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 [email protected]