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Concordance of HIV surveillance and medical record data: What do CD4 and viral loads not tell us about linkage to HIV care ?. Charu Sabharwal, MD MPH Medical Director Epidemiology and Field Services Program Bureau of HIV/AIDS Prevention and Control NYC Department of Health.

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Charu Sabharwal, MD MPH Medical Director Epidemiology and Field Services Program

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Concordance of HIV surveillance and medical record data: What do CD4 and viral loads not tell us about linkage to HIV care?

Charu Sabharwal, MD MPH

Medical Director

Epidemiology and Field Services Program

Bureau of HIV/AIDS Prevention and Control

NYC Department of Health


Acknowledgements

  • Sarah Braunstein

  • Rebekkah Robbins

  • Colin Shepard

  • HIV Epidemiology and Field Services Program


Background


National HIV/AIDS Strategy

  • NHAS (July, 2010) - first comprehensive roadmap

  • Amore coordinated response to the HIV epidemic

  • Primary Goals for 2015:

    • Reduce infections

    • Increase access to care

    • Reduce health disparities


HIV Continuum of Care

Das, MoupaliPrevention of HIV Acquisition: Behavioral, Biomedical, and Other Interventions.

Medscape 2012


Monitoring HIV Care – CD4/VL

  • HIV Care = outpatient HIV visit with provider authorized to prescribe ART1

  • Clinical monitoring/treatment guidelines2

    • Traditionally, 1st CD4/VL at initial HIV care visit

    • CD4/VL: every 3-6 months;  frequency after ART initiation

  • CD4/VLs proxy for HIV care [HIV care visits not reported]

  • Since 2004, CSTE encouraged all states (59 jurisdictions) to report allCD4 and VLs3[New York2005]

  • Limited comprehensive evaluation of the validity of surveillance data as proxy of HIV care

  • 1Health Resources and Services Administration. The HIV/AIDS Program: HAB Performance Measures Group 1. In; 2009. 2DHHS Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. In; 2012. 3 CSTE Position statement 04-ID-07


    Measuring linkage to care

    • Surveillance traditionally measures linkage by a single event: 1streported CD4/VL on/after HIV diagnosis date

    • Accuracy of 1st CD4/VL1,2 drawn prior to referral to HIV care. For example, at the time of

      • Confirmatory testing after + rapid/point-of-care test

      • Inpatient diagnosis: CD4 impacts treatment decision

      • In New York City: routinemedical record (MR) abstraction for linkage to care is not feasible

      • 3,500 diagnosing providers; 3,000+ HIV cases yearly

      • Timely linkage – entry into care within 3 months of diagnosis. Local3 and national measure

    1 BertolliA. et al The Open AIDS Journal 2012,6:131-141. 2Keller et al. J Acquir Immune DeficSyndr2013.

    3New York City HIV/AIDS Surveillance Slide Sets. http://www.nyc.gov/html/doh/html/data/epi-surveillance.shtml


    New York City’s Care Validation Study

    • Validate CD4 and VL tests for persons living with HIV (PLWH) in NYC as proxy measure for HIV care in the first year after diagnosis

      1° Objective – evaluate the correspondence between a patients 1st CD4/VL on/after HIV diagnosis and linkage HIV care


    Purpose

    Validate 1st lab test (CD4/VL) from the diagnosing facility as measure of timely linkage toHIV care

    • Hypothesis: early post-diagnostic lab tests within first 2 weeks arepart of diagnostic work-up and not an actual linkage event


    Methods

    Methods


    Study population selection: New York City HIV Registry

    • Selected high-volume HIV diagnosing sites with co-located care (n=24)

      • Patients with new, confirmed HIV diagnosis in 2009 reported the Registry

      • Patients who had to linked to care at the same diagnosing facility within 12 months as per the Registry

        • PLEASE NOTE – Even though Surveillance does not require linkage to care at the same site of diagnosis, we did in order to conduct this validation study


    Figure 1: Final study population

    3,536 new, confirmed HIV diagnoses

    among > 13 years in NYC in 2009

    1,263 (36%) patients reported from high-volume

    (> 20 diagnoses) co-located HIV care sites

    947 (75%) patients had 1st CD4/VL reported

    from co-located site within 12 months of diagnosis eligible for medical record (MR) abstractions

    165 (17%) excluded: MR unavailable

    782 (83%) patients

    Registry (1st CD/VL) and MR (care visit) data


    Data Analysis


    Analytic population (n=782)

    Linkage within 12 months, per Registry

    NO

    YES

    HIV care visit confirmed by MR

    No medical visit group

    Medical visit group

    • Compared the subgroups based on:

    • Key demographic characteristics (age, gender, risk)

    • Proportion concurrently diagnosed with HIV/AIDS(AIDS within 31 days of HIV diagnosis – local definition)

    • Proportion diagnosed on inpatient service

    • Proportion that died within 12 months of diagnosis


    Timely linkage to HIV care

    • Compared the proportion who linked to HIV care within 3 months of diagnosis (timely) by Registry (1st CD/VL) vs. MR (care visit)


    Do 1st reported CD4/VLs indicate timely linkage to HIV care?

    • Compared subgroups:

      • Median time to 1st lab per the Registry

      • Proportion of 1st labs in 0-7 days and 0-14 days

    • Calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of Registry data in correctly classifying patients’ true timely linkage to care status based on the 1st CD/VL within:

      • 0-91 days (no labs excluded: National standard)

      • 8-91 days (excluded labs from 0-7 days)

      • 15-91 days (excluded labs from 0-14 days)


    RESULTS


    Figure 2: Linkage to care (n=782)Registry vs. MR

    No Medical visit

    20% (n=157)

    1st CD4/VL

    100% (n=782)

    Medical visit

    80% (n=625)


    Table 1: Demographics/clinical outcomes


    Figure 3: Inpatient diagnoses

    No medical visit

    Medical visit


    Figure 4: Mortality outcomes:Deaths within 12 months of HIV diagnosis


    Timely Linkage to Care


    Figure 5: Timely linkage to careRegistry vs. MR

    97%

    1st CD4/VL

    (proxy measure):

    0-91 days

    75%

    True linkage event

    (HIV care visit):

    0-91 days


    Are labs within the early

    post-diagnostic period indicative of timely linkage to care?

    Timely linkage


    Figure 6: Median time (days) to linkage based on 1st CD4/VL, by subgroups

    No medical

    visit

    1 day (IQR 0-5 days)

    p <0.001

    Medical visit


    Figure 7: Proportion of 1st labs in the early post-diagnostic period, by subgroups

    p <0.001

    p <0.001

    19%

    31%

    No

    medical

    visit

    No

    medical

    visit

    Medical

    visit

    Medical

    visit


    Figure 8: Performance of Registry data

    99%

    0-91 days

    8-91 days

    15-91 days


    Refinement of NYC’s timely linkage to care indicator


    Figure 9: Final study population: Refining timely linkage to care

    No lag applied

    Lag applied


    Figure 10: New York City’s refined Timely linkage to care indicator

    No lag

    No lag

    Lag

    Lag


    Conclusions

    • First population-based study to validate the use of HIV Surveillance’s proxy measure of timely linkage to care

    • Substantial misclassification of timely linkage in the early post-diagnostic period

    • NYC DOHMH implemented a refined definition of timely linkage to care (labs 8-91 days after diagnosis)

      • HIV labs in 1st 7 days  not indicative of linkage

    • Surveillance data overestimated linkage for older persons, non-traditional HIV risk transmission, and those who died soon after diagnosis


    Limitations

    • Selection of provider

      • A portion had a CD4/VL at an alternate provider which may be the linkage to care visit –DID NOT validate if these patients EVER linked

      • Oversampled the acute care setting

    • Selection of study population

      • Due to the complexities of HIV laboratory reporting, the 1st lab may have been misclassified to the incorrect provider


    Future directions

    • Exploration of surveillance-based retention in care measures vs. medical abstraction data

      • All care visits at diagnosing provider during first 12 months immediately following diagnosis

    • In depth exploration of mortality within 12 months of HIV diagnosis


    Thank you!

    cjain@health.nyc.gov


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