Epidemiology of the Viral Hepatitis-HIV Syndemic in San Francisco: A Collaborative Surveillance Approach

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1 Dt Hrmoniztion nd Registry Mtching Epidemiology of the Virl Heptitis-HIV Syndemic in Sn Frncisco: A Collbortive Surveillnce Approch Meliss A. Snchez, PhD, MA Susn Scheer, PhD, MPH b Sue Shllow, MPH, CACLS c Shron Pipkin, MPH b Sndr Hung, MD c ABSTRACT Objectives. To describe the epidemiology of people coinfected with heptitis B virus (HBV) or heptitis C virus (HCV) nd HIV in Sn Frncisco, the Sn Frncisco Deprtment of Public Helth s Communicble Disese Control nd Prevention Section nd the HIV Epidemiology Section collborted to link their registries. Methods. In Sn Frncisco, heptitis reporting is primrily through pssive lbortory-bsed surveillnce, nd HIV/AIDS reporting is primrily through lbortory-initited ctive surveillnce. We conducted the registry linkge in 2010 using sequentil lgorithm. Results. The registry mtch included 31,997 HBV-infected people who were reported strting in 1984; 10,121 HCV-infected people who were reported strting in 2001; nd 34,551 HIV/AIDS cses reported beginning in Of the HBV nd HCV cses, 6.3% nd 12.6% were coinfected with HIV, respectively. The mjority of cses were white mles; however, blck people were disproportiontely ffected. For more thn 90% of the HBV/HIV cses, mleto-mle sexul contct (men who hve sex with men [MSM]) ws the risk fctor for HIV infection. Injection drug use ws the most frequent risk fctor for HIV infection mong the HCV/HIV cses; however, 35.6% of the HCV/HIV coinfected mles were MSM but not injection drug users. Conclusions. By linking the two registries, we found new wys to foster collbortive work nd expnd our progrmmtic flexibility. This nlysis identified prticulr popultions t risk for coinfection, which cn be used by virl heptitis nd HIV screening, prevention, nd tretment progrms to integrte, enhnce, trget, nd prioritize prevention services nd clinicl cre within the community to mximize helth outcomes. Sn Frncisco Deprtment of Public Helth, Communicble Disese Control nd Prevention Section, Chronic Heptitis Surveillnce, Sn Frncisco, CA b Sn Frncisco Deprtment of Public Helth, HIV Epidemiology Section, Sn Frncisco, CA c Sn Frncisco Deprtment of Public Helth, Communicble Disese Control nd Prevention Section, Sn Frncisco, CA Address correspondence to: Meliss A. Snchez, PhD, MA, Sn Frncisco Deprtment of Public Helth, Chronic Heptitis Surveillnce, Communicble Disese Control nd Prevention Section, 101 Grove St., Ste. 408, Sn Frncisco, CA 94102; tel ; fx ; e-mil <meliss.snchez@sfdph.org> Assocition of Schools nd Progrms of Public Helth 95

2 96 Dt Hrmoniztion nd Registry Mtching In the United Sttes, n estimted 1.1 million people re chroniclly infected with heptitis B virus (HBV), 1 n estimted 3.2 million people re chroniclly infected with heptitis C virus (HCV), 2 nd n estimted 1.1 million people re infected with humn immunodeficiency virus (HIV). 3 Coinfection with HBV or HCV mong HIV-infected individuls is common, s ll three viruses shre similr modes of trnsmission, including sexul prctices mong men who hve sex with men (MSM), injection drug use, nd other percutneous exposures to infected blood. While the estimted prevlence of chronic HBV nd HCV in the generl U.S. popultion is reltively low 0.3% 1 nd 1.3%, 2 respectively both HBV nd HCV prevlence mong HIV-infected people is higher. The prevlence of chronic HBV mong HIVinfected people is estimted to be 6% 14%, 4 8 nd the estimted prevlence of HCV mong HIV-infected people in the U.S. is estimted t 25%. 9 Additionlly, rtes of coinfection with chronic HBV or HCV nd HIV vry by risk group, type of exposure, nd efficiency of trnsmission. Coinfection with HBV nd HIV is most commonly linked to sexul prctices mong MSM. It is estimted tht 15% 25% of ll new HBV infections in the U.S. occur mong MSM. 9 Coinfection with HCV nd HIV is most commonly linked to injection drug use. However, there re limited dt describing the epidemiology of coinfection with HBV nd HIV or with HCV nd HIV either in Sn Frncisco, Cliforni, or in the U.S. s whole. With the gol of describing the epidemiology of individuls who re coinfected with either chronic HBV or HCV infection nd HIV, two sections within the Sn Frncisco Deprtment of Public Helth (SFDPH) the Communicble Disese Control nd Prevention (CDCP) Section s (Chronic Virl Heptitis Registry Tem nd the HIV Epidemiology Section s HIV/AIDS Surveillnce Unit collborted to link their respective registries to describe the epidemiology of people coinfected with HBV or HCV nd HIV in Sn Frncisco. These two sections re orgnized nd function seprtely within the SFDPH but hve history of collbortion nd support. This linkge offered unique opportunity to look t the epidemiology of people living in Sn Frncisco who re coinfected with HBV or HCV nd HIV. METHODS Heptitis reporting Reporting of chronic heptitis B nd pst or present heptitis C infection is primrily through pssive lbortory-bsed surveillnce. Lbortories nd providers re mndted by the Title 17 Cliforni Code of Regultions, Sections 2500 nd 2505, to report positive lbortory results for heptitis B nd heptitis C. 10 Most cses re reported by lbortories rther thn providers. Although test results consistent for infection with heptitis B did not become lbortory reportble until My 1995, some lbortories voluntrily reported these tests to the SFDPH. Since 1984, dtbse tht contins limited informtion from the first reported lbortory mrker of chronic heptitis B hs been mintined. Test results consistent with mrkers of HCV infection becme reportble by lbortories in July 2007, but some lbortories were voluntrily reporting positive lbortory tests for HCV to SFDPH prior to July Since July 2001, SFDPH hs registered limited informtion from the first reported lbortory mrker for HCV infection. Since October 2005, longitudinl person-bsed registry hs been mintined by CDCP for cses with positive lbortory mrkers for chronic heptitis B nd/or with positive mrkers for infection with HCV. All positive test results for ech cse re entered into this dtbse. The Centers for Disese Control nd Prevention (CDC)/Council of Stte nd Territoril Epidemiologists (CSTE) lbortory criteri for dignosis re pplied to identify people who meet the lbortory criteri for either probble or confirmed chronic heptitis B 11 or infection with HCV. 12 People infected with chronic HBV included in this nlysis met the CDC/CSTE lbortory criteri for either probble or confirmed heptitis B nd were reported from Jnury 1, 1984, to April 22, People with HCV infection included in this nlysis met the CDC criteri for pst or present infection with HCV nd were reported from July 1, 2001, to April 22, Enhnced surveillnce ctivities re implemented monthly on rndom smple of the newly reported cses through ptient interviews nd dt-collection forms sent to the ptients providers, which mesure the completeness of ptients lbortory reports. HIV/AIDS reporting Sn Frncisco HIV/cquired immunodeficiency syndrome (AIDS) cses re reported primrily through lbortory-initited ctive surveillnce. Cse report forms re completed by SFDPH stff through review of lbortory reports, pthology reports, nd medicl records. Cses re lso identified through pssive surveillnce, including reports received from helth-cre providers nd confidentil testing sites, review of deth certifictes, hospitl billing records, other disese registries, nd reports from other helth deprtments. AIDS cses included in this nlysis cover the entirety of the

3 Virl Heptitis-HIV Syndemic in Sn Frncisco 97 HIV epidemic from 1981 to April Confidentil reporting of AIDS cses by nme begn in Mrch HIV reporting ws implemented on July 1, 2002, using non-nme code; on April 17, 2006, HIV reporting by nme ws implemented. 13 Completeness of HIV/ AIDS cse reporting is reviewed nnully nd hs been consistently found to be highly complete. 14 Dt linkge People were included in this mtch if they were residents of Sn Frncisco t the time of either their HIV or AIDS dignosis. Becuse surveillnce for chronic heptitis B nd HCV infection is pssive nd lbortory bsed, nd HIV cse scertinment is primrily through ctive surveillnce ctivities, for this linkge, dt on rce/ethnicity, county of residence, nd trnsmission risk fctors were tken from dt obtined through HIV/AIDS surveillnce. Dt linkge ws conducted using sequentil lgorithm. The first mtch ws n identicl mtch between full nme nd full dte of birth. Additionl mtches were performed using prtil dte of birth, soundex (n lph numeric code derived from the lst nme), nd Socil Security number. Any mtches mde fter the identicl mtch were mnully exmined to confirm mtches. Dt for certin rcil/ethnic ctegories hve been grouped. People of Ltino origin, regrdless of rce, were grouped into the Ltino ctegory. Thus, white, blck, nd Asin rce ctegories re ll non-ltino. The other ctegory includes rcil/ethnic ctegories in which the numbers of people in tht prticulr group were smll nd/or did not represent significnt trends (e.g., Ntive Americns nd people of mixed rce). Risk ctegories were lso grouped into the other ctegory when the number of people in tht group ws smll. Other my include trnsfusion recipients, hemophilics, heterosexuls, people cquiring HIV through perintl trnsmission, or people of unidentified risk. A memorndum of understnding ws estblished between the CDCP Section nd the HIV/AIDS Surveillnce Section to document nd ensure tht ll linked dt were mnged ccording to the CDC security nd confidentility requirements for both sections. Dt linkge nd ll nlyses were conducted using SAS version RESULTS The registry mtch between SFDPH s Chronic Heptitis Registry nd HIV Registry ws implemented on April 22, As of tht dte, the Chronic Heptitis Registry included 31,997 people infected with HBV who were reported to CDCP from Jnury 1, 1984, to April 22, 2010, nd 10,121 people infected with HCV who were reported from July 1, 2001, to April 22, The HIV Registry included 34,551 people with HIV/AIDS who were reported to the HIV Epidemiology Section from Jnury 1, 1981, to April 22, Of the 31,997 HBV cses, 2,018 (6.3%) were coinfected with HIV, nd of the 10,121 HCV cses, 1,278 (12.6%) were coinfected with HIV. A totl of 504 cses were infected with both HBV nd HCV; of these coinfected cses, 101 cses (20.0%) were lso infected with HIV (dt not shown). Tble 1 presents the gender nd rce/ethnicity of the HBV/HIV nd HCV/HIV coinfected cses. Of the 2,018 HBV/HIV coinfected cses, 96.5% (n51,948) were mle nd 3.5% (n570) were femle. Among the mle cses, 63.4% (n51,236) were white, 17.4% (n5339) were blck, nd 12.0% (n5234) were Ltino. Among femles, 54.3% (n538) were blck, 27.1% (n519) were white, nd 10.0% (n57) were Ltino. Among the 1,278 HCV/HIV coinfected cses, 86.7% (n51,108) were mle, nd 13.3% (n5170) were femle. Among mles, 58.7% (n5650) were white, 23.5% (n5260) were blck, nd 12.5% (n5138) were Ltino. Of the 170 coinfected femles, 44.7% (n576) were blck, nd 42.9% (n573) were white. HIV trnsmission ctegories for HBV/HIV nd HCV/HIV coinfected mle cses by rce/ethnicity re presented in Tble 2. Among the 1,948 HBV/HIV coinfected men, 1,783 (91.5%) hd recorded trnsmission ctegory tht indicted mle-to-mle sexul contct, including 1,340 (68.8%) MSM who were not injection drug users (IDUs) nd 443 (22.7%) MSM who were IDUs. Of the 1,948 coinfected men, 582 (29.9%) hd n HIV trnsmission ctegory tht indicted injection drug use, including 139 (7.1%) IDUs who were not MSM nd 443 (22.7%) men who were both MSM nd IDUs. For white nd Ltino mles, the distribution cross ll reported HIV trnsmission ctegories ws comprble with the distribution for ll 1,948 HBV/HIV coinfected men. For the 339 blck mles, the distribution differed from the overll distribution mong other rces/ethnicities with higher percentge of men, 20.6% (n570), in n HIV trnsmission ctegory tht indicted injection drug use risk only, nd lower proportion, 49.3% (n5167), in the MSM but not IDU trnsmission ctegory. For the 98 Asin mles, the mjority (89.8%, n588) were in the MSMonly trnsmission ctegory. Among the 1,108 HCV/HIV coinfected men, 693 (62.5%) hd n HIV trnsmission ctegory tht indicted injection drug use, including 486 (43.9%) MSM who were lso IDUs nd 207 (18.7%) IDUs who were not MSM. Of the 1,108 coinfected men, 880 (79.4%) hd n HIV trnsmission ctegory tht indicted

4 98 Dt Hrmoniztion nd Registry Mtching Tble 1. Demogrphic chrcteristics of 2,018 coinfected HBV/HIV nd 1,278 coinfected HCV/HIV cses identified through linkge of the SFDPH Chronic Heptitis nd HIV registries: Sn Frncisco, 2010 Rce/ethnicity Mle Femle Totl HBV/HIV coinfected cses White 1,236 (63.4) 19 (27.1) 1,255 (62.2) Blck 339 (17.4) 38 (54.3) 377 (18.7) Ltino 234 (12.0) 7 (10.0) 241 (11.9) Asin 98 (5.0) 3 (4.3) 101 (5.0) Other 41 (2.1) 3 (4.3) 44 (2.2) Totl 1,948 (96.5) 70 (3.5) 2,018 (100.0) HCV/HIV coinfected cses White 650 (58.7) 73 (42.9) 723 (56.6) Blck 260 (23.5) 76 (44.7) 336 (26.3) Ltino 138 (12.5) 15 (8.8) 153 (12.0) Asin 42 (3.8) 1 (0.6) 43 (3.4) Other 18 (1.6) 5 (2.9) 23 (1.8) Totl 1,108 (86.7) 170 (13.3) 1,278 (100.0) Row percent HBV 5 heptitis B virus HIV 5 humn immunodeficiency virus HCV 5 heptitis C virus SFDPH 5 Sn Frncisco Deprtment of Public Helth mle-to-mle sexul contct, including 394 (35.6%) MSM who were not IDUs. For white mles, the distribution cross ll HIV trnsmission ctegories ws comprble with the overll distribution for ll 1,108 HCV/HIV coinfected men. For the 260 blck mles, when compred with the overll distribution mong other rces/ethnicities, lower proportion (15.0%, n539) were in the MSM-only trnsmission ctegory, nd higher proportion (39.6%, n5103) were in the IDU but not MSM trnsmission ctegory. For the 138 Ltino mles nd the 42 Asin mles, when compred with the overll distribution, higher proportion (50.7%, n570 Ltino mles nd 59.5%, n525 Asin mles) were in the MSM-only trnsmission ctegory (Tble 2). HIV trnsmission ctegories for HBV/HIV nd HCV/HIV coinfected femles by rce/ethnicity re presented in Tble 3. Among the 70 HBV/HIV coinfected women, 54 (77.1%) were in n HIV trnsmission ctegory tht indicted injection drug use, nd 13 (18.6%) were clssified s hving heterosexul contct s their only risk for HIV infection. The 19 white femles were more likely to be IDUs (94.7%, n518) thn were coinfected women of other rces/ ethnicities. The distribution cross HIV trnsmission ctegories for the 38 blck nd seven Ltino femles ws comprble with the overll distribution for ll 70 HBV/HIV coinfected women. Among the 170 HCV/HIV coinfected women, 154 (90.6%) were in n HIV trnsmission ctegory tht indicted injection drug use, nd 12 (7.1%) were clssified s hving heterosexul contct s their only risk for HIV infection. For white, blck, nd Ltino femles, the distribution cross ll HIV trnsmission ctegories ws comprble with the overll distribution for ll 170 HCV/HIV coinfected women, with the exception of the 10 (13.2%) blck women who were clssified s hving heterosexul contct s their only risk for HIV infection (Tble 3). DISCUSSION Consistent with the progrm collbortion nd service integrtion (PCSI) principles, this surveillnce collbortion enbled the chronic heptitis nd HIV epidemiologists to begin to describe the epidemiology of the virl heptitis-hiv syndemic in Sn Frncisco nd, consequently, develop more complete understnding of these coinfected popultions for public helth plnning nd the development of more effective, integrted pproches to service delivery. This Chronic Heptitis Registry nd HIV Registry mtch provided the SFDPH CDCP Section nd the SFDPH HIV Epidemiology Section with unique opportunity to shre nd link our dt, mximize our collective resources, nd use the unique progrmming nd nlyticl skills of epidemiologists from ech section to successfully implement the registry mtch nd nlyze the results. Although the mjority of HBV/HIV coinfected

5 Virl Heptitis-HIV Syndemic in Sn Frncisco 99 cses in Sn Frncisco were white mles, we found tht blck people were disproportiontely ffected. Blck mles comprised only 6.6% of the Sn Frncisco mle popultion but ccounted for 17.4% of HBV nd HIV coinfected mles. Correspondingly, blck femles comprised 7% of the Sn Frncisco femle popultion but ccounted for 54.3% of coinfected femles in this mtch. 16 For more thn 90% of this coinfected popultion, MSM ws the risk fctor for infection with HIV. This finding is consistent with severl studies of HBV infection mong HIV-infected popultions in Western Europe nd the U.S. 4 7 Although the gretest burden of HCV/HIV coinfection ws mong white mles, blck people were disproportiontely ffected. Blck mles comprised 23.5% of the HCV/HIV coinfected mles, nd blck femles comprised 44.7% of the HCV/HIV coinfected femles in this registry mtch. Overll, findings mong this HCV/HIV coinfected popultion re consistent with those from severl studies of HCV infection mong HIV-infected popultions in Western Europe nd the U.S. 4,8,9 Injection drug use ws the most frequent risk fctor for cquisition of HIV infection mong the HCV/ HIV coinfected popultion; however, notbly, mong HCV/HIV coinfected mles, 35.6% were MSM but not IDUs. This high percentge of coinfected, noninjection drug-using MSM suggests tht sexul ctivity my be prominent mode of trnsmission for HCV infection mong this HIV-infected mle popultion. While sex is not considered n efficient mode of HCV trnsmission, severl studies suggest tht high-risk sexul behviors, such s hving multiple sexul prtners nd receptive nl fisting, increse the risk for infection Building upon the collbortive frmework developed for this registry mtch, next steps to ddress this issue will involve further dtbse integrtion with SFDPH s Sexully Trnsmitted Diseses Prevention nd Control Services Progrm, which collects highrisk sexul prctice dt for cses within its registry. Dtbse integrtion mong ll three sections would provide us the opportunity to exmine the high-risk sexul prctices of the HCV/HIV coinfected popultion to better understnd the role of sexul prctices in trnsmitting HCV nd to develop nd implement specific prevention recommendtions to popultions ffected by this syndemic. Tble 2. HIV trnsmission ctegories of 1,948 HBV/HIV nd 1,108 HCV/HIV coinfected mle cses identified through linkge of the SFDPH Chronic Heptitis nd HIV registries, by rce/ethnicity: Sn Frncisco, 2010 Rce/ethnicity MSM not IDU IDU not MSM Heterosexul, not MSM or IDU MSM nd IDU Other/ unknown Totl HBV/HIV coinfected cses White 885 (71.6) 51 (4.1) 2 (0.2) 289 (23.4) 9 (0.7) 1,236 (63.4) Blck 167 (49.3) 70 (20.6) 4 (1.2) 95 (28.0) 3 (0.9) 339 (17.4) Ltino 180 (76.9) 13 (5.6) 4 (1.7) 37 (15.8) 0 (0.0) 234 (12.0) Asin 88 (89.8) 2 (2.0) 1 (1.0) 5 (5.1) 2 (2.0) 98 (5.0) Other 20 (48.8) 3 (7.3) 1 (2.4) 17 (41.5) 0 (0.0) 41 (2.1) Totl 1,340 (68.8) 139 (7.1) 12 (0.6) 443 (22.7) 14 (0.7) 1,948 (100.0) HCV/HIV coinfected cses White 257 (39.5) 83 (12.8) 2 (0.3) 300 (46.2) 8 (1.2) 650 (58.7) Blck 39 (15.0) 103 (39.6) 4 (1.5) 110 (42.3) 4 (1.5) 260 (23.5) Ltino 70 (50.7) 15 (10.9) 0 (0.0) 52 (37.7) 1 (0.7) 138 (12.5) Asin 25 (59.5) 3 (7.1) 0 (0.0) 13 (31.0) 1 (2.4) 42 (3.8) Other 3 (16.7) 3 (16.7) 1 (5.6) 11 (61.1) 0 (0.0) 18 (1.6) Totl 394 (35.6) 207 (18.7) 7 (0.6) 486 (43.9) 14 (1.3) 1,108 (100.0) Row percent HIV 5 humn immunodeficiency virus HBV 5 heptitis B virus HCV 5 heptitis C virus SFDPH 5 Sn Frncisco Deprtment of Public Helth MSM 5 men who hve sex with men IDU 5 injection drug user

6 100 Dt Hrmoniztion nd Registry Mtching Tble 3. HIV trnsmission ctegories of 70 HBV/HIV nd 170 HCV/HIV coinfected femle cses identified through linkge of the SFDPH Chronic Heptitis nd HIV registries, by rce/ethnicity: Sn Frncisco, 2010 Rce/ethnicity IDU Heterosexul, not IDU Other/unknown Totl HBV/HIV coinfected cses White 18 (94.7) 1 (5.3) 0 (0.0) 19 (27.1) Blck 28 (73.7) 8 (21.1) 2 (5.3) 38 (54.3) Ltino 5 (71.4) 2 (28.6) 0 (0.0) 7 (10.0) Asin 1 (33.3) 1 (33.3) 1 (33.3) 3 (4.3) Other 2 (66.7) 1 (33.3) 0 (0.0) 3 (4.3) Totl 54 (77.1) 13 (18.6) 3 (4.3) 70 (100.0) HCV/HIV coinfected cses White 68 (93.2) 2 (2.7) 3 (4.1) 73 (42.9) Blck 65 (85.5) 10 (13.2) 1 (1.3) 76 (44.7) Ltino 15 (100.0) 0 (0.0) 0 (0.0) 15 (8.8) Asin 1 (100.0) 0 (0.0) 0 (0.0) 1 (0.6) Other 5 (100.0) 0 (0.0) 0 (0.0) 5 (2.9) Totl 154 (90.6) 12 (7.1) 4 (2.4) 170 (100.0) Row percent HIV 5 humn immunodeficiency virus HBV 5 heptitis B virus HCV 5 heptitis C virus SFDPH 5 Sn Frncisco Deprtment of Public Helth IDU 5 injection drug user Limittions These findings were subject to t lest three limittions. First, the risk fctor dt from this registry mtch cme exclusively from the HIV registry; thus, they relte only to HIV infection, not HBV or HCV infection. Second, risk fctor dt were collected by reviewing the HIVinfected cses medicl records, nd the ccurcy of these dt is solely relint on providers hving obtined comprehensive, unbised ptient histories nd, subsequently, ccurtely, nd completely recording these histories in the ptients chrts. The risk fctor dt were not vlidted by ptient interviews; therefore, they my be bised if the ptient did not give the provider complete risk fctor history or if the provider did not scertin or record ll of the ptient s risk fctors. Finlly, lthough the registry mtch llowed the two SFDPH sections to begin to describe the epidemiology of the virl heptitis-hiv syndemic in Sn Frncisco, it did not provide the two sections with the opportunity to updte their registry with dt from the other registry. The SFDPH is currently chnging its prctices to develop integrted security nd confidentility policies nd integrted communicble disese surveillnce systems for dt exchnge nd shring tht will ultimtely improve dt completeness nd vlidity for public helth disese plnning nd mngement. CONCLUSION Through the collbortion between our two sections to mtch our registries nd nlyze the coinfection dt, we found new wys to foster collbortive work nd expnd our progrmmtic flexibility. The results from this syndemic dt nlysis identified prticulr popultions t risk for HBV nd/or HCV nd HIV coinfection, which cn be used by virl heptitis nd HIV screening, prevention, nd tretment progrms to integrte, enhnce, trget, nd prioritize prevention services nd clinicl cre within the community to mximize helth outcomes. These results were used by Sn Frncisco s PCSI Prevention nd Clinicl Working Group to inform guidelines for HIV testing, HBV vccintion, nd HCV screening, nd to identify pproprite settings for integrted clinicl services. In ddition, these results provide bseline mesure from which to monitor trends in demogrphic nd risk fctor chrcteristics of the HIV/heptitis coinfected popultion, s well s to cknowledge future successes in screening, vccintion, nd disese prevention. The uthors thnk the Centers for Disese Control nd Prevention (CDC) for its support (Coopertive Agreement #3U01CI nd #5U62PS ). This content is

7 Virl Heptitis-HIV Syndemic in Sn Frncisco 101 solely the responsibility of the uthors nd does not necessrily represent the officil views of CDC. The uthors lso thnk the Cliforni Emerging Infections Progrm for its finncil nd technicl support of the Sn Frncisco Chronic Virl Heptitis Registry Project; the Chronic Heptitis Tem Rchel Arrington, Alex Leung, Mrtin Li, nd Kren Luk for their contributions to dt collection nd registry mintennce, nd Amy Nishimur nd Dvid Stier, the project s Coordintor nd Clinicl Advisor, respectively; the humn immunodeficiency virus (HIV) Surveillnce Project Coordintor, Field Stff Coordintor, nd Core Surveillnce Director Mree Ky Prisi, Viv Delgdo, nd Ling Hsu, respectively s well s the field stff for coordinting nd collecting HIV surveillnce dt; nd the lbortorins, clinicins, nd people living with HIV, chronic heptitis B, nd heptitis C who provided the informtion tht mde this registry mtch possible. Drwing on the gols nd objectives of progrm collbortion nd service integrtion, the uthors pproched CDC nd requested to use HIV surveillnce funding to support n epidemiologist within the Sn Frncisco Deprtment of Public Helth Communicble Disese Control nd Prevention Section to tke the led on the registry mtch nd subsequent nlyses. Without this support, given the limited stff nd reduced funding for the Chronic Virl Heptitis Registry Project, the uthors would not hve been ble to conduct the mtch of the two registries. This nlysis ws conducted using routinely collected surveillnce dt; therefore, it ws exempt from institutionl review bord review. REFERENCES 1. Weinbum CM, Willims I, Mst EE, Wng SA, Finelli L, Wsley A, et l. Recommendtions for identifiction nd public helth mngement of persons with chronic heptitis B virus infection. MMWR Recomm Rep 2008;57(RR08): Armstrong GL, Wsley A, Simrd EP, McQuilln GM, Kuhnert WL, Alter MJ. 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