RE-LINKAGE TO CARE OF HIV AND HEPATITIS C CO-INFECTED PATIENTS IN NEW YORK CITY

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1 RE-LINKAGE TO CARE OF HIV AND HEPATITIS C CO-INFECTED PATIENTS IN NEW YORK CITY HIV EPIDEMIOLOGY AND FIELD SERVICES PROGRAM FIELD SERVICES UNIT NANCY KUZMYAK AND TANZILA PERVIN, PUBLIC HEALTH ADVISORS

2 NYC BUREAU OF HIV PREVENTION Epidemiology and Field Services Program Surveillance Field Services Research Partner Services (PS) Newly-diagnosed or unresolved PS issues Linkage/re-linkage to care Out-of-care (OOC) or Never-in-care (NIC) Data Support

3 FIELD SERVICES UNIT AIMS ESTABLISHED 2006 Persistent problem of late HIV diagnosis NYC partner services (PS) outcomes lagged behind NYS and other national benchmarks Missing surveillance information 30% of cases with no transmission risk identified Delayed linkage to care (LTC) ~25% with no VL/CD4 1 year after initial diagnosis Elevated risk of morbidity/mortality and onward HIV transmission

4 FSU WORK FLOW HIV+ Patients Elicit Notify Test for HIV HIV+ HIV- Link to HIV Care Link to PEP/PrEP Disease Intervention Specialists assist HIV-diagnosed persons with PS and LTC

5 OUT OF CARE WORK FLOW In 2007, FSU began outreach to patients on the basis of CD4 or HIV viral load (VL) results reported to HIV surveillance registry as proxy measures of engagement in care This information was used to identify PWLH presumed out of care (OOC) (no labs > 13 months) Once identified, OOC clients were assigned to Disease Intervention Specialists for return to care (RTC) for HIV and for HCV evaluation and care if indicated In 2013, FSU began matching names of OOC-PLWH with the HCV surveillance registry to prioritize HCV co-infected OOC-PLWH for RTC and HCV linkage to care and treatment

6 WORK FLOW Step1: Presumed OOC HIV/HCV co-infected cases selected from the surveillance registry Step 2: Pre-field Checks Other databases: HASA, BCD MAVEN, New York State Electronic HIV Management System (NYEHMS) Step 3: Assign, investigate, and link to care Search engines: - Worker Connect, Parole system check People search - Lexis-Nexis, USPS, Google, etc. Electronic Clinical Data Healthix, NYCIG, Bronx RHIO

7 FIELD INVESTIGATION

8 FSU HIV/HCV CO-INFECTION OUTREACH OUTCOMES CASES ASSIGNED FROM 2016 TO 2017

9 FLOW CHART OF HIV AND HCV CO-INFECTION PRESUMED OUT OF CARE (OOC) ASSIGNED FOR LINKAGE TO CARE OUTREACH IN NYC, Presumed OOC 577 Not traced 75 (13%) Traced 502 (87%) Other dispositions 138 (27%) Moved/out of jurisdiction 53 (38%) HIV-negative or unconfirmed 69 (50%) Deceased 10 (7%) Other 6 (4%) Current with care 89 (18%) Confirmed OOC 275 (55%) Refused linkage to care 73 (27%) Returned to care 202 (73%) Returned to care with lab 189 (69%)

10 RETURNED TO HIV CARE OUTCOMES, Returned to HIV Care Outcomes of Confirmed OOC Clients (n=275) 73% 69% 27% Returned to care Returned to care with labs Refused linkage Returned to care: patient kept the appointment Returned to care with labs: patient kept the appointment and had CD4/VL labs done Refused linkage: patient refused FSU linkage service

11 HCV EVALUATION AFTER RETURNED TO CARE, Returned to HIV Care (N=202) N % Hepatitis C (HCV) Screening Total number screened for HCV (Preliminary or Confirmatory) 93 46% Preliminary HCV Positive (AB + ) 28 14% Confirmed HCV Positive (NAAT/RNA + ) 68 34% Confirmed HCV Negative (NAAT/RNA - ) 25 12%

12 HCV TREATMENT Confirmed HCV Positive (NAAT/RNA+) (n=68) N % Currently on treatment 14 21% Referred to treatment 17 25% Treatment deferred due to medical conditions 19 28% Insurance issue 3 4% Other reason not on treatment - Patient refused treatment 10 15% Incarcerated 1 1% Don't know/missing 4 6%

13 CHALLENGES & LESSONS LEARNED

14 CHALLENGES Client - o Clients lack of HCV knowledge and do not think HCV is their top priority (e.g. other medical conditions) o Concerns about side effects of the medication o Many clients also had substance, alcohol, or mental health issues Provider - o Lack of communication between provider and client o Providers do not want to initiate treatment immediately (e.g. too high HIV viral load, not compliant to the follow-up appointment) Administrative & Data - o Some insurance does not cover the medication - high cost of the medication o Substantial number of clients subsequently tested HIV negative during case investigation (e.g. misreported HCV viral load as HIV viral load)

15 LESSON LEARNED Build relationship with clients Reduce stigma and increase willingness to care by educating clients about HCV Methadone program can be helpful to link people to HIV care and HCV evaluation Work with HCV care coordinators (Project INSPIRE: NYC Hep C Care Coordination Program)

16 THANK YOU QUESTIONS?