Research Article: Using HIV Surveillance Laboratory Data to Identify Out-of-Care Patients

Date Published: March 6, 2017

Publisher: Springer US

Author(s): John Christian Hague, Betsey John, Linda Goldman, Kshema Nagavedu, Sophie Lewis, Rebecca Hawrusik, Serena Rajabiun, Noelle Cocoros, H. Dawn Fukuda, Kevin Cranston.


HIV-associated laboratory tests reported to public health surveillance have been used as a proxy measure of care engagement of HIV+ individuals. As part of a Health Resources and Services Administration (HRSA) Special Projects of National Significance (SPNS) Initiative, the Massachusetts Department of Public Health (MDPH) worked with three pilot clinical facilities to identify HIV+ patients whose last HIV laboratory test occurred at the participating facility but who then appeared to be out of care, defined as an absence of HIV laboratory test results reported to MDPH for at least 6 months. The clinical facilities then reviewed medical records to determine whether these patients were actually not in care, or if there was another reason that they did not have a laboratory test performed, and provided feedback to MDPH on each of the presumed out-of-care patients. In the first year of the pilot project, 37% of patients who appeared to be out of care based on laboratory data were confirmed to be out of care after review of clinical health records. Of those patients who were confirmed to be out of care, 55% had a subsequent laboratory test within 3 months, and 72% had a laboratory test within 6 months, indicating that they had re-engaged with a care provider. MDPH found that it was essential to have clinical staff confirm the care status of patients who were presumed to be out of care based on surveillance data.

Partial Text

Engagement in HIV care and treatment has been shown to contribute to improved health outcomes and reduced risk of onward HIV transmission [1]. The U.S. Department of Health and Human Services recommends that HIV+ individuals receive viral load testing at least every 6 months [2]. HIV-associated laboratory tests that are reported to public health surveillance have been used as a proxy measure of care engagement of HIV+ individuals [3–5].

Per Massachusetts disease reporting regulations, MHASP receives all positive HIV antibody laboratory test results, as well as CD4+ T-lymphocyte counts and HIV viral load laboratory tests regardless of result value. The majority of laboratory results are received electronically within three days of the test result date, and paper laboratory results are received within two weeks and entered into a unified database upon receipt. Combined with information about patients’ current residence and vital status, MHASP can use laboratory data to identify HIV+ individuals receiving care in Massachusetts. Those without recent laboratory test results may be OOC.

During the first year of this pilot intervention, a total of 1137 individuals appeared on the presumed OOC line lists. Of these, 421 (37%) were confirmed OOC based on feedback from clinical staff (Fig. 2). Among those who were confirmed as not OOC, the most common reasons for appearing to be out of care were that the patient had a laboratory test that was received after the line list was generated or that was not reported to HIV surveillance (24%); or that the patient was directed by a clinician to wait >6 months between laboratory tests (for example, because the patient was on a stable regimen with established viral suppression) (21%). No statistically significant differences were noted between the proportion confirmed OOC versus proportion not confirmed by age, sex, race/ethnicity, and risk/exposure mode categories (by Chi square test, significance measured at p < 0.05) (Table 1). However, several qualitative differences are apparent: people of younger age, Hispanic ethnicity, and having a history of intravenous drug use were more likely confirmed OOC than not. Conversely, black (non-Hispanic) patients were more likely not confirmed OOC. Among patients who were confirmed OOC, 55% had a subsequent laboratory test within 3 months of appearing on the OOC line list, and 72% had a subsequent laboratory test within 6 months.Fig. 2The proportion of patients confirmed OOC versus not confirmed OOC (with reason not OOC) after receiving clinical staff feedback regarding patients on the presumed OOC line list, June 2013–May 2014Table 1Demographic and risk/exposure mode for patients who appeared on the presumed out-of-care line listConfirmed out-of-careNot confirmed out-of-careN = 421N = 716Birth sex Male261 (62)451 (63) Female160 (38)265 (37)Age category 20–29 years21 (5)29 (4) 30–39 years76 (18)93 (13) 40–49 years122 (29)179 (25) 50–59 years151 (36)279 (39) 60 and older51 (12)136 (19)Race/ethnicity Non-Hispanic white139 (33)222 (31) Non-Hispanic black134 (32)286 (40) Hispanic/Latino143 (34)186 (26) Other/unknown5 (1)22 (3)Risk/exposure mode MSM93 (22)165 (23) IDU126 (30)179 (25) MSM/IDU14 (3)29 (4) Heterosexuala88 (21)150 (21) Presumed Heterosexualb50 (12)86 (12) Other/unknown50 (12)107 (15)MSM male sex with male, IDU injection drug useraHeterosexual exposure includes high-risk heterosexual contact, defined as heterosexual contact with an MSM, IDU, or Person Living with HIV/AIDSbPresumed heterosexual = females reported heterosexual contact, but not high-risk Using state surveillance data as a proxy for identifying HIV+ patients who are OOC, we found that only 37% were confirmed OOC following clinical review. While we anticipated that many individuals identified as presumed OOC via surveillance data would not be truly out-of-care, the intervention appears to be a useful care monitoring tool for the participating clinical sites. The majority of confirmed OOC patients had a subsequent laboratory test, indicating that they had returned to care. Through ongoing discussions with the pilot sites, they reported that the line lists were a helpful tool in managing patients’ engagement in care.   Source:


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