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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 MPHMedical DirectorEpidemiology and Field Services ProgramBureau of HIV/AIDS Prevention and ControlNYC Department of Health
Acknowledgements• Sarah Braunstein• Rebekkah Robbins• Colin Shepard• HIV Epidemiology and Field Services Program
• NHAS (July, 2010) - first comprehensive roadmap
• A more coordinated response to the HIV epidemic
• Primary Goals for 2015:– Reduce infections– Increase access to care– Reduce health disparities
National HIV/AIDS Strategy
HIV Continuum of Care
Das, Moupali Prevention of HIV Acquisition: Behavioral, Biomedical, and Other Interventions. Medscape 2012
• 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 all CD4 and VLs3 [New York2005]
• Limited comprehensive evaluation of the validity of surveillance data as proxy of HIV care
Monitoring HIV Care – CD4/VL
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
• Surveillance traditionally measures linkage by a single event: 1st reported 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: routine medical 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
Measuring linkage to care
1 Bertolli A. et al The Open AIDS Journal 2012,6:131-141. 2Keller et al. J Acquir Immune Defic Syndr 2013. 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
PurposeValidate 1st lab test (CD4/VL) from the diagnosing facility as measure of timely linkage to HIV care • Hypothesis: early post-diagnostic lab
tests within first 2 weeks are part of diagnostic work-up and not an actual linkage event
• 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
Study population selection: New York City HIV Registry
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
Figure 1: Final study population
782 (83%) patients Registry (1st CD/VL) and MR (care visit) data
Analytic population (n=782)Linkage within 12 months, per Registry
No medical visit group Medical visit group
HIV care visit confirmed by MR
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
YESNO
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)
Figure 2: Linkage to care (n=782)Registry vs. MR
Registry MR0%
20%
40%
60%
80%
100%
% L
inke
d to
car
e w
ithin
12
mon
ths
of d
iagn
osis
Medical visit80% (n=625)
1st CD4/VL100% (n=782)
No Medical visit20% (n=157)
No medical visit
N=157
Medical visit
N=625 P value
Age at HIV diagnosis (median, range) 42 (16-80) 37 (15-78) 0.001
Male Gender (%) 69.4 74.2 0.220
Race/ethnicity (%)
Black 54.1 48.0 0.370
Hispanic 36.9 37.4
White 7.6 11.0
Transmission risk (%)
Men who have sex with men 18.5 42.9 <0.001
Injection drug use 8.9 4.2
Heterosexual 33.8 29.3
No identified risk 38.9 23.7
Concurrent AIDS diagnosis 61.8 37.0 <0.001
Table 1: Demographics/clinical outcomes
Figure 3: Inpatient diagnoses
Diagnosed in acute setting0%
20%
40%
60%
80%
100%
73%
32%
% S
tudy
pop
ulati
on
p<0.001
No medical visit Medical visit
Figure 4: Mortality outcomes:Deaths within 12 months of HIV diagnosis
No medical visit Medical visit0
5
10
15
20
18%
1 %
% D
ied
with
in 1
2 m
onth
s of
HIV
di-
agno
sis
p<0.001
Figure 5: Timely linkage to careRegistry vs. MR
Registry MR0%
20%
40%
60%
80%
100%
% L
inke
d to
car
e w
ithin
12
mon
ths
of d
iagn
osis
97%
1st CD4/VL(proxy measure):
0-91 days
75%
True linkage event(HIV care visit):
0-91 days
Timely linkageAre labs within the early
post-diagnostic period indicative of timely linkage to care?
Figure 6: Median time (days) to linkage based on 1st CD4/VL, by subgroups
MR0%
20%
40%
60%
80%
100%
% L
inke
d to
car
e w
ithin
12
mon
ths
of d
iagn
osis
8 days (IQR 0-20days)
1 day (IQR 0-5 days)No medical visit
Medical visit
p <0.001
Figure 7: Proportion of 1st labs in the early post-diagnostic period, by subgroups
0 - 7 days 0 - 14 days0%
20%
40%
60%
80%
100%
80% 85%
49%
66%
% P
atien
ts w
ith fi
rst l
ab o
ccur
ing
in
time
peri
od
No medical
visit
No medical
visit Medical
visit Medical
visit
p <0.001p <0.001
31%
19%
Sensitivity Specificity PPV NPV0%
20%
40%
60%
80%
100%
84%
24%
76%
33%
73%
23%
73%
22%
11%
77%
96%99%
0-91 days 8-91 days 15-91 days
Figure 8: Performance of Registry data
Figure 9: Final study population: Refining timely linkage to care
Study population0
20
40
60
80
100 97%
81%75%
% L
inke
d tim
ely
(with
in 3
m
onth
s) to
car
e Gold standard: care visit
Lag applied
No lag applied
Figure 10: New York City’s refined Timely linkage to care indicator
All new 2009 diagnoses All new 2010 diagnoses0
20
40
60
80
100
75% 73%66% 66%
% L
inke
d tim
ely
to c
are
No lagLag
No lagLag
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