Re-engagement and Retention:

Successfully Using Surveillance Data in Tennessee

NASTAD Technical Assistance Meeting

July 31, 2015

Melissa Morrison, MAHIV Prevention Director

Tennessee Department of Health

Demographics of HIV in TN (2013)

Characteristic Population Diagnosed & Living Newly Diagnosed

6,497,269 n = 15,583 n = 792

Gender

Male 49% 73% 80%

Female 51% 27% 20%

Race / Ethnicity

Black (NH) 17% 57% 60%

White (NH) 75% 37% 31%

Hispanic 5% 4% 5%

Transmission Category

MSM -- 46% 58%

HRH -- 24% 21%

IDU -- 8% 1%

MSM/IDU -- 3% 1%

NIR -- 18% 10%

Age (years)

15-24 14% 4% 25%

25-34 13% 16% 31%

35-44 13% 27% 17%

>44 41% 53% 26%

AIDS <=1yr of Dx -- -- 31%

Demographics of People with Diagnosed HIV(TN, 2013, excluding people with no identified risk)

3657

3130

1881

766526

398287 274 228 224 195 157 153 143 102 77 60

0

500

1000

1500

2000

2500

3000

3500

4000

Tennessee HIV Continuum of Care(2010, 2012, 2013, 2015 Goals)

64%

29%

35%

72%

55% 54%

80%

55% 56%

80%

64%

51%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Diagnosed Linked Engaged Achieved Viral Suppression

Pe

rso

ns

wit

h H

IV

Engagement in HIV Care

TN (2010) TN (2012) TN (2013) TN Goal (2015)

HIV Continuum of Care: Statewide vs. Ryan White Clients (TN, 2013)

80%

55% 56%

88%

69% 70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Linked Engaged Achieved Viral Suppression

Pe

rso

ns

wit

h H

IV

Engagement in HIV Care

All Clients in TN Ryan White Clients Only

Accurint Software To improve data accuracy, we used the commercial, person-

locating software application Accurint©

Software package owned by Lexis-Nexis, an information service company

Direct connection to over 37 billion current public records held within 10,000 databases

Used to verify identities, obtain current address and telephone information, conduct investigations

Same software used by police and fire departments, bill collectors, federal, state, and local agencies

Cost is $160/user/month

Generating Out of Care Lists

Each year, Surveillance generates a list of living HIV clients who reside in Tennessee and who have been out of care for more than 1 year

Clients with evidence of any HIV care (as evidenced by either a CD4 or VL entry) during the prior 3 years (e.g. January 1, 2010 through December 31, 2012)

Clients with evidence of any of the following are then eliminated from the list: i. Death

ii. Receipt of HIV care in the last year (e.g. January 1, 2012 through December 31, 2012)

iii. No longer living in Tennessee

Generating Out of Care Lists

September, 2013 - First list generated from eHARS

3,111 Eligible Clients

2,264 (after removing Out-of-State, deceased)

In Feb 2014, Accurint was applied to the entire eHARSdatabase (15% of clients were removed due to updated info)

2014 list generated from eHARS

1,430 Eligible Clients (after removing OOS & deceased)

2015 list generated from eHARS

1465 Eligible clients (~25% already appeared on prior list)

Lists are sorted by Public Health Regions and Metro Areas

Outward Migration: Top 10 States

Georgia- 419 Florida- 369 Mississippi- 268 Texas- 255 California- 189 Illinois- 133 North Carolina- 121 Kentucky- 120 Arkansas- 116 Alabama- 110

Majority of migration occurred among states in the South

Migration to states that directly border TN (n=7) was 1,187 or 36% of total migration

Reinforces the fact that HIV prevalence in the South has increased over the last decade

15% Out of State!

Privacy Concerns

Discussions with community partners at statewide meetings

Decision to use specially trained DIS for re-engagement

Addressing ‘Big Brother’ issues with contacting clients out of care

New Re-Engagement List(April 2014)

302, 21%

297, 21%

114, 8%

432, 30%

285, 20%

80% Individuals reside in CAPUS DIS jurisdictions

East Nashville Middle TN Memphis Other

Re-Engagement in Medical Care

Develop Out-of-Care Lists for 5 DIS Re-Engagement Specialists Identify known diagnosed PLWH who have been out of care for > 1yr

Clients with evidence of any care during prior 3 years (1/1/10 – 12/31/12)

Eliminate anyone who…

• Received care w/in the past 1 year,

• Moved out of state, or

• Died

Stratify remaining list by geography & distribute monthly to DIS Specialists

Each year fully implemented > 1000 cases / year (200 cases per DIS/year)

• > 70% cases contacted

o > 70% contacted cases linked to care < 3 mos (or > 49% of total)

DIS Re-Engagement Specialists

Training

Passport to Partner Services 106 hours of on-line modules, followed by

5 days of in-person training

ARTAS (Antiretroviral Treatment and Access to Services)

Located in geographically distinct areas

2 in Memphis

1 in Nashville

1 in Middle TN

1 in East TN(Note: These 5 DIS cover the jurisdictions that account for ~80% of all known positives

who have been identified as being out of medical care for > 1 year.)

Distribution of Client Names

Client names from the CAPUS list are distributed by the CAPUS Epi or CAPUS central office staff to the CAPUS DIS

Distributed via two methods

Secure transfer (FileZilla)

Secure USB Flash Drive

25 client names containing most recent contact information are provided to each CAPUS DIS on a monthly basis

Re-Engagement Process

OOC Lists generated and sorted

25 names per month given to DIS by region

Record searches• eHARS• Ryan White Part A• PRISM • RW eligibility system• PTBMIS• VA contacts

Re-Engagement Process

Contact attempted and documented

Use traditional DIS locating techniques Facebook

Court documentation/arrest records

Other electronic databases

Accurint searches

Assessment of care status and barriers if truly out of care

Re-engagement support

Disposition of Clients From OOC List

Deceased

Out of Jurisdiction

Contacted – Already in Care

Contacted – In progress

Contacted – Pending Appointment

Contacted – Linked to Care

Contacted – Prefers no contact

Unable to Locate

Contact attempts in progress

No Contact Attempted

TN’s Data-to-Care Program: Progress(Oct 13 – Jan 15: 16 months)

Names Distrib

Deceasedor

Living Out of State

Remaining Eligible Names

Contacted /Investigate

d by DIS

In Medical Care in 2013

NOT in Medical Care in 2013

Contacted Clients In Care (>70%)

Total Eligible Clients in

Care ( >50%)

Total Linked < 3 mos

Shelby (2 DIS) 582 127 455 280 (62%)

180 74 42 222(79%)

222 (49%)

Mid-Cumberland

250 40 210 173 (82%)

108 67 29 137 (79%)

137(65%)

Davidson 326 43 283 210(74%)

170 26 4 174 (83%)

174 (61%)

East TN 305 23 282 220(78%)

199 19 7 206(94%)

206(73%)

TOTAL 1463 233 1230 883 (72%)

657(74%)

186(21%)

82(44%)

739 (84%)

739(60%)

Data to Care: Lessons Learned

eHARS accuracy lacking with respect to location and (to a lesser extent) vital status

Despite reporting requirements, HIV-1 viral load and CD4 reporting to TDH not comprehensive

While overall “in-care” rates exceeded original target, these numbers were driven by clients found to already be in care Informative (ID labs that hadn’t been reporting CD4 & VL results)

As data reporting improves, future linkage-to-care rates among contacted clients are likely to be lower than originally targeted (45% versus 70%)

Application of Lessons Learned

Accurint applied to entire eHARS database

Laboratories previously not reporting have been approached and reporting deficiencies have been reconciled (files back-dated to 1/1/12) Waiting to generate “list” of sub-optimal responders

Cleaner data New CAPUS out of care list generated in April 2014

• More accurate wrt to location and OOC status

(80% of names located within jurisdictions covered by CAPUS DIS)

HIV Continuum of Care more reflective of true picture

Thank you!melissa.morrison@tn.gov