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1 originlcontributions Evluting the HIV Continuum of Cre within Lrge Integrted Helth System by Michel J. Willims, PhrmD nd Thoms J. Dilworth, PhrmD Abstrct Objective: The primry study objective ws to describe the HIV continuum of cre within lrge integrted helth system. Secondry objectives imed to ddress potentil gps long this internl continuum nd compre to ntionl nd sttewide dt. Methods: Ptients 13 yers of ge with positive HIV ntigen/ ntibody nd/or HIV rpid ntigen test(s) between Jnury 2012 nd August 2016 were identified using SAP business filtering softwre. The electronic helth record of queried ptients with positive result ws reviewed to determine ech ptient s plce long the HIV continuum of cre. Ptients with flse positive test were excluded. The overll HIV continuum of cre within our helth system ws then constructed nd compred to ntionl nd sttewide dt. Results: Of 79,442 HIV ntigen/ ntibody nd HIV rpid test collections, 211 (0.27%) were positive from which there were 115 (54.5%) unique ptients; of these, 86 (74.8%) met our inclusion criteri. Among these 86 ptients: 70.9% were linked to cre, 58.1% remined engged in cre, 34.9% were retined in cre, nd 45.3% chieved virl suppression within one yer fter HIV dignosis. Our internl linkge to cre results re comprble to ntionl dt yet lie below Wisconsin sttewide dt. Retention in cre offered the gretest opportunity compred to sttewide dt. Conclusion: To this end, we will investigte internl resources to improve linkge to cre nd ptient retention, s the ltter reveled strong correltion to virl suppression. We recommend repliction of this evlution t other institutions in which ptients re dignosed with HIV. The Centers for Disese Control nd Prevention (CDC) clim tht s of 2015, nerly one million persons 13 yers of ge in the United Sttes re infected nd living with humn immunodeficiency virus (HIV), disese ssocited with pproximtely 12,000 deths from ny cuse per yer. 1 This infection, which trgets CD4 T-cells, cn cuse severe immunosuppression llowing for the development of opportunistic infections to infiltrte the system s the CD4 count declines. Progression of immunosuppression to CD4 count < 200 cells/mm 3 is referred s the cquired immunodeficiency syndrome (AIDS). A dignosis of AIDS is ssocited with worsened prognosis s the CDC reported nerly 7,000 deths directly ttributble to AIDS in 2014 lone. Trnsmission of HIV from HIVinfected persons occurs primrily vi sexul intercourse nd the shring of intrvenous needles. Less common methods of HIV trnsmission include verticl trnsmission from n HIV-infected mother to their newborn or exposure of n open wound or mucosl membrne to infected bodily fluids. 2 Approprite mngement of the HIV-infected popultion is vitl in order to optimize survivl nd qulity of life, s well s to prevent dditionl HIV trnsmission. While there is no known cure for HIV, ntiretrovirl therpy (ART) induces virl suppression, defined in this report by n undetectble HIV RNA quntified lbortory vlue (< 40 copies/ml). The efficcy of these medictions is not only dependent on ptient dherence, but lso on pproprite drug combintion selection bsed on ptient-specific fctors, including the presence of HIV drug resistnce muttion(s). Recently published ntionl dt suggest only 37% of people dignosed with HIV re on ctive ART, nd less thn one-third of HIV-infected persons in the U.S. re virlly suppressed. 3 When ssessing survivl rtes of individuls on ART, compred to those without HIV, life expectncy is nerly equivlent. 4 As result, ART is the stndrd of cre for chieving HIV suppression nd is now recommended for ll people with HIV, regrdless of CD4 count. 5,6 In 2013, the CDC sought to gin comprehensive understnding of the United Sttes HIV popultion. Referenced s the HIV Cre Continuum, the project ctegorized persons living with HIV long five-step pthwy to virl suppression following forml HIV dignosis. These stges include: linkge to cre, enggement nd retention in cre, initition of ART, nd virl suppression (Tble 1, Figure 1). 7 The stte of Wisconsin Deprtment of Helth Services (WDHS) performed similr evlution of the stte s HIV popultion. Utilizing the sme methodology, it ws determined tht 6,337 people living with HIV resided in Wisconsin s of December 31, While 85% of those dignosed hd completed follow-up office visit within three months of dignosis, only 61% of the infected popultion hd chieved virl suppression t the end of the nlyzed time period. The proportion of persons in Wisconsin dignosed with concomitnt HIV nd AIDS decresed from 30% to 18% between 2012 nd In response to both the CDC nd WDHS results, s well nticiption of Ntionl HIV/AIDS Strtegy for 2020 gols (NHAS) which dvocte for n 85% linkge to cre within 30 dys nd 90% retention rte, we sought to describe the HIV continuum of cre within Auror Helth Cre (AHC). 10 As the lrgest notfor-profit helth system in the stte, AHC provides helthcre services in Wisconsin through 16 hospitls nd more thn 150 outptient clinics. 56 The Journl July/August

2 Methods Ptient Criteri Ptients who hd n HIV test performed t n AHC fcility were identified vi systemtic extrction from the electronic helth record (EHR) using SAP Business Objects Business Intelligence pltform filtering softwre 4.1, version (SAP Americ, Inc., Newtown Squre, PA). Ptients with positive HIV rpid ntigen nd/or HIV ntibody test(s) between Jnury 1, 2012 nd August 1, 2016 were included in our nlysis. Ptients were excluded if they were less thn 13 yers old t the time of HIV dignosis nd/or if the HIV test result ws determined to be flse positive s identified by chrt review. Ptients who hd positive HIV test within AHC but hd n estblished history of HIV infection prior to the study period were lso excluded from our nlysis. Ptient demogrphics were recorded including: ge, gender, nd rce. Dt Collection nd Anlysis Ptients were mtched ginst the predefined stges long the continuum (Tble 1). Those who received HIV cre outside of AHC but for whom documenttion of HIV cre nd outcomes ws described in the limited cpcity inter-institutionl shred EHR were included in the study. Subjects lost to follow-up, referred elsewhere, nd/or lcking dequte subsequent documenttion were noted s such nd included in the nlysis. Ptients who presented within three months of dignosis for ny reson other thn n HIV follow-up office visit (e.g. emergency room visit) were not considered to be linked or engged in cre. Initil HIV virl lod (VL) (copies/ml) nd CD4 count (cells/mm 3 ) were recorded s the first vlue mesured since HIV dignosis. Ptients with VL or CD4 count obtined on the dy of dignosis were not considered to be linked to cre. However, subsequent lbortory TABLE 1. The HIV Continuum of Cre Defined. 7 Defines the stges long the continuum of cre within which ptient is ctegorized. 13 yers of ge dignosed within the time period nd still living t the Dignosed with HIV end of the investigted period Hd t lest one CD4 or VL obtined within 3 months of HIV dignosis, not including ptients for whom CD4 or VL ws obtined on the dy Linked to Cre of dignosis. Subsequent CD4 or VL vlues obtined fter the dy of dignosis, but within 3 months were considered linked Hd t lest one CD4 or VL obtined outside of the first three months Engged but within yer of dignosis Hd t lest one CD4 or VL obtined within yer of HIV dignosis but Retined in Cre t lest 3 months fter being engged in cre Prescribed ART b Documenttion of prescribed ART in the electronic medicl record Achieved Virl Suppression VL=virl lod b ART=ntiretrovirl therpy vlue collection within 90 dys qulified s linkge to cre. Furthermore, if ptient did not become linked to cre, he or she remined eligible to become engged or retined in cre. Subsequent nlyses were performed within two subgroups. The first group, ptients without documented ART, ws evluted vi electronic helth record review for ny comments regrding rtionle for lck of ART. The second subgroup nlysis focused on ptients who were newly dignosed but filed to estblish documented follow-up within or outside of the AHC system. This project ws reviewed by the Auror Helth Cre Institutionl Review Bord nd grnted pprovl with no oversight necessry per bord review given the nture of dt collection nd hndling. Primry nd Secondry Objectives The primry objective of our study ws to describe the HIV continuum of cre within the AHC system s previously performed on both stte nd ntionl levels. Our secondry objective ws to use these dt to identify ny opportunities to improve the qulity of HIV cre within AHC. A specil focus ws plced on ny Serum VL <40 copies/ml or undetectble by current lb techniques within yer of HIV dignosis potentil gps in ptients without ART nd ptients not linked to cre. Sttisticl Anlysis Subjects bseline chrcteristics were summrized using descriptive sttistics. Continuous vribles were summrized using the men nd stndrd devition or the medin nd interqurtile rnge (IQR). The nnul proportion of newly dignosed HIV ptients who were dignosed with concomitnt HIV nd AIDS ws compred cross ll study yers using the likelihood rtio chi-squred test. A p-vlue of 0.05 ws considered sttisticlly significnt. All nlyses were performed in JMP Pro version (SAS Institute Inc., Cry, NC, United Sttes). Results Bseline Popultion The initil smple query resulted in 79,442 HIV ntigen/ntibody nd HIV rpid test collections. After filtering by rective nd positive results, 211 (0.27%) dt points remined. As both tests my be used in the sme ptient to estblish n HIV dignosis, duplicte medicl record numbers were removed, leving 115 (54.5%) unique ptients. Ptient mtch FIGURE 1. The HIV Continuum of Cre Steps. 7 Illustrtes the steps of the continuum defined in Tble 1. Linked Engged Retined Dignosis CD4/VL CD4/VL CD4/VL 1 Yer < 3 months > 3 months July/August 2017 The Journl 57

3 TABLE 2. Bseline Ptient Chrcteristics. Describes the bseline chrcteristics of the inclusion popultion (n=86). Chrcteristic ginst exclusion criteri further eliminted 29 from prticiption in the nlysis with 86 (74.8%) pproprite ptients remining from the initil 211 (Figure 2). The bseline popultion consisted primrily of Cucsin mles with medin ge of 39 yers (IQR 30, 49) (Tble 2). Sixty percent of ptients were dignosed t lbortory visit nd 35% were dignosed in the hospitl. The remining ptients were dignosed in clinic setting. Primry Objective Of 86 eligible ptients, 61 (70.9%) were ppropritely linked to cre; this does not ccount for 11 ptients (12.8%) who hd CD4 nd/or virl lod collected on the dy of dignosis. Men time to linkge ws 14.6 ± 18.1 dys. Regrding NHAS 2020 gols, 57.4% of ptients linked to cre met the new 30-dy to linkge metric. Additionlly, 58% of the totl dignosed popultion ws engged in cre followed by subsequent 35% retined in cre. Of those retined in cre, 96.7% of ptients were prescribed ART nd subsequent 83.3% chieved virl suppression. Fortyfive percent of the totl smple chieved virl suppression within yer of dignosis (Figure 3). The proportion of ptients dignosed with concomitnt HIV nd AIDS ws 43.7% overll, nd there ws no sttisticlly significnt difference in this Result Mle 71 (82.6) Rce White Blck/Africn Americn Asin Other Ethnicity Non-Hispnic or Ltino Hispnic or Ltino Other 43 (50.0) 37 (43.0) 3 (3.5) 3 (3.5) 69 (80.2) 14 (16.3) 3 (3.5) Age t dignosis (yers), medin (IQR b ) 39 (30, 49) Virl lod (copies/ml), medin (IQR b ) 63,327 (16,952, 226,391) CD4 count (cells/mm 3 ), medin (IQR b ) 203 (33, 492) Dignosis Encounter Type Lb services/not specified Hospitl Office visit All dt summrized using number (percentge) unless otherwise noted. b IQR = interqurtile rnge 52 (60.4) 30 (34.9) 4 (4.7) proportion per nnum (p=0.779). Secondry Objectives Our internl HIV continuum of cre evlution produced useful informtion nd reveled opportunities for HIV cre improvement. Linkge to cre within the AHC system ws comprble to the ntionl verge but fell below the stte of Wisconsin verge by 14%. Eleven ptients within AHC were excluded from linkge to cre nlysis becuse CD4 nd/or virl lod ws collected on the dte of dignosis. In comprison to the stte s decresing nnul proportion of ptients dignosed with concomitnt HIV nd AIDS, we observed consistently high proportion of ptients receiving this concomitnt dignosis within our helth system. Nineteen ptients (22.1%) were found to be without documented ART. Of these, one ptient hd n undetectble virl lod t bseline nd yer from dignosis without recorded therpy. Rtionle for lck of therpy mong the 19 ptients included: referred for HIV cre outside of AHC with no documented follow-up (n=11), lost to follow-up (n=7), nd moved out of stte (n=1). Of the entire smple size, 14 (16.3%) did not estblish linkge to cre within three months of dignosis. Six of the 14 ptients (42.9%) were referred outside of AHC for HIV cre without documenttion of HIV outcomes in the electronic medicl record. Additionlly, 6 ptients (42.9%) were lost with no documented referrl to cre fter HIV dignosis. The remining 2 subjects (14.3%) estblished cre fter the 90-dy linkge period hd expired. Discussion The results of our internl HIV continuum of cre nlysis suggest mny similrities with both ntionl nd sttewide dt; however, we did identify opportunities for improvement. Ptient cpture within the first month of dignosis is the initil focus in order to positively ffect the subsequent stges, especilly considering NHAS 2020 gols. Enggement in cre best identifies ptients who hve willingly ttended n HIVspecific follow-up ppointment outside of the linkge to cre time period. In our evlution, enggement my pper flsely low s four dditionl ptients hve time remining within their yer from dignosis to become engged in cre; thus, there is potentil for this proportion of ptients to increse should these ny of these four ptients complete enggement follow-up criteri. In comprison to ntionl dt, AHC ptients re more likely to be engged in cre. 3 Retention in cre dt hs the potentil to improve if ny of the twelve ptients with time remining in their yer from dignosis fulfill retention criteri. The incidence of undetectble virl lods t one yer from HIV dignosis ws 45% with potentil to improve if the seven ptients with time remining in the yer chieve virl suppression. It is importnt to note tht our lbortory testing sensitivities defined n undetectble virl lod s <40 copies/mm 3. This criteri is stricter thn both ntionl nd stte definitions which clssified ptients with virl lods <200 copies/mm 3 s virlly suppressed, thus hving potentil to reflect lower percentge of virlly suppressed ptients within our helth system. Both AHC nd sttewide dt show higher number of ptients chieving virl suppression compred to those retined in cre, which is contrry to ntionl dt. This incresed percentge likely occurred for two resons. The first is tht some ptients my hve chieved n undetectble virl lod t the 58 The Journl July/August

4 FIGURE 2. Ptient Selection. Illustrtes the filtering process from initil ptient query to unique ptients who meet inclusion criteri. Ptient Query Lb Test HIV 1/2 Rpid Test 79,442 ptients HIV Ag/Ab Screen Rective Result n=105 n=106 Duplicte MRNs Removed Exclusions n=97 n=18 9 prior dignoses 6 decesed 1 flse positive 6 prior dignoses 6 decesed 1 flse positive Unique Ptients n=81 n=5 MRN=medicl record number n=86 enggement to cre mrk nd thus did not continue to meet retention criteri. However, these ptients then did hve confirmtory virl suppression vlues fter one yer from dignosis suggesting mintined virl suppression. A second explntion is bsed on the pre-specified definition of ptient retention. While some ptients engged in cre hd multiple lb vlues confirming virl suppression, the collections occurred within three months of enggement, thus disllowing chrcteriztion within the retention metric. In comprison to sttewide dt, we did not observe decline in the proportion of ptients with dul HIV/ AIDS dignosis during the study period. 9 However, over one-third of the ptients in our study were dignosed with HIV in the hospitl, nd these ptients my hve presented with n AIDS-ssocited opportunistic infection. Ultimtely, identifying nd resolving gps in HIV ptient cre is n issue tht hs been ddressed within other helth systems. Ds nd collegues discussed brriers in ptient dherence to the continuum. 11 One strtegy suggested by the uthors ws tht ptients return to the provider for confirmtory testing of n initil HIV positive test suggestive of infection, rther thn notifying the ptient of the initil test result nd relying on the ptient for follow-up. 11 At the confirmtory visit, it is predicted tht the ptient my then become better linked to cre with n incresed chnce of ART offer. A second opportunity for improvement recognized within our ssessment is the lck of documented follow-up fter referrl hs been mde. While this disprity is surely multifctoril, Ds et l. noted one key potentil issue: ptient referrl nd subsequent follow-up t externl helthcre fcilities my occur, but this informtion is not universlly ccessible given lck of unifiction in the electronic medicl record. 11 As observed within AHC, fewer ptients were lost completely thn those who were referred elsewhere nd then lost to follow-up; inbility to electroniclly trck ptients post-referrl my contribute to indequte surveillnce of ptients throughout the continuum of cre within helth system. While primry fctor in the vlidity of follow-up sttistics depends upon the ptients coopertion, n integrted electronic medicl record my ese fcilittion of HIV cre mong different helth cre orgniztions. In recent yers, reserchers hve been investigting methods to ppropritely ddress gps in the continuum of cre. One method studied is the use of short messge service (SMS) technology in which ptient with n HIV dignosis my be sent ppointment reminders through secure text messging vendor. This ws triled in one HIV clinic with the objective of improving ppointment ttendnce. 12 Unfortuntely, nerly hlf of the popultion declined the service while others disconnected their mobile device during the study. Of the ptients who completed the study, there ws no significnt difference in ppointment ttendnce between those who received text messge interventions nd those who did not (72% versus 81%, p=0.42). Currently, lrger tril is evluting similr intervention using ppointment reminders coupled with July/August 2017 The Journl 59

5 FIGURE 3. HIV Continuum of Cre Across Multiple Levels: Ntion, Stte, System.,b,c,d,1,2,3,7,8 Compres the stges of the HIV continuum of cre between ntionl, stte, nd system levels. The ntionl smple size is extrpolted from 2014 dt citing 955,081 persons with n HIV dignosis. However, the only continuum of cre dt vilble comes from 2009 nd 2011 CDC reports. Linkge to cre nd retined in cre dt re extrpolted from 2009 dt with totl dignosed popultion of n=902,000. Engged in cre nd virl suppression dt re extrpolted from 2011 dt bsed on totl dignosed popultion of n=1,032,000. b Auror Helth Cre (AHC) dt reported does not ccount for four ptients who re not engged, but still hve time remining within yer from dignosis to become engged in cre. c Within the AHC popultion, twelve ptients not yet retined still hd time remining to become retined. d Within the AHC popultion, seven ptients still hve time remining to become virlly suppressed. three times week encourgement messges t select HIV clinics in Sn Frncisco. 13 The results my support mobile interventions to increse rtes of virl suppression s well s ptient retention in cre. A second theory involves the delegtion of n HIV ptient services coordintor. This role of ccountbility nd orgniztion would expectedly increse initil linkge to cre, subsequent enggement nd retention in cre, ART cceptnce, nd ultimtely virl suppression. One multi-center tril demonstrted significnt improvement in ptient follow-up within yer of dignosis in the cse-mnged group versus control (64% versus 49%, p=0.006). 14 A second study utilized cse mngers to re-engge ptients who hd been lost to follow-up. Of 409 ptients verified to be lost to follow-up, 57% returned for clinic visit s result of cse mngement contct. 15 While these uthors did not further evlute ptients long the HIV continuum of cre, our dt suggest fvorble correltion between follow-up, ART, nd virl suppression s nerly ll ptients retined in cre were on ART, mjority of whom chieved virl suppression. Conclusions As observed in our evlution, the HIV continuum of cre within AHC contins opportunities to improve cre for HIVinfected ptients, notbly in retention to cre our lrgest observed disprity compred with stte nd ntionl dt tht hs strong reltionship to virl suppression. We pln to tke steps to improve these spects of HIV cre within our helth system by first continuing to investigte externl references s well s by potentilly creting network of HIV cre providers within AHC to whom these ptients cn be referred fter dignosis. Ongoing reserch my inform methods to improve cre for HIV-infected ptients, including mobile reminders, n HIV services coordintor, or other novel pproches. We recommend tht institutions nd helth systems in which ptients re dignosed with HIV perform similr evlution of their HIV continuum of cre. Michel Willims is PGY-1 Phrmcy Resident, Auror Helth Cre Metro, Inc. Milwukee, WI. Thoms Dilworth is Specilty Phrmcy Coordintor, Infectious Disese, Deprtment of Phrmcy Services, Auror St. Luke s Medicl Center, Milwukee, WI. Disclosure: Michel J. Willims nd Thoms J. Dilworth declre no rel or potentil conflicts or finncil interest in ny product or service mentioned in the mnuscript, including grnts, equipment, medictions, employment, gifts, nd honorri. Michel J. Willims cknowledges full ccess to the dt in the study nd tkes full responsibility for the integrity nd ccurcy therein. P R This rticle hs been peer-reviewed. The contribution in reviewing is gretly pprecited! References 1. Dignoses of HIV Infection in the United Sttes nd Dependent Ares, Centers for Disese Control nd Prevention. pdf/librry/reports/surveillnce/cdc-hiv-surveillncereport-2015-vol-27.pdf. Accessed Februry 26, Skrbinski J, Rosenberg E, Pz-biley G, et l. Humn immunodeficiency virus trnsmission t ech step of the cre continuum in the United Sttes. JAMA Intern Med. 2015;175(4): Brdley H, Hll HI, Wolitski RJ, et l. Vitl signs: HIV dignosis, cre, nd tretment mong persons living with HIV- -United Sttes, MMWR Morb Mortl Wkly Rep. 2014;63(47): Smji H, Cescon A, Hogg RS, et l. Closing the gp: increses in life expectncy mong treted HIV-positive individuls in the United Sttes nd Cnd. PLoS One. 2013;8(12):e Pnel on Antiretrovirl Guidelines for Adults nd Adolescents. Guidelines for the 60 The Journl July/August

6 use of ntiretrovirl gents in HIV-1-infected dults nd dolescents. Deprtment of Helth nd Humn Services. gov/contentfiles/adul- tndadolescentgl. pdf. Accessed Jnury 23, Lundgren JD, Bbiker AG, Gordin F, et l. Initition of ntiretrovirl therpy in erly symptomtic HIV infection. N Engl J Med. 2015;373(9): Centers for Disese Control nd Prevention. Understnding the HIV cre continuum. librry/fctsheets/cdc-hiv-cre-continuum.pdf. Published Accessed Jnury 23, Schumnn, C. DHS Wisconsin. Wisconsin 2015 HIV cre continuum: sttewide nd select popultion groups through April Accessed Jnury 23, Wisconsin AIDS/HIV Progrm. DHS Wisconsin. Summry of the Wisconsin HIV/AIDS surveillnce nnul review: new dignoses, prevlent cses nd deths reported through December 31, p pril-sup.pdf. Accessed Jnury 23, The Office of Ntionl AIDS Policy. The ntionl HIV/AIDS strtegy: updted to 2020 indictor supplement. ids.gov/federl-resources/ntionl-hiv-idsstrtegy/nhs-2020-indictors.pdf. Published July Accessed Februry 26, Ds M, Christopoulos KA, Geckeler D, et l. Linkge to HIV cre in Sn Frncisco: implictions of mesure selection. J Acquir Immune Defic Syndr. 2013;64(Suppl 1):S Norton BL, Person AK, Cstillo C, Pstrn C, Subrmnin M, Stout JE. Brriers to using text messge ppointment reminders in n HIV clinic. Telemed J E Helth. 2014;20(1): Christopoulos KA, Riley ED, Tulsky J, et l. A text messging intervention to improve retention in cre nd virologic suppression in U.S. urbn sfety-net HIV clinic: study protocol for the Connect4Cre (C4C) rndomized controlled tril. BMC Infect Dis. 2014;14: PSW CONFERENCE CALENDAR July 31, 2017 Advnced Physicl Assessment Medicl College of Wisconsin, Milwukee August 3-6, 2017 Ledership Phrmcy Conference (invittion only) Egle Ridge Resort, Glen IL September 14-15, 2017 Immuniztion Delivery for Phrmcists Rdisson Hotel, LCrosse September 14-16, 2017 PSW Annul Meeting Rdisson Hotel, LCrosse October 13-14, 2017 PSW Technicin Eductionl Forum Rdisson Pper Vlley Hotel, Appleton Support our dvertisers 14. Grdner L, Metsch L, Anderson-Mhoney P, et l. Efficcy of brief cse mngement intervention to link recently dignosed HIV-infected persons to cre. AIDS. 2005;19(4): Udegu CC, Webster TR, Bocour A, Michel P, Sheprd CW. Lost or just not following up: Februry 8, 2018 PSW Legisltive Dy Monon Terrce, Mdison April 5-6, 2018 PSW Eductionl Conference Monon Terrce, Mdison June 7-8, 2018 PSW Senior Cre Conference Milwukee Mrriott West, Wukesh August 23-25, 2018 PSW Annul Meeting Klhri Theme Prk & Convention Center, Wisconsin Dells October 26-27, 2018 PSW Technicin Eductionl Forum Stoney Creek Hotel & Conference Center, Rothschild, WI (ner Wusu) Concordi University SOP Inside Front Cover Phrmcists Mutul Co. Inside Bck Cover Medicl College of Wisconsin Sympoosium pg. 45 PSW Annul Meeting pg. 23 PSW Advnced Physicl Assessment pg. 61 ADVERTISING INFORMATION Ads, contrcts, insertion orders, pyments, nd ll other relted communictions cn be requested t or mgrnt@pswi.org public helth effort to re-engge HIV-infected persons lost to follow-up into HIV medicl cre. AIDS. 2013;27(14): July/August 2017 The Journl 61