Rebecca Eavou

Project nGage: Network supported HIV care engagement for younger black men who have sex with men and transgender persons

Background Young Black men who have sex with men and transgender persons (YBMSMT) aged 13–29 carry the nation’s highest burden of new HIV infections. Studies indicate that YBMSMT have poor retention in care, which is associated with reduced medication adherence and increased virologic failure. Objective Project nGage is a randomized controlled (RCT) trial evaluating the feasibility and preliminary efficacy of a brief, dyadic intervention designed to promote adherence to HIV primary care in safety-net clinics. Network visualization is used to identify and engage a support confidant (SC) from participants’ social networks. A social work interventionist then meets with the SC and SC-participant dyad to activate and maintain HIV-specific social support. Methods Project nGage is operating in two phases. In Phase I, the Team refined study protocols based on pilot testing. In Phase II, 94 HIV infected YBMSMT ages 16–29 will be recruited, enrolled and randomly assigned to receive Project nGage or treatment as usual (TAU). The primary outcome is appointment attendance; the secondary outcomes are medication adherence and viral load. Results Implementation challenges include coordinating sites, managing dyadic intervention logistics, and recruiting non-adherent patients or those who have fallen out of care. The team continues to address implementation issues as the study progresses. Conclusions Project nGage is addressing a gap in HIV care-related research by focusing on supportive relationships as a mechanism through which to promote retention in care. Pending study results, a larger RCT would compare the relative effectiveness of the Project nGage intervention versus TAU over 18 to 24 months.

Implementing Routine HIV Screening in Three Chicago Hospitals: Lessons Learned.

Objective. This study describes routine HIV screening implementation and outcomes in three hospitals in Chicago, Illinois. Methods. Retrospective data from three hospitals were examined, and routine testing procedures, testing volume, reactive test results, and linkage-to-care outcomes were documented. Results. From January 2012 through March 2014, 40,788 HIV tests were administered at the three hospitals: 18,603 (46%) in the emergency department (ED), 7,546 (19%) in the inpatient departments, and 14,639 (36%) in outpatient clinics. The screened patients varied from 1% to 22% of the total eligible patient population across hospitals. A total of 297 patients tested positive for HIV for a seropositivity rate of 0.7%; 129 (43%) were newly diagnosed and 168 (57%) were previously diagnosed, with 64% of those previously diagnosed out of care at the time of screening. The inpatient areas had the highest seropositivity rate (0.6%). The percentage of newly diagnosed patients overall who were linked to care was 77%. Of newly diagnosed patients, 51% had ≥1 missed opportunity for testing (with a mean of 3.8 visits since 2006), and 30% of patients with missed opportunities were late testers (baseline CD4+ counts <200 cells per cubic millimeter). Conclusion. Routine screening is an essential tool for identifying new infections and patients with known infection who are out of care. Hospitals need to provide HIV screening in inpatient and outpatient settings—not just EDs—to decrease missed opportunities. Routine screening success will be driven by how notification and testing are incorporated into the normal medical flow, the level of leadership buy-in, the ability to conduct quality assurance, and local testing laws.

Expanded HIV Testing and Linkage to Care: Conventional vs. Point-of-Care Testing and Assignment of Patient Notification and Linkage to Care to an HIV Care Program

Objective. The University of Chicago Medicine (UCM) led the Expanded Testing and Linkage to Care (X-TLC) program for disproportionately affected populations on the South Side of Chicago. The X-TLC program aimed to expand routine HIV testing to high-prevalence communities with disproportionately affected populations (i.e., minority men and women, men who have sex with men, and intravenous drug users) according to CDC guidelines at multiple clinical sites. Methods. The X-TLC program used standard blood-based laboratory testing vs. point-of-care rapid testing or rapid laboratory testing with point-of-care results notification. Site coordinators and the linkage-to-care coordinator at UCM oversaw testing, test notification, and linkage to care. Results. From February 1, 2011, through December 31, 2013, the X-TLC program completed 75,345 HIV tests on 67,153 unique patients. Of the total tests, 48,044 (63.8%) were performed on patients who self-identified as African American and 6,606 (8.8%) were performed on patients who self-identified as Hispanic. Of the 67,153 patients tested, 395 (0.6%) tested positive and 176 (0.3%) were previously unaware of their HIV-positive status. Seroprevalence was even higher for EDs, where 127 of 12,957 patients tested positive for HIV (1.0% seroprevalence), than for other patient care sites, including for new diagnoses, where 50 of 12,957 patients tested positive for HIV (0.4% seroprevalence). Of the 176 newly diagnosed patients, 166 of 173 (96.0%) patients who were still alive when testing was complete received their test results, and 148 of the 166 patients who were eligible for care (89.0%) were linked to care. Patients linked to X-TLC physicians did well with respect to the continuum of care: 77 of 123 (62.6%) patients achieved HIV viral load of <200 copies/milliliter. Conclusion. Lead organizations such as UCM were able to assist and oversee HIV screening and linkage to care for HIV patients diagnosed at community sites. HIV screening and linkage to care can be accomplished by incorporating standard testing for HIV into routine medical care.

Gender Differences in HIV Testing, Diagnosis, and Linkage to Care in Healthcare Settings: Identifying African American Women with HIV in Chicago

Women account for 25% of all people living with HIV and 19% of new diagnoses in the United States. African American (AA) women are disproportionately affected. Yet, differences in the care continuum entry are not well understood between patient populations and healthcare sites. We aim to examine gender differences in diagnosis and linkage to care (LTC) in the Expanded HIV Testing and Linkage to Care (X-TLC) program within healthcare settings. Data were collected from 14 sites on the South and West sides of Chicago. Multivariate logistic regression analysis was used to determine the differences in HIV diagnoses and LTC by gender and HIV status. From 2011 to 2016, X-TLC performed 281,017 HIV tests; 63.7% of those tested were women. Overall HIV seroprevalence was 0.57%, and nearly one third (29.4%) of HIV-positive patients identified were cisgender women. Of newly diagnosed HIV-positive women, 89% were AA. 58.5% of new diagnoses in women were made at acute care hospitals, with the remainder at community health centers. Women who were newly diagnosed had a higher baseline CD4 count at diagnosis compared with men. Overall, women had lower odds of LTC compared with men (adjusted odds ratio = 0.58, 95% confidence interval 0.44-0.78) when controlling for patient demographics and newly versus previously diagnosed HIV status. Thus, interventions that focus on optimizing entry into the care continuum for AA women need to be explored.

Identifying African American Women with HIV Infection in an Expanded HIV testing and Linkage to Care (X-TLC) Program in Healthcare Settings on the South and West Sides of Chicago.

Abstract Background Women account for 25 % of HIV infections nationally, and African American (AA) women are disproportionately affected. We report important gender differences observed in an expanded HIV testing and linkage to care (X-TLC) program conducted on the South and West Sides of Chicago. Methods X-TLC is funded by CDPH with CDC prevention B funds. X-TLC has expanded from 3 sites to 14 sites, including acute care hospitals (academic, community), community health centers (CHCs), and family planning clinics. We report descriptive stats, group comparisons by Chi-square, and multivariate analyses adjusted for demographics. Results Since 2011, X-TLC has conducted 308,038 HIV screens, and 63.7 % of those tested were women. Overall seroprevalence for HIV was 0.56 %, and 30.5 % of HIV patients identified were cis-gender women (seroprevalence 0.15 %). The seroprevalence for women testing in EDs was higher (0.44 %). Similar to men, only 52.9 % of HIV positive women were new diagnoses. Women accounted for 28.5 % of all new diagnoses, compared with 15.4 % for Chicago overall. In 2016 X-TLC screened 91,865 persons for HIV, and 65.2 % of those tested were women. There were 193 new diagnosis and 32.1 % (62) were women, 85.7 % AA. In comparison, in 2015 there were 139 women with a new HIV diagnosis for all of Chicago. Women newly diagnosed were less likely to be linked to care (adjusted odds ratio, aOR, 0.54, 0.35–0.85). Linkage was lower for women diagnosed at CHCs (84.6 % vs. 76.3 %, P = 0.02). Most CHCs did not have on site HIV providers. At our site, however, women linked to care were more likely to be retained in care (aOR 0.58, 0.43–0.78). We also conduct targeted outreach testing, partner services (PS) testing, and social network strategy (SNS) testing, but women are not identified by these programs (16/171 tested women, 8 new diagnoses were men for PS; 507 tested, 471 men and 36 trans-gender women, 38 new positives, 0 cis-gender women for SNS). Conclusion More women than men were offered and/or accept HIV screening in healthcare settings. The proportion of seropositive women identified was higher than the national average. X-TLC is reaching a large proportional of AA women with HIV unaware of their status. Other testing strategies will rarely identify cis-gender women with HIV infection. Gender differences in linkage to and retention in care will require strategies targeted at women. Disclosures J. P. Ridgway, Gilead FOCUS: Grant Investigator, Grant recipient; N. Glick, Gilead FOCUS: Grant Investigator, Grant recipient; D. Pitrak, Gilead Sciences FOCUS: Grant Investigator, Grant recipient

Use of electronic data to assist with long-term follow-up in an urban HIV clinic

Abstract Background The University of Chicago Medicine (UCM) HIV clinic follows up 565 patients, with case management by one social worker. This large cohort makes active case follow-up difficult. Our clinic is located in a neighbourhood on the south side of Chicago. This area includes four of the six communities with the highest annual HIV diagnosis rates in the city and contains neighbourhoods with an HIV prevalence of 1% or more. We describe a programme that used medical informatics to re-link patients lost to follow-up into care and to assist in the long-term management of this group. Methods Patients at the UCM HIV clinic were eligible for the study if they had attended at least one appointment but had not been seen in clinic for 6 months or more, our criterion for lost to follow-up. We used an electronic clinic database and electronic medical records to identify these patients. Those patients classified as lost to follow-up were re-linked to care by clinic social workers by phone or, if that failed, by follow-up letters. Patients were contacted from February to June, 2013, by the social worker and a social work intern. In an open programme, patients will become eligible for re-linkage on a rolling basis. Findings Among 565 patients, 56 (10%) had not been seen for 6 months to 1 year, 40 (7%) had not been seen for 1–2 years, and 27 (5%) had not been seen for more than 2 years. Overall, 442 (78%) of our patients were retained in care and 123 (22%) patients were determined to be lost to follow-up. Age, sex, race, ethnicity, and insurance coverage did not predict lost to follow-up status. Ten patients (8%) were dead. Among 113 living patients, 64 (57%) were contacted by phone. 32 had moved or were in care elsewhere. 30 of the remaining 32 (94%) scheduled a clinic visit. Ten patients scheduled a visit in response to a letter or voicemail, but 49 (9% of the clinic cohort) remain lost to follow-up. Interpretation Our retention rate is much higher than the US national retention rate of about 40%. Nonetheless, with a large cohort, it is important to implement measures to track retention. With this aim, we found electronic data to be useful for identification of patients lost to follow-up and to aid in efforts towards retention in care. We were very successful at collecting data from or re-linking patients who we could contact by phone, but less so when we had to send a letter. In addition to re-engaging patients into care, it is important for us to know if patients have died or transferred care to adequately assess our local cascade of engagement in care. With this study we hope to show the feasibility and sustainability of clinic-wide re-linkage initiatives. Funding None.