Regional Collaboration to Optimize the Cascade: The Northwestern Public Health CFAR Consortium
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1 Regional Collaboration to Optimize the Cascade: The Northwestern Public Health CFAR Consortium Julie Dombrowski, MD, MPH Assistant Professor of Medicine, University of Washington Deputy Director, Public Health-Seattle & King County HIV/STD Program National CFAR/APC HIV Continuum of Care Working Group Meeting February 4, 2014
2 Northwestern Public Health CFAR Consortium Goal: To enhance collaboration between UW CFAR and health departments region-wide Estimated no. PLWHA in the 6 states = 20,120 ~54% in 2 major urban centers (Seattle & Portland) ~46% outside urban areas Barriers to HIV diagnosis & care vary Barriers to measurement of the cascade vary
3 % of all HIV-Infected Persons Dombrowski JC et al, Under Review The Cascade in King County-2011, US 2009*, US-2010* 100% 90% 80% 70% 60% 50% 40% 30% 57% 36% 25% 20% 10% 0% HIV-infected HIV-diagnosed Linked to Care In Care Retained in Continuous Care Prescribed ART Virally Suppressed *US retention & suppression estimates derived from *Medical Monitoring Project and *14 jurisdiction lab reporting
4 Impact of Individual Case Investigation 35% 30% 25% 20% 15% 10% 5% 0% on Estimates of Retention in Care Estimated % of PLWHA out of care (no CD4 or VL 12 mo.) in King County, WA 31% Standard surveillance 16% Surveillance + case investigation 8% unknown N= % In-county 47% moved Region-wide investigation of cases with no lab results in past year with comparable disposition data 7% died Buskin SB et al, STD 2014
5 Surveillance-Based Outreach to Promote Relinkage to Care and ART: King County 1464 cases from surveillance investigated to date Criteria: no CD4 or VL in past year OR VL>500 & CD4<500 Plus cases identified through STD partner services and clinics As of 12/ completed individual intervention Factors participants identified as important barriers (not mutually exclusive) Barriers to HIV Care (N=235) Reasons for never initiating ART (N=55) No insurance 123 Side effect concerns 41 (52%) (72%) Forget appointments 79 (34%) Can control HIV with a healthy 34 attitude, at least for now (59%) Trouble getting appointments 76 (32%) Adherence concerns 32 (58%) No transportation 70 (30%) Doctor said I don t need ART 27 (49%) Don t know how to find doctor 63 (27%) CD4 count high 26 (47%) Poor relationship with doctor 63 (27%) Depressed 26 (51%) Reasons for discontinuing ART (N=130) Depressed 62 (47%) Side effects 55 (42%) Wanted a break 53 (41%) Non-adherent, worried 53 about resistance (41%) Couldn t afford med 42 (32%) Using drugs 39 (30%)
6 Washington State Expansion Goal to investigate cases with no labs in past year & re-link out-of-care persons to HIV care CDC-funded: HIV prevention demonstration grant SUCCESSES Increased crossjurisdictional collaboration Improved coordination between prevention & care; surveillance & outreach CHALLENGES Data systems Different perspectives on the balance between project planning & implementation
7 Regional Collaboration: Public Health CFAR Consortium Primary goal of supplement: Improve accuracy of cascade estimates in Northwestern US Region-wide investigation of cases with no CD4 or VL data in past year Update surveillance data to accurately reflect the current population Assess impact of migration on estimates of retention Lay groundwork for future study of intervention to improve care engagement and viral suppression Underlying goal of supplement: catalyze new research collaboration
8 Case Investigation Procedures WA State protocol adapted for region-wide use Idaho: clinic-based instead of health dept-based Standardized core data elements Common disposition definitions Common questions on key barriers to care for contacted persons Access database created for states without data system to track investigations De-identified data submitted to UW CFAR Re-linkage procedures vary by site
9 Estimated Case Loads State Estimated Number of PLWHA Estimated Number of Cases with No CD4 or VL 12 months % Out of Care Alaska 1, % Idaho Idaho Clinics 1, %* Montana % Oregon 5, (70% Multnomah) Washington 11, (42% King) 19% 26% Wyoming % OVERALL 20,118 4,695 23% *Estimate from largest clinic (N=600) used to estimate 3-clinic case load, assuming equal proportions of patients had no visit in past 12 months
10 Expected Outcomes of the Project Analyses Impact of migration adjustment on retention in care estimates Prevalence of perceived barriers to care Preliminary assessment of contact and relinkage success Future directions Grant to study clinic or population-based intervention to increase retention in care and virologic suppression
11 Other Work & Future Directions of Consortium HIV Diagnosis Method for local estimation of undiagnosed fraction Developing specialized care infrastructure for MSM Appropriate role of home HIV testing Promotion and assessment of routine testing in healthcare settings Linkage and retention in care Impact of migration on care (beyond the measurement effects) Clinic & population-based interventions
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