomes, the estimate dropped to only 6.4% (95% CI: 3.4 to 9.4). Clinic-based tracing and surveillance data together provide a better understanding of care status than either method alone. Using surveillance data to inform clinic-based outreach efforts may be an effective strategy, although tracing efforts are most likely to be successful if conducted in real time.

Using HIV surveillance registry data to re-link persons to care: the RSVP Project in San Francisco.

BackgroundPersons with unsuppressed HIV viral load (VL) who disengage from care may experience poor clinical outcomes and potentially transmit HIV. We assessed the feasibility and yield of using the San Francisco Department of Public Health (SFDPH) enhanced HIV surveillance system (eHARS) to identify and re-engage such persons in care.MethodsUsing SFDPH eHARS data as of 4/20/2012 (index date), we selected HIV-infected adults who were alive, had no reported VL or CD4 cell count results in the past nine months (proxy for “out-of-care”) and a VL >200 copies/mL drawn nine to 15 months earlier. We prioritized cases residing locally for investigation, and used information from eHARS and medical and public health databases to contact them for interview and referral to the SFDPH linkage services (LINCS). Twelve months later, we matched-back to eHARS data to assess how HIV laboratory reporting delays affected original eligibility, and if persons had any HIV laboratory results performed and reported within 12 months after index date (‘new labs’).ResultsAmong 434 eligible persons, 282 were prioritized for investigation, of whom 75 (27%) were interviewed, 79 (28%) could not be located, and 48 (17%) were located out of the area. Among the interviewed, 54 (72%) persons accepted referral to LINCS. Upon match-back to eHARS data, 324 (75%) in total were confirmed as eligible, including 221 (78%) of the investigated; most had new labs.ConclusionsAmong the investigated persons presumed out-of-care, we interviewed and offered LINCS referral to about one-quarter, demonstrating the feasibility but limited yield of our project. Matching to updated surveillance data revealed that a substantial minority did not disengage from care and that most re-engaged in HIV care. Verifying persons’ HIV care status with medical providers and improving timeliness of transfer and cross-jurisdictional sharing of HIV laboratory data may aid future efforts.