The HIV Care Cascade Measured Over Time & by Age, Sex & Race in a Large National Integrated Care System

HIV care cascades can evaluate programmatic success over time. However, methodologies for estimating cascade stages vary, and few have evaluated differences by demographic subgroups. 

We examined cascade performance over time and by age, sex, and race/ethnicity in Kaiser Permanente, providing HIV care in eight US states and Washington, DC. We created cascades for HIV+ members' age ≥13 for 2010–2012. We measured “linkage” (a visit/CD4 within 90 days of being diagnosed for new patients; ≥1 medical visit/year if established); “retention” (≥2 medical visits ≥60 days apart); filled ART (filled ≥3 months of combination ART); and viral suppression (HIV RNA <200 copies/mL last measured in year). The cascades were stratified by calendar year, sex, age, and race/ethnicity. 

• We found men had statistically higher percent linkage, filled ART, and viral suppression for 2010 and 2011 but not for 2012. 
• Women had significantly greater retention for all years. Annually, older age was associated with retention, filled ART, and viral suppression but not linkage. 
• Latinos had greater retention than whites or blacks in all years, with similar retention comparing blacks and whites. 
• Filled ART and viral suppression was increased for whites compared with all racial/ethnic groups in all years. 

Cascade methodology requiring success at upstream stages before measuring success at later stages (i.e., “dependent” methodology) underreported performance by up to 20% compared with evaluating each stage separately (“independent”). 

Thus, care results improved over time, but significant differences exist by patient demographics. Specifically, retention efforts should be targeted toward younger patients and blacks; women, blacks, and Latinos require greater ART prescribing.

Purchase full article at: http://goo.gl/aeF5Gh

By: Michael Alan Horberg, MD, MAS,^1,2,3 Leo Bartemeier Hurley, MPH,^3,4 Daniel Benjamin Klein, MD,^3,5William James Towner, MD,^3,6 Peter Kadlecik, MD,^1,3 Diana Antoniskis, MD,^3,7 Miguel Mogyoros, MD,^3,8Philip Sigmund Brachman, MD,^3,9 Carol Louise Remmers, PhD,¹⁰ Rebecca Claire Gambatese, MPH,¹⁰Jackie Blank, MBA,^2,3 Courtney Georgiana Ellis, BS,^3,4 and Michael Jonah Silverberg, PhD, MPH^3,4

¹Division of Infectious Diseases, Kaiser Permanente Mid-Atlantic States, Washington, District of Columbia.

²Kaiser Permanente, Mid-Atlantic Permanente Research Institute, Rockville, Maryland.

³Kaiser Permanente HIV Initiative, Oakland, California.

⁴Division of Research, Kaiser Permanente Northern California, Oakland, California.

⁵Division of Infectious Diseases, Kaiser Permanente Northern California, Hayward, California.

⁶Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, California.

⁷Immunodeficiency Clinic, Kaiser Permanente Northwest, Portland, Oregon.

⁸Division of Infectious Diseases, Kaiser Permanente Colorado, Denver, Colorado.

⁹Division of Infectious Diseases, Kaiser Permanente Georgia, Atlanta, Georgia.

¹⁰Kaiser Permanente, Oakland, California.

  

More at:  https://twitter.com/hiv_insight

Improvement of Sexually Transmitted Disease Screening among HIV-Infected Men Who Have Sex with Men Through Implementation of a Standardized Sexual Risk Assessment Tool

Screening for gonorrhea (GC) and chlamydia (CT) and syphilis among HIV-positive (HIV+) men who have sex with men (MSM) is recommended at least annually. However, significant gaps in screening coverage exist. We conducted a quality improvement intervention to determine whether informing providers of preintervention screening rates and routinizing sexual risk assessment would improve sexually transmitted disease (STD) screening in a large HIV care clinic.

In partnership with Kaiser Permanente Northern California, we developed and implemented a 10-item assessment addressing sexual and other behavioral risk factors among HIV+ MSM. We analyzed the proportion of patients screened for GC/CT and syphilis in a preintervention period (June 25-September 26, 2012) and during the intervention period (June 25-September 26, 2013).

Of 364 HIV+ MSM seen for care during the intervention period, 

• 47.3% completed the sexual risk assessment. 

Improvements in GC/CT screening and syphilis screening were observed; when comparing the preintervention period with the intervention period, the proportion of HIV+ MSM receiving GC/CT screening increased 

• by 26.8% at any anatomical site and 
• by 45% at the pharyngeal site. 
• Syphilis screening significantly increased by 18.8%.

Overall STD screening increases were observed after this intervention that included didactic training on the urgency of STD screening needs for HIV+ MSM, a presentation of preintervention clinic STD screening data, and the implementation of self-reported sexual risk assessment. Additional efforts are needed to determine feasible ways to accurately assess the appropriateness of STD screening and success of interventions to improve STD screening.

Via:  http://ht.ly/SlVX1 

By: Scarborough AP1, Slome S, Hurley LB, Park IU.

• 1From the *California STD/HIV Prevention Training Center, University of California San Francisco, San Francisco, CA; †The Permanente Medical Group, Oakland, CA; ‡Kaiser Permanente Northern California Division of Research, Oakland, CA; and §Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA.
• 
  More at:  https://twitter.com/hiv_insight