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The Real World of STD Prevention

Inadequate Engagement in HIV Care Among People With HIV Newly Diagnosed With a Sexually Transmitted Disease: A Multijurisdictional Analysis

Norkin, Sarah K. MPH; Benson, Samantha MPH; Civitarese, Anna M. MPH; Reich, Amanda MPH; Chomsky Albright, Madison MPH§; Convery, Christine MPH; Kasarskis, Irina M. MPH; Cassidy-Stewart, Hope MHS∗∗; Howe, Katharine MPH; Wang, Xueyan MPH††; Golden, Matthew R. MD, MPH§§,¶¶; Khosropour, Christine M. PhD, MPH§§; Glick, Sara N. PhD, MPH‡‡,§§,¶¶; Kerani, Roxanne P. PhD, MPH‡‡,§§

Author Information
Sexually Transmitted Diseases: August 2021 - Volume 48 - Issue 8 - p 601-605
doi: 10.1097/OLQ.0000000000001381

In 2019, the United States launched the Ending the HIV Epidemic (EHE) initiative with the goal of reducing new HIV infections by 90% by 2030.1 Increasing the successful treatment of HIV is a pillar of the EHE initiative. In 2017, only approximately 58% of people living with HIV (PLWH) received continuous HIV medical care and 62% were virally suppressed.2 Previously diagnosed but unsuppressed persons are thought to be the source of more than 60% of all HIV transmissions in the United States,3 highlighting the importance of improving HIV care to prevent ongoing HIV transmission.

In an effort to increase HIV care engagement and viral suppression, the US Centers for Disease Control and Prevention requires that health departments receiving federal HIV prevention funding conduct data-to-care (D2C) investigations. These investigations involve using HIV surveillance data to identify individuals with an HIV diagnosis who are not engaged in HIV care and provide them with outreach services to link them back into care and promote their viral suppression. Although health departments have invested substantial resources into D2C investigations, evaluations of these efforts have been discouraging.4–6 In some studies, only 10% of individuals identified as out of care per HIV surveillance data still reside in the jurisdiction, are successfully contacted, and are confirmed to be out of care, substantially impacting the practicality and efficiency of this intervention.4,5 Processes that aim to target individuals at the time they present for other services may be more successful and efficient in reaching the population that is truly out of care in real time.

Leveraging sexually transmitted disease (STD) surveillance data with partner services programs to reengage individuals into HIV care and promote their viral suppression is one model of real-time D2C. All state health departments in the United States provide STD partner services, which involve outreach by specially trained health department staff (disease intervention specialists) to interview persons with STDs—typically syphilis, but also gonorrhea (GC) in some jurisdictions—and notifying partners and other persons within the sociosexual network of the need to test and possibly treat. Individuals with syphilis or GC who are coinfected with HIV but not adequately engaged in HIV care are theoretically an ideal population for public health outreach because they are engaged in partner services and they have an increased risk of transmitting HIV to their partners. Moreover, these individuals are known to seek care in the jurisdiction where they were diagnosed with an STD, surmounting one of the key limitations of D2C programs.

Integrating D2C into STD partner services has intuitive appeal, but the potential reach and impact of this integration are unknown. In this multijurisdictional study, we quantified the proportion of individuals reported with syphilis or GC who had a prior HIV diagnosis and were inadequately engaged in HIV care at the time of their STD diagnosis.

MATERIALS AND METHODS

Study Design and Population

This analysis used HIV and STD surveillance data from 6 US health departments—Louisiana, Michigan, Mississippi, Oregon, Rhode Island, and Texas. Each jurisdiction reviewed all reported syphilis and GC cases among people at least 14 years old diagnosed between January 1, 2016, and December 31, 2017. Staff in each health department matched these cases of syphilis and GC to state HIV surveillance data (described hereinafter) to identify STD cases with previously diagnosed HIV. These cases were then analyzed to determine the proportion inadequately engaged in HIV medical care. Inadequate engagement in HIV care was defined as having no documented CD4 count or viral load during the 13 months before the STD diagnosis (i.e., out of care) or a last documented viral load in the 13 months before STD diagnosis of ≥1500 copies/mL (i.e., viremic). These 2 categories are mutually exclusive. The analysis was limited to PLWH diagnosed a minimum of 6 months before STD diagnosis to exclude persons who may not have had enough time to adequately engage in HIV care before a GC or syphilis diagnosis.

Data Sources

Syphilis and GC cases in each jurisdiction were obtained from each jurisdiction's STD surveillance database. Sexually transmitted disease surveillance data were matched to each jurisdiction's enhanced HIV/AIDS Reporting System at the state level, using individual state protocols and algorithms (summarized in Supplemental Table 1, http://links.lww.com/OLQ/A630).

Analysis

The unit of analysis was a case of GC or syphilis. Because each reported instance of STD represents a potential reengagement opportunity, PLWH diagnosed with GC or syphilis were counted each time they were diagnosed and reported with an STD, during the study period. However, if a PLWH was diagnosed with the same STD twice within 30 days, only one instance of that STD case was counted, as this is most likely not a true second STD diagnosis, and thus should not be counted as another diagnosis or reengagement opportunity. Syphilis was categorized as either early syphilis (ES), which included primary, secondary or nonprimary, nonsecondary syphilis, or late syphilis (LS), which included late latent and syphilis of unknown duration. Syphilis staging varies by state (details available from corresponding author). Investigators in each jurisdiction analyzed their local data and shared only aggregate numbers and proportions with the larger study team. These aggregate data included the number and proportion of cases of each STD occurring in persons with a prior HIV diagnosis, and the number of these persons who were out of care or viremic. Each jurisdiction also produced these numbers stratified by demographic and clinical characteristics. Data from each jurisdiction were then compiled to display aggregate outcomes across all jurisdictions. Evaluating surveillance data to identify PLWH inadequately engaged in care is considered a standard public health activity; therefore, this analysis did not require a review by an institutional review board.

RESULTS

Proportion of PLWH With an STD Diagnosis Who Were Inadequately Engaged in Care

Across the 6 states included in this study, there were 17,781 ES, 15,950 LS, and 167,118 GC cases diagnosed between January 1, 2016, and December 31, 2017, and the total number of STDs reported varied dramatically between states based on their size, from 109,741 in Texas to 2252 in Rhode Island (Table 1). The percentage of STD cases occurring in persons with a prior HIV diagnosis was highest among persons with ES (33% [n = 5900]; range, among states, 23%–36%) and the lowest occurring in persons with GC (5% [n = 8315]; range, 3%–7%), although the total number of STD cases occurring in persons with a prior HIV diagnosis was greater for GC than for ES.

TABLE 1 - Numbers and Proportions of Adult Early Syphilis, Late Syphilis, and Gonorrhea Cases, Coinfection with HIV, and Inadequate Engagement in HIV Care in 6 States*, 2016 to 2017
Louisiana Michigan Mississippi Oregon Rhode Island Texas Total
n (%) n (%) n (%) n (%) n (%) n (%) n (%)
Early syphilis
 Total adult cases 2620 1484 1677 1182 289 10,529 17,781
 Living with HIV, % of total adult cases 845 (32) 635 (43) 522 (31) 407 (34) 80 (28) 4453 (42) 6942 (39)
 Previously diagnosed§, % of total adult cases 730 (28) 537 (36) 419 (25) 384 (32) 66 (23) 3764 (36) 5900 (33)
 Inadequately engaged in care, % of previously diagnosed with HIV 147 (20) 123 (23) 153 (37) 61 (16) 17 (26) 1042 (28) 1543 (26)
 Out of care, % of previously diagnosed with HIV 39 (5) 42 (8) 96 (23) 19 (5) 5 (8) 323 (9) 524 (9)
 Viremic**, % of previously diagnosed with HIV 108 (15) 81 (15) 57 (14) 42 (11) 12 (18) 719 (19) 1019 (17)
Late duration syphilis
 Total adult cases 2728 1824 170 528 171 10,529 15,950
 Living with HIV, % of total adult cases 584 (21) 316 (17) 29 (17) 103 (20) 33 (19) 3264 (31) 4329 (27)
 Previously diagnosed§, % of total adult cases 403 (15) 222 (12) 21 (12) 79 (15) 22 (13) 2612 (25) 3359 (21)
 Inadequately engaged in care, % of previously diagnosed with HIV 127 (32) 69 (22) 9 (43) 24 (30) 2 (9) 882 (34) 1113 (33)
 Out of care, % of previously diagnosed with HIV 24 (6) 18 (8) 6 (29) 11 (14) 2 (9) 271 (10) 332 (10)
 Viremic**, % of previously diagnosed with HIV 103 (26) 51 (23) 3 (14) 13 (16) 05 (0) 611 (23) 781 (23)
Gonorrhea
 Total adult cases 22,797 28,279 16,186 9381 1792 88,683 167,118
 Living with HIV, % of total adult cases 1440 (6) 1350 (5) 480 (3) 680 (7) 127 (7) 5432 (6) 9509 (6)
 Previously diagnosed§, % of total adult cases 1240 (5) 1186 (4) 421 (3) 627 (7) 102 (6) 4739 (5) 8315 (5)
 Inadequately engaged in care, % of previously diagnosed with HIV 275 (22) 349 (29) 135 (32) 101 (16) 18 (18) 1513 (32) 2391 (29)
 Out of care, % of previously diagnosed with HIV 95 (8) 187 (16) 73 (17) 31 (5) 6 (6) 615 (13) 1007 (12)
 Viremic**, % of previously diagnosed with HIV 180 (15) 162 (14) 62 (15) 70 (11) 12 (12) 898 (19) 1384 (17)
*The 6 states include Louisiana, Michigan, Mississippi, Oregon, Rhode Island, and Texas.
Age 14 years at STD diagnosis.
Diagnosed with HIV on the same date or before sexually transmitted infection diagnosis.
§Diagnosed with HIV 6 months before sexually transmitted infection diagnosis.
No HIV laboratory results in 13 months, no HIV laboratory results ever, or most recent viral load in prior 13 months 1500.
No HIV laboratory results in ≥13 months or no HIV laboratory results ever.
**Most recent viral load in prior 13 months ≥1500.

Among 17,574 GC or syphilis cases reported with a prior HIV diagnosis across all jurisdictions, 29% (range, 17%–34%) were inadequately engaged with care, including 11% (range, 7%–20%) who were out of HIV medical care and an additional 18% (range, 9%–20%) who were viremic (data not shown). Among STD cases with a prior HIV diagnosis, the proportion occurring among those inadequately engaged in care was 26% for ES (range among states, 16%–37%), 33% for LS (9%–43%), and 29% for GC (16%–32%) (Table 1). The composition of the inadequately engaged population varied substantially between states. In Mississippi, most ES cases who were inadequately engaged with care were out of care, whereas in the other states, there were more cases that were in care but viremic. Mississippi and Texas had the highest proportions of STD cases with prior HIV diagnosis that were inadequately engaged in care in each STD category.

Demographic Characteristics of PLWH With an STD Diagnosis and Inadequate Engagement in Care

In general, compared with all STD cases with a prior HIV diagnosis, those who were inadequately engaged in care were more often younger, Black/African American, and men who have sex with men (Table 2). Individual state data revealed that in Louisiana, Michigan, Mississippi, and Texas, most ES cases with a prior HIV diagnosis who were also inadequately engaged in care were younger than 35 years, whereas in Oregon and Rhode Island, a majority were 35 years and older (Supplemental Table 2, http://links.lww.com/OLQ/A630). Race/ethnicity, sex, and HIV transmission mode among STD cases with a prior HIV diagnosis were mostly similar across states, with a few exceptions. In Louisiana, Michigan, and Mississippi, STD cases with a prior HIV diagnosis—including those inadequately engaged in care—were mostly Black/African American, whereas in Oregon and Rhode Island, they were White. In Texas, the plurality of ES cases with prior HIV diagnosis was Hispanic, whereas those who were inadequately engaged in care were more often Black/African American.

TABLE 2 - Demographic Characteristics of Early Syphilis, Late Syphilis, and Gonorrhea Cases PD With HIV and IEC in 6 States*, 2016 to 2017
Early Syphilis Late Syphilis Gonorrhea
PD IEC PD IEC PD IEC
n (%) n (%) n (%) n (%) n (%) n (%)
Total 5900 1543 3359 1113 8315 2391
Age, y
 14–24 723 (12) 259 (17) 292 (9) 136 (12) 1449 (17) 471 (20)
 25–34 2371 (40) 744 (48) 1305 (39) 535 (48) 3799 (46) 1197 (50)
 35+ 2806 (48) 540 (35) 1762 (52) 442 (40) 3067 (37) 723 (30)
Race/ethnicity
 Black/African American 2450 (42) 771 (50) 1452 (43) 588 (53) 4349 (52) 1475 (62)
 White 1609 (27) 335 (22) 783 (23) 212 (19) 1936 (23) 408 (17)
 Hispanic 1561 (26) 359 (23) 991 (30) 271 (24) 1699 (20) 424 (18)
 Other 280 (5) 78 (5) 133 (4) 42 (4) 331 (4) 84 (4)
Gender
 Male 5754 (98) 1493 (97) 3200 (95) 1043 (94) 7769 (93) 2156 (90)
 Female 57 (1) 22 (1) 82 (2) 37 (3) 454 (5) 202 (8)
 Transgender 89 (2) 28 (2) 77 (2) 33 (3) 92 (1) 33 (1)
Transmission mode
 MSM 5396 (91) 1385 (90) 2890 (86) 920 (83) 7053 (85) 1862 (78)
 Heterosexual Contact 116 (2) 34 (2) 120 (4) 48 (4) 443 (5) 184 (8)
 Non-MSM PWID and other 378 (6) 124 (8) 349 (10) 145 (13) 819 (10) 345 (14)
*The 6 states include Louisiana, Michigan, Mississippi, Oregon, Rhode Island, and Texas.
IEC indicates inadequately engaged in care (meets one of these criteria: no HIV laboratory results in ≥13 months, no HIV laboratory results ever, or viral load in the last 13 months ≥1500); MSM, men who have sex with men.; PD, previously diagnosed (adult cases of syphilis or gonorrhea diagnosed with HIV ≥6 months before sexually transmitted infection diagnosis); PWID, persons who inject drugs.

Across all states, most STD cases with a prior HIV diagnosis who were out of medical care had been out of medical care for 37 months or more: 39% among ES diagnoses, 52% among LS diagnoses, and 41% among GC diagnoses (Table 3). There were some state-specific exceptions (Supplemental Table 3, http://links.lww.com/OLQ/A630). In Mississippi, ES cases with a prior HIV diagnosis who were out of medical care were more likely to be out of care between 13 and 24 months (43%). In Louisiana, high percentages of ES and GC cases with a prior HIV diagnosis had never engaged in medical care, 31% and 48%, respectively.

TABLE 3 - Length of Time Out of Care Among Early Syphilis, Late Syphilis, and Gonorrhea Cases Previously Diagnosed with HIV in 6 States*, 2016 to 2017
Early Syphilis Late Syphilis Gonorrhea
n (Range) % (% Range) n (Range) % (% Range) n (Range) % (% Range)
Total out of care 524 (5–323) 332 (2–271) 1007 (6–615)
6–12 mo 35 (0–16) 7 (0–31) 16 (0–11) 5 (0–17) 94 (0–46) 9 (0–48)
13–24 mo 196 (3–125) 37 (26–60) 85 (1–76) 26 (8–50) 358 (3–252) 36 (20–50)
25–36 mo 87 (1–52) 16 (5–21) 58 (0–46) 17 (0–25) 147 (2–92) 15 (11–33)
≥37 mo 206 (1–130) 39 (20–52) 173 (1–138) 52 (50–72) 408 (1–233) 41 (14–67)
*The 6 states include Louisiana, Michigan, Mississippi, Oregon, Rhode Island, and Texas.
No HIV laboratory results ≥13 months or no HIV laboratory results ever.
This category is only applicable to cases never linked to care.

DISCUSSION

This analysis found that a substantial proportion of ES, LS, and GC diagnoses from 2016 to 2017 were among PLWH (39%, 27%, and 6%, respectively). Twenty-six percent of ES cases, 33% of LS cases, and 29% of GC cases were inadequately engaged in care at the time of their STD diagnosis. Gonorrhea cases represented the largest absolute number of individuals who were inadequately engaged at the time of STD diagnosis. The large number and proportion of STD cases with a prior HIV diagnosis who were inadequately engaged in HIV care serves as a reminder that being diagnosed with an STD does not necessarily indicate adequate HIV care engagement, as they were seeking STD testing and treatment but were not actively participating in HIV care. The data also highlight that these are missed opportunities for initial engagement or reengagement into HIV medical care.

Our results suggest that integrating HIV care engagement into STD services, including STD partner services, and/or prioritizing D2C lists via routine matching to STD surveillance data would potentially be a more efficient approach to D2C. Although health departments throughout the United States have implemented D2C programs, these efforts have faced significant challenges. Inaccurate surveillance data that incorrectly classify people as out of care and provides out-of-date locating information for persons who are truly out of care are some of the most significant limitations to the current D2C program. These limitations result in an inefficient program in which health department staff initiate many investigations to relink a very small number of persons.7–9 When a PLWH is diagnosed with a new STD, the reported diagnosis confirms that the PLWH has recently been in the jurisdiction and interacted with a healthcare provider. Therefore, integrating an assessment of HIV care engagement and provision of linkage to care support into STD partner services, and/or routinely matching STD data to HIV surveillance data to prioritize D2C lists, may yield higher results and be less resource intensive than traditional D2C activities. Future program evaluations should assess the efficiency and effectiveness of D2C focusing on persons with reportable STDs.

Across jurisdictions in this study, most individuals who were out of care had been out of care for greater than 24 months, and the plurality was out of care for greater than 37 months. This most likely represents individuals who are truly out of care and virally unsuppressed, as there were no care indicators during this time period. In addition, LS cases with prior HIV diagnosis had been out of care for greater than 37 months. An LS diagnosis is usually an infection that has been undetected for 12 months or more, or that occurs in a person with no recent syphilis testing. In both instances, persons with LS may have a higher chance of being entirely disengaged from medical care, including HIV medical care, for longer periods of time.

Health departments routinely provide partner services to persons with newly diagnosed ES, and this population is an obvious focus for real-time D2C. However, relatively few health departments routinely provide partner services to persons newly diagnosed with GC because of the large number of cases. Only 4 of the jurisdictions included in this analysis regularly provided partner services to persons with GC in some capacity (Supplemental Table 1, http://links.lww.com/OLQ/A630). Attempting to provide partner services to all persons reported with GC, or even all PLWH reported with GC, is likely a heavier workload than most health departments can undertake. Our findings highlight how a very targeted approach to GC partner services, one that focuses on those diagnosed with HIV and inadequately engaged in care, representing approximately 1.4% of all reported GC cases, could be an efficient and strategic expansion of partner services. Expanding partner services to this population would be additional work and will require more funding. We believe that a focused expansion of partner services among persons with GC designed to improve care engagement is aligned with the goals of the new EHE initiative and might be fundable through that effort. This expansion of partner services to include the integration of STD treatment and linkage and/or reengagement to HIV medical care would in turn be an important addition to the EHE pillars. In addition, viral loads may increase among PLWH who are not well engaged in care and who acquire a concomitant sexually transmitted infection, increasing the likelihood of HIV transmission10,11 and demonstrating the importance of STDs and their treatment as components of the EHE initiative.

Strengths of this study include incorporating data from geographically heterogeneous states with diversity in age, race, ethnicity, and STD morbidity, and matching STD surveillance data to HIV surveillance data to ascertain HIV status among STD cases. There were also several limitations to this study. Each participating state operates its own state-specific STD surveillance program, which may lead to differences in reporting and matching completeness. This study assumes PLWH are living in the same state as their STD diagnosis, but some individuals may be receiving medical care in bordering states or country and as a result seem to be out of care. Also, this analysis relies on the reporting of CD4 counts and viral loads as indications of HIV medical care. Not all laboratory results may be reported for PLWH who are engaged in care, possibly inflating the number of PLWH who are out of care. In addition, for those STD cases who seemed out of care, the last viral load and, if applicable, the first viral load after being out of care were not assessed for viral suppression. This possibly included STD cases adherent to their medication and virally suppressed who do not routinely attend medical appointments or receive viral loads, inflating the number of individuals out of care. Some states had small sample sizes for subpopulations defined by demographic characteristics, making estimates of the proportion of these subpopulations inadequately engaged in care unstable in those states. Lastly, although duplicate diagnoses of STDs were removed, individuals with multiple unique STD diagnoses were included multiple times, which does not allow estimates of total (across all 3 STD) PLWH who were inadequately engaged to be generated.

This study demonstrates that the integration of HIV and STD surveillance data can identify substantial numbers of PLWH who are out of care or not virally suppressed; this should prompt health departments to integrate ascertainment of HIV treatment status into STD partner services interviews and to make both linkage and reengagement to HIV treatment an explicit and monitored partner services outcome. Identifying PLWH who are diagnosed with STDs and out of care and prioritizing D2C lists using this information require regular data matching with the most current data possible. However, among the 6 jurisdictions included in this study, at the time of analysis, 3 routinely matched HIV and STD surveillance data to enhance disease investigation and/or partner services. The current national initiative to end the HIV epidemic encourages efforts to expand or develop new interventions to promote HIV care reengagement and viral suppression, and additional funding for this initiative could provide the means for more health departments to accomplish routine data matching and/or the expansion of partner services. Although additional programmatic research is needed to prove that STD partner services can be used to promote HIV care, the findings of this study should prompt greater integration of HIV and STD control, and through that effort improve the highly connected landscape of HIV/STD care and transmission.

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