{"id":870,"date":"2013-06-17T15:43:18","date_gmt":"2013-06-17T15:43:18","guid":{"rendered":"https:\/\/blogs.bmj.com\/sti\/?p=870"},"modified":"2013-06-17T21:44:38","modified_gmt":"2013-06-17T21:44:38","slug":"taking-seriously-the-public-health-impact-of-disengagement-from-hiv-care-in-the-us","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/sti\/2013\/06\/17\/taking-seriously-the-public-health-impact-of-disengagement-from-hiv-care-in-the-us\/","title":{"rendered":"Taking seriously the public health impact of disengagement from HIV care in the US"},"content":{"rendered":"<p>ART as a strategy for \u201ctreatment-as-prevention\u201d is frequently acknowledged.\u00a0 Public health efforts, in the US as elsewhere, have focussed on prompt initiation of ART for the newly-diagnosed so as to shorten the duration of viremia \u2013 and thereby also reduce transmission risk.\u00a0 But what about the public health implications of people living with HIV (PLWH) who have been diagnosed, but are disengaged, or poorly engaged with ART?<\/p>\n<p>Contributions to STIs journal from the UK have discussed disengagement from a clinical perspective, its various social and behavioural concomitants (<a href=\"http:\/\/sti.bmj.com\/content\/early\/2013\/05\/21\/sextrans-2012-050966.abstract?sid=a9129e3e-e0b9-4e00-ad11-7023dd74276f\">http:\/\/sti.bmj.com\/content\/early\/2013\/05\/21\/sextrans-2012-050966.abstract?sid=a9129e3e-e0b9-4e00-ad11-7023dd74276f<\/a>; <a href=\"http:\/\/sti.bmj.com\/content\/79\/4\/349.3.full?sid=a9129e3e-e0b9-4e00-ad11-7023dd74276f\">http:\/\/sti.bmj.com\/content\/79\/4\/349.3.full?sid=a9129e3e-e0b9-4e00-ad11-7023dd74276f<\/a>).\u00a0 However, in the US (and no doubt other countries) where the proportion of PLWH with consistently suppressed viral load (VL) is estimated at just 28%, with a large proportion of PLWH lost to follow-up (an estimated 35% in New York City), the public health impact of disengagement also becomes a serious concern.\u00a0 For a start, the impact of early ART initiation as a \u201ctreatment-as-prevention\u201d strategy can only be very limited.<\/p>\n<p>A recent longitudinal study of a New York City (NYC) Health Department intervention to re-engage \u201cpersons lost to follow-up\u201d (LTFU), sets out to consider the public health case for deploying resources on the \u201cdisengaged\u201d, as well as the \u201cnot yet initiated\u201d (<a href=\"http:\/\/journals.lww.com\/aidsonline\/pages\/results.aspx?txtKeywords=Udeagu\">http:\/\/journals.lww.com\/aidsonline\/pages\/results.aspx?txtKeywords=Udeagu<\/a>).\u00a0 Existence of mandatory named HIV and laboratory reporting in NYC makes such an intervention a theoretical possibility. But how useful would surveillance data prove in locating LTFU \u2013 and how willing would the LTFU themselves be to re-engage with care?\u00a0 These were the issues confronting the public health case workers conducting the investigation over the period 2008-2010.<\/p>\n<p>Of the 797 PLWH presumed LTFU 409 (60%) were confirmed LTFU after elimination of those who could not be located, and those who turned out current-to-care after all.\u00a0 Of these 409, 240 (59%) are classified as having returned to care as a result of the intervention \u00a0on the basis of HIV visit confirmed through medical record review or CD4\/VL test report; however, most (97%) of the 240 also had at least one CD4 or VL test performed during the 12-months subsequent to their first return-to-care visit.\u00a0 The returned-to-care group were much more likely to have had CD4\/VL reported that those who refused linkage-to-care (95% vs 39%).\u00a0 More disappointingly \u2013 only 65 partners were named in the course of the exercise, and ultimately only 3 newly diagnosed with HIV infection as a direct result of the study intervention.<\/p>\n<p>The most important finding is the willingness of LTFU clients to re-engage with care, and the extent of their successful retention in care after re-engagement.\u00a0 Other findings relate to the serviceability of the laboratory, surveillance and jurisdictional infrastructure for the purposes of the provision of a more comprehensively \u201cwrap-around\u201d care programs capable of improving retention in care.\u00a0 Here the issues identified are the timely availability of laboratory information, the potential of linkage between surveillance data and the hospital record system, both of which could have saved expenditure on the location of presumed LTFU who turned out to be \u201ccurrent-to-care\u201d. (The Louisiana Information Public Health Exchange is held up as a potential model of what can be achieved: <a href=\"http:\/\/www.lsms.org\/site\/images\/stories\/LaPhie-Non-techincal%20Guide.pdf\">http:\/\/www.lsms.org\/site\/images\/stories\/LaPhie-Non-techincal%20Guide.pdf<\/a>).<\/p>\n","protected":false},"excerpt":{"rendered":"<p>ART as a strategy for \u201ctreatment-as-prevention\u201d is frequently acknowledged.\u00a0 Public health efforts, in the US as elsewhere, have focussed on prompt initiation of ART for the newly-diagnosed so as to shorten the duration of viremia \u2013 and thereby also reduce transmission risk.\u00a0 But what about the public health implications of people living with HIV (PLWH) [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/sti\/2013\/06\/17\/taking-seriously-the-public-health-impact-of-disengagement-from-hiv-care-in-the-us\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":152,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2042,1613,1694],"tags":[],"class_list":["post-870","post","type-post","status-publish","format-standard","hentry","category-hiv-care","category-sexual-health-services","category-sti-prevention-and-surveillance"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - 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