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Migration Distorts Surveillance Estimates of Engagement in Care: Results of Public Health Investigations of Persons Who Appear to be Out of HIV Care

Buskin, Susan E. PhD, MPH*†; Kent, James B. MS*†; Dombrowski, Julia C. MD, MPH*†‡; Golden, Matthew R. MD, MPH*†‡

Sexually Transmitted Diseases: January 2014 - Volume 41 - Issue 1 - p 35–40
doi: 10.1097/OLQ.0000000000000072
Original Study

Background Prevention and clinical efforts are increasingly focused on improving the HIV care cascade, the sequential steps from diagnosis to engagement in care and viral suppression. Monitoring of this cascade is largely dependent on HIV laboratory surveillance data. However, little is known about the completeness of these data or the true care status of individuals for whom no data are reported.

Methods We investigated people presumed to be living with HIV/AIDS in King County, WA, who had no laboratory results reported to HIV surveillance for at least 1 year between 2006 and 2010. We determined whether each person had relocated, died, or remained in the county.

Results Of 7379 HIV-infected people presumed living in King County, 2545 (35%) had 1 or more 12-month gap in laboratory reporting. Among these individuals, 47% had relocated, 7% died, and 38% remained in King County; we were unable to determine the status of 8%. Of individuals remaining in the area, 91% had evidence of returning to or being in HIV care. Case investigations reduced the proportion of individuals thought to be out of care in 2011 from 27% to 16%.

Conclusions Investigations of individuals without laboratory results reported to HIV surveillance identified large numbers of people who are no longer living in the area. Our findings suggest that current estimates of the HIV care cascade may be too pessimistic and that individual case investigations are required to accurately define the size and composition of the population of people living with HIV in local areas.

King County investigated potential care gaps of at least 1 year among people reported with HIV through 2011. Dispositions were found for 92%, including relocations (52%) and deaths (8%).

From the *Public Health Seattle & King County, Seattle, WA; †Department of Epidemiology, University of Washington, Seattle, WA; and ‡Department of Medicine, University of Washington, Seattle, WA and Center for AIDS and STD, Seattle, WA

Sources of support: Centers for Disease Control and Prevention HIV/AIDS Surveillance and Category C Grants (CDC-RFA-PS08-80205CONT12 and PS12-1201, respectively); Ryan White HIV Emergency Relief Project Grants, Part A (H89HA00022); Demonstration Projects to Implement and Evaluate Innovative, High-Impact HIV Prevention Interventions and Strategies (1U62PS003666-01); the National Institutes of Mental Health (K23MH090923; to J.C.D.]; and the University of Washington Center for AIDS Research, a National Institutes of Health–funded program (P30 AI027757) which is supported by the following National Institutes of Health institutes and centers: National Institute of Allergy and Infectious Diseases; National Cancer Institute; National Institute of Mental Health; National Institute on Drug Abuse; National Institute of Child Health and Human Development; National Heart, Lung, and Blood Institute; and National Institute on Aging.

The authors have no conflicts of interest to report.

Correspondence: Susan E. Buskin, PhD, MPH, Public Health-Seattle & King County, 401 5th Ave Suite 1152, Seattle, WA 94104. E-mail:

Received for publication June 6, 2013, and accepted November 5, 2013.

© Copyright 2014 American Sexually Transmitted Diseases Association