Monitoring HIV Care in the United States Indicators and Data Systems (2012) / Chapter Skim
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2 Indicators Related to Continuous HIV Care and Access to Supportive Services
2 Indicators Related to Continuous HIV Care and Access to Supportive Services
Pages 39-126
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From page 39... ...
Based on its statement of task, however, the committee focused its attention on linkage and access to and provision of appropriate HIV care and related supportive services for people already diagnosed with HIV/AIDS.1 1 Although the committee did not focus on indicators specifically related to reducing the transmission of HIV by people in care for HIV (e.g., condom use) , some indicators, such as those related to undetectable viral load, also promote transmission reduction.
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"Core indicators" are those indicators deemed by the committee to be fundamental both to assessing the extent to which persons diagnosed with HIV are connected to appropriate medical care, are maintained in care over time, and have access to needed supportive services in the United States and to gauging the impact of the NHAS and the ACA in improving HIV/AIDS care. Indicators may include process measures and outcome measures.
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. These sources provide a basis for the committee's development of a set of indicators for measuring HIV care and access to mental health, substance abuse, and supportive services in the United States (Appendix Table 2-1)
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2. CD4+ cell count measurement (mea- P Level II and QM sured at least twice annually)
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Research has shown that patients who receive more routine office visits; appropriate initiation and prescription of antiretroviral therapy (ART) ; and appropriate screenings, prophylaxis, and immunizations have better outcomes than those who do not (Kitahata, 1996; Kitahata et al., 2000, 2003; Landon et al., 2005)
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. The PEPFAR indicators that pertain to the treatment of PLWHA and the provision of supportive services, such as food assistance, also provided a basis for the committee's development of core indicators related to continuous care and access to supportive services for PLWHA in the United States (Box 2-2)
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HIV-8. Reduce the number of perinatally acquired HIV and AIDS cases Death, Survival and Medical Healthcare After Diagnosis of HIV Infection and AIDS HIV-9.
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and other housing supports to all needy people living with HIV.) Although the NHAS does not specify it explicitly, the text makes clear that the continuous care target for Ryan White clients serves as a measurable proxy of efforts to ensure that all diagnosed HIV-infected persons are maintained in care (ONAP, 2010, pp.
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From page 47... ...
Since the issue of continuity of care clearly is not limited to Ryan White HIV/AIDS Program clients, the continuity-of-care indicator identified by the committee is directed toward the general population of PLWHA but can also be applied to Ryan White HIV/AIDS Program clients or any other subpopulation. The same is true for the indicators relating to permanent housing and undetectable viral load.
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hence, the core indicators reflect Figure 2-2 aspects of clinical HIV care, New more general while more specific aspects are included in the additional indicators. In addition, the committee was specifically asked to address indicators related to access to supportive services, such as housing.
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From page 49... ...
Although the specific details of the indicators (e.g., threshold CD4+ cell counts) may evolve over time as the science and practice of HIV care changes, the prin 5 Although there is a low rate of new HIV diagnoses among 13- to 14-year-olds (CDC, 2012, Table 1a)
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Newly diagnosed patients also should receive recommended testing and screening, including CD4 and viral load testing, screening for concurrent infections and antiretroviral (ARV) drug resistance, and routine laboratory tests (Aberg et al., 2009, p.
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ART may be initiated more promptly, with an attendant reduction in viral load, which leads to improved health outcomes and a reduction in HIV transmission. In addition, prompt receipt of prevention services, such as screening and treatment for STIs and mental health and substance use disorders, risk reduction counseling and behavioral interventions, assistance with partner notification, and housing assistance and other supportive services, is important for reducing transmission of the virus and improving health outcomes among PLWHA (CDC, 2010b; Crepaz, et al., 2006; Kamb et al., 1998; Shain et al., 1999; Weinhardt et al., 1999; Wolitski et al., 2005)
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. Although not directly representative of office visits, because patients may have office visits in addition to those associated with laboratory testing or receive laboratory testing independent of an office visit, regular monitoring of patients' CD4 and viral load levels can serve as proxies for care visits when evaluating continuity of care.
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CD4 and Viral Load Testing As process measures, CD4 and viral load testing in accordance with recommended guidelines not only demonstrate continuity of care but also are acceptable indicators of quality HIV care. Regular CD4 testing improves health outcomes in PLWHA by permitting providers to monitor individuals' immune function, determine when to initiate ART, assess immunologic response to ART, and assess the need for initiation or discontinuation of prophylaxis for opportunistic infections (OIs)
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From page 54... ...
Accordingly the committee recommends the following core indicators for regular CD4 and viral load testing. • roportion of people with diagnosed HIV infection who received P two or more CD4 tests in the preceding 12 months • roportion of people with diagnosed HIV infection who received P two or more viral load tests in the preceding 12 months ART Initiation and Adherence Appropriate initiation of ART, the third benchmark of quality HIV care, is crucial to increased longevity and reduced morbidity among PLWHA and important for reducing transmission of the virus to others (HHS, 2011d)
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In formulating a core indicator for initiation of ART, the committee followed the HHS panel's recommended threshold of 500 cells/mm3. • roportion of people with diagnosed HIV infection and a measured P CD4+ cell count <500 cells/mm3 who are not on ART Initial results from the HIV Treatment Prevention Network's HPTN 052 clinical trial funded by the National Institutes of Health indicate that early initiation of ART in PLWHA reduces sexual transmission of HIV in serostatus-discordant couples by 96 percent (Cohen et al., 2011)
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• roportion of people with diagnosed HIV infection who have been P on ART for 12 or more months and have a viral load below the level of detection This indicator serves not only as a measure of the status of the epidemic in terms of optimal health outcomes and decreased risk of HIV transmission but also as a surrogate measure of treatment adherence and the prescription of effective drug regimens. An alternate indicator would be the time from diagnosis to virologic suppression.
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To avoid the difficulties inherent in identifying and reporting which deaths among PLWHA resulted directly or indirectly from HIV infection, the committee recommends the use of all-cause mortality in the following indicator. • ll-cause mortality rate among people with diagnosed HIV infection A Taken together, the committee recommends the preceding indicators as core indicators related to continuous and quality clinical care for PLWHA.
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Mental health disorders and symptoms can be associated with HIV in two ways: first, individuals with mental health disorders may be at greater risk for acquiring, as well as transmitting, HIV; second, HIV-infected individuals are at greater risk for developing neurocognitive disorders. In addition, HIV-infected patients, as they live longer and age, increasingly have high rates of medical comorbidity associated with the normal aging process as well as side effects from their ART (Bisson et al., 2003; Goulet et al., 2007)
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From page 59... ...
. Unhealthy substance abuse or misuse behaviors, such as chronic and heavy intake of alcohol and illicit drug use, particularly injection drug use, are significantly related to the acquisition of HIV infection and for some PLWHA serve as a way to cope with and manage HIV-related symptoms (Brion et al., 2011)
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The committee recommends two core indicators relating to mental health and substance abuse. • roportion of people with diagnosed HIV infection and mental P health disorder who are referred for mental health services and receive these services within 60 days • roportion of people with diagnosed HIV infection and substance P use disorder who are referred for substance abuse services and receive these services within 60 days Studies have shown that referrals for mental health and substance abuse services that can be accessed in a short period of time after they have been recommended have some of the best outcomes and high levels of patient satisfaction (Kowal et al., 2011)
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Housing, Food Security, and Transportation Assessment of food and housing needs and referral to appropriate services are essential to improving HIV care, improving health outcomes, and reducing health disparities among the HIV-infected population (Anema et al., 2009; McMahon et al., 2011; Reily et al., 2011; Weiser et al., 2009a,b)
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From page 62... ...
. Whether via physiological or psychosocial mechanisms, homelessness or unstable housing is associated with lower CD4 counts, higher viral loads, and higher rates of comorbidities among PLWHA, controlling for a wide range of individual and medical care variables (Clements-Nolle et al., 2008; Kidder et al., 2007; Knowlton et al., 2006; LeGrand et al., 2010)
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From page 63... ...
Nonmedical supportive services including food assistance can serve to attract clients who need other services and can facilitate their entry into and maintenance in HIV medical care (see Ashman et al., 2002; Conover and Whetten-Goldstein, 2002; Conviser, 2007; Conviser and Pounds, 2002a,b; Messeri et al., 2002)
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. Given the importance of adequate housing, food, and transportation to the health outcomes of PLWHA, the committee identified three core indicators related to access to services that promote housing stability, food security, and transportation.
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• roportion of people with diagnosed HIV infection who were P homeless or temporarily or unstably housed at least once in the preceding 12 months • roportion of people with diagnosed HIV infection who experi P enced food or nutrition insecurity at least once in the preceding 12 months • roportion of people with diagnosed HIV infection who had an un P met need for transportation services to facilitate access to medical care and related services at least once in the preceding 12 months Additional Indicators Related to Clinical HIV Care In addition to the core indicators for HIV care, the committee identified a number of additional indicators, based on other, more granular, process measures, that provide a comprehensive measure of the quality of HIV care (Appendix Table 2-1)
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Immunizations and Prophylaxis Appropriate immunizations and prophylaxis are other important elements of quality HIV care. The effect of HIV infection on the immune system places PLWHA at greater risk for serious complications of seasonal influenza, pneumococcal pneumonia, and the occurrence of OIs, including pneumocystis pneumonia, TB, and viral hepatitis.
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. • roportion of people with diagnosed HIV infection who have re P ceived an influenza immunization during the preceding 12 months • roportion of people with diagnosed HIV infection who have P received a pneumococcal immunization at least once since HIV diagnosis • roportion of people with diagnosed HIV infection who have re P ceived a hepatitis B vaccination, or who have documented immunity The need for revaccination varies with the effectiveness of the vaccine at preventing future infection.
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From page 68... ...
• roportion of people with diagnosed HIV infection and HIV P associated nephropathy, hepatitis B (when treatment is indicted) , or active tuberculosis who are not on ART • roportion of pregnant women with diagnosed HIV infection who P are not on ART ARV Resistance Testing The HHS Guidelines also indicate that ARV drug resistance testing should be performed prior to the initiation of ART, or if previously performed, repeat testing should be considered (HHS, 2011d, p.
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• roportion of people with diagnosed HIV infection who were P screened for mental health disorders at least once during the pre ceding 12 months • roportion of people with diagnosed HIV infection who were P screened for substance use disorders at least once during the pre ceding 12 months • roportion of people with diagnosed HIV infection who were as P sessed for need for housing at least once during the preceding 12 months • roportion of people with diagnosed HIV infection who were P assessed for need for food or nutrition at least once during the preceding 12 months • roportion of people with diagnosed HIV infection who were as P sessed for need for transportation at least once during the preced ing 12 months Summing Up Taken together, the core and additional indicators for clinical HIV care and mental health, substance abuse, and supportive services identified by the committee provide a means for assessing the impact of public health policies across the HIV care continuum. Figure 2-4 shows the continuum of care arrow depicted in Figure 2-2 with the indicators mapped to it.
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, or active Proportion who • housing received 2 or more tuberculosis who are • food or nutrition not on ART viral load tests • transportation Proportion immunized for hepatitis B Proportion of HIV (if needed) Proportion screened Proportion screened for mental health disorders infected pregnant for chlamydia, at least once in preceding 12 months women who are not gonorrhea, and on ART Proportion immunized syphilis for pneumococcal Proportion screened for substance use pneumonia disorders at least once in preceding 12 months Proportion screened for hepatitis C Proportion assessed for need for Proportion who • housing received drug Proportion immunized • food or nutrition resistance testing for influenza • transportation prior to ART initiation FIGURE 2-4 Continuum of HIV care arrow mapped to indicators for HIV care and supportive services.
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From page 71... ...
. Evidence also suggests that culturally and linguistically specific care increased adherence to treatment among Latinos, which then significantly improved CD4 counts and decreased viral loads (Oh et al., 2009; Silverberg
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. The NHAS specifies targets for increasing the proportion of PLWHA with an undetectable viral load among black Americans, Latinos, and gay
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• roportion of black Americans with diagnosed HIV infection who P have been on ART for 12 or more months and have a viral load below the level of detection • roportion of Latinos with diagnosed HIV infection who have been P on ART for 12 or more months and have a viral load below the level of detection • roportion of gay and bisexual men with diagnosed HIV infection P who have been on ART for 12 or more months and have a viral load below the level of detection Other indicators, such as a continuity-of-care indicator -- that is, the proportion of people with diagnosed HIV infection who are in continuous care (two or more visits for routine HIV medical care in the preceding 12 months at least 3 months apart) -- could be applied to these and other subpopulations of interest.
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From page 74... ...
can be derived from those identified by the committee. Examples of such indicators include the following: • Proportion of people living in rural areas and newly diagnosed with HIV who are linked to clinical care for HIV within 3 months of diagnosis • Proportion of people with diagnosed HIV infection who are living in rural areas and have been on ART for 12 or more months and have a viral load below the level of detection • Proportion of people with diagnosed HIV infection who are living in rural areas who are in continuous care (two or more visits for routine HIV medical care in the preceding 12 months at least 3 months apart)
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Data pertaining to supportive services inform indicators related to access to those services. Demographic and other personal data inform indicators related to payer sources and disparities (racial, ethnic, and sexual minorities; geographic)
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. With respect to HIV, for example, claims data may provide reasonable information on how many CD4 and viral load tests are performed in a given period, but they will not provide information on the results of those tests and so are not of use in identifying treatment failure or tracking the effect of various therapeutic interventions on CD4 counts and viral load over time.
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In addition, clinical data are apt to give a more accurate picture than claims data of patients' health status (Roos et al., 1991; Tang et al., 2007)
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. Use of EHR data for quality measurement also reduces provider burden by reusing clinical data already being entered as part of patient care (Tang et al., 2007)
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For this reason, all-cause mortality may provide a more accurate measure of mortality with in a population diagnosed with a particular disease. Survey and Interview Data Surveys or interviews are additional sources of data that can be used to evaluate health care quality and outcomes.
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Claims data provide information about the number of PLWHA who are in care and the frequency with which they are seen, although it may not always be possible to gauge whether a visit for an unrelated health concern also included HIV care, nor are claims data designed to measure care quality. Claims data also can yield information about what tests and other procedures are being provided to an individual and the frequency with which they are being done.
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From page 81... ...
Other factors, such as substance use, mental health disorders, housing instability, and food insecurity, can negatively affect health outcomes even when individuals receive and adhere to quality HIV care and treatment. For this reason, clinical data pertaining to health outcomes, such as lower viral loads and higher CD4 counts, are important for tracking the overall success of HIV care in improving health outcomes for PLWHA and controlling the epidemic.
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From page 82... ...
It is important that complete data on both race and ethnicity be collected not only to evaluate and track health disparities but also because of the essential role they play in clinical care decisions. For example, Latinos, African Americans, American Indians, and some subpopulations of Asian and Pacific Islanders are at higher risk for diabetes and its complications than are whites, raising concerns about the use of some ARVs with higher associations of metabolic syndromes.
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83 INDICATORS parameters and body composition in response to ART initiation than either blacks or whites (Gibert et al., 2009)
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Minimizing the burden of data collection is an important consideration, but it must be balanced against the importance of the information for clinical decision making and the evaluation and monitoring of treatment and care, which may differ in quality based on many of the aforementioned demographic data elements. The committee supports the HHS efforts to increase the scope and granularity of demographic data collected in national population-based health surveys and recommends that the expanded data collection standards be extended to all HHS-sponsored data collection activities to the extent practicable.
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From page 85... ...
As such, the routine collection of standardized data on race and ethnicity, as well as sexual orientation and gender identity, by private insurers would facilitate their usefulness for tracking changes in access to and the provision of HIV care. Core Indicators for Clinical HIV Care The data elements required to assess the core indicators for clinical HIV care are date of HIV diagnosis, date of first visit for HIV care, dates of subsequent routine HIV care visits, dates and results of ongoing CD4 and viral load tests, date of diagnosis of AIDS or AIDS-defining condition (if applicable)
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Core Indicators for Mental Health, Substance Abuse, and Supportive Services Data elements for assessing the core indicators for mental health and substance abuse include dates of mental health screening, as well as dates
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Data elements for assessing the core indicators for supportive services include housing and food security status (e.g., as previously defined) and need for transportation services to access medical care and related services.
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Surveys and interviews can be particularly effective collection tools for this type of data, which can be used to supplement data obtained from clinical and administrative sources. CONCLUSIONS AND RECOMMENDATIONS • Measures of continuous HIV care as well as access to and quality of care can be monitored by a limited number of core indicators.
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From page 89... ...
The Department of Health and Human Ser vices should use the following core indicators13 to assess the impact of the National HIV/AIDS Strategy and the Patient Protection and Affordable Care Act on improving HIV/AIDS care and access to supportive services for individuals with HIV: Core Indicators for Clinical HIV Care roportion of people newly diagnosed with HIV with a CD4+ cell P count >200 cells/mm3 and without a clinical diagnosis of AIDS roportion of people newly diagnosed with HIV who are linked to P clinical care for HIV within 3 months of diagnosis roportion of people with diagnosed HIV infection who are in P continuous care (two or more visits for routine HIV medical care in the preceding 12 months at least 3 months apart) roportion of people with diagnosed HIV infection who received P two or more CD4 tests in the preceding 12 months roportion of people with diagnosed HIV infection who received P two or more viral load tests in the preceding 12 months roportion of people with diagnosed HIV infection in continuous P care for 12 or more months and with a CD4+ cell count ≥350 cells/ mm3 roportion of people with diagnosed HIV infection and a measured P CD4+ cell count <500 cells/mm3 who are not on ART roportion of people with diagnosed HIV infection who have been P on ART for 12 or more months and have a viral load below the level of detection ll-cause mortality rate among people diagnosed with HIV A infection 13 The rationale for each of the indicators is summarized in Appendix Table 2-1.
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Data from surveys and interviews can fill additional data gaps by providing information on hard-to-reach populations, such as homeless individuals and PLWHA who are not in care, and permitting collection of data not routinely collected by health care providers, such as need for and access to supportive services, and data on subjective experiences, such as HIV stigma and discrimina tion. Various types of data are needed to estimate the core indica tors related to continuous, quality HIV care and access to mental health, substance abuse, and supportive services for people living with HIV, and hence to assess the impact of NHAS and ACA on improving HIV/AIDS care.
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From page 91... ...
Recommendation 2-2. The Department of Health and Human Ser vices and the Office of Management and Budget should continue to expand the demographic data elements to be captured by federal data systems relevant to HIV care to permit calculation of the in dicators for subgroups of the population of people with diagnosed HIV infection, including, but not limited to, the following: Age Race Ethnicity Sex (assigned at birth)
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From page 92... ...
2009. Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2009 update by the HIV Medicine Association of the Infectious Diseases Society of America.
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2002. Late di agnosis of HIV infection in the era of highly active antiretroviral therapy: Consequences for AIDS incidence.
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2006. Achievements in public health: Re duction in perinatal transmission of HIV infection -- United States, 1985-2005.
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2012. Impact of adherence counseling dose on antiretroviral adherence and HIV viral load among HIV-infected methadone maintained drug users.
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2009. Aging, neurocognition, and medication adherence in HIV infection.
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2009. Nutrition issues in chronic drug users living with HIV infection.
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Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. National Institutes of Health.
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2011d. Leading Health Indicators for Healthy People 2020.
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2009. Guide lines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.
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1999. Clinical progression and virological failure on highly active antiretroviral therapy in HIV-1 patients: A prospective cohort study.
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2010. Inability to access addiction treatment and risk of HIV infection among injection drug users recruited from a supervised injection facility.
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2009. HIV infection and psy chiatric illness.
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Topics in HIV Medicine 17(1)
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2009. Investigating the effects of San Fran cisco's Treatment on Demand Initiative on a publicly-funded substance abuse treatment system: A time series analysis.
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2006. Efficacy of interventions in improving Highly Active Antiretroviral Therapy adherence and HIV-1 RNA viral load: A meta-analytic review of randomized controlled trials.
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From page 107... ...
2010. Addressing research priorities for prevention of HIV infection in the United States.
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In Positive Prevention: Reducing HIV Transmission Among People Living with HIV/AIDS, edited by Seth Kalichman. New York: Kluwer Academic/Plenum Publishers.
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109 INDICATORS APPENDIX TABLE 2-1 follows on next page
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From page 110... ...
improves individual health outcomes for HIV within 3 months of and reduces transmission of the virus diagnosis to others. Proportion of people with Dates of CD4 or viral load tests PLWHA who are in continuous • Dates of routine HIV-care visits diagnosed HIV infection who can be used if dates of visits for HIV care experience better health are in continuous care (two routine HIV care are not available.
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From page 111... ...
Decreased viral load, and undetectable viral load in individuals on ART, is associated with improved health outcomes and reduced transmission of the virus. Proportion of people with Dates of CD4 or viral load tests Achieving and maintaining a CD4+ • Dates of routine HIV-care visits diagnosed HIV infection in can be used if dates of visits for • Dates of CD4 tests cell count >350 cells/mm3 reduces the continuous care for 12 or R routine HIV care are not available.
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Core Indicators for Mental Health, Substance Abuse, and Supportive Services Indicator Data Elements Needed Proxy/Alternative Data Elements Rationale Proportion of people with D Evidence of mental health Untreated mental health disorders can • ate of diagnosis or evidence of diagnosed HIV infection and mental health disorder assessment and any visits for negatively affect maintenance in care, mental health disorder who D mental health services during the adherence to treatment, and health • ate of mental health referral are referred for mental health D same reporting period can be used outcomes for PLWHA, reducing • ate of first visit for mental services and receive these health services if specific dates of mental health treatment effectiveness and increasing services within 60 daysa referral and mental health visits risk of transmitting the virus to are not available. others.
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From page 113... ...
Proportion of people with H Evidence of reported need for Housing instability can negatively • ousing status diagnosed HIV infection who housing assistance during the affect maintenance in care, adherence were homeless or temporarily reporting period can be used if to treatment, and health outcomes or unstably housedc at least information about housing status for PLWHA, reducing treatment once in the preceding 12 is not available. effectiveness and increasing risk of months*
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From page 114... ...
increasing risk of transmitting the virus to others. Additional Indicators for Clinical HIV Care Indicator Data Elements Needed Proxy/Alternative Data Elements Rationale Proportion of people with Yes/no documentation of TB test All PLWHA with diagnosed active D • ate of HIV diagnosis/treatment diagnosed HIV infection and results in medical record or yes/ tuberculosis should receive ART to or documentation of infection who have had a documented no documentation of TB test results improve health outcomes.
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From page 115... ...
once in the preceding 12 months Proportion of people with Yes/no documentation of hepatitis Individuals coinfected with HIV and D • ate of hepatitis B screening or diagnosed HIV infection B screening within reporting hepatitis B virus are at greater risk for date of documented immunity who have had hepatitis B period or documented immunity developing chronic hepatitis and for screening performed at least can be used if specific dates of accelerated liver damage and serious once since HIV diagnosis HIV diagnosis and hepatitis B liver-related morbidity and mortality. or for whom there is assessment are not available.
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From page 116... ...
Proportion of people with Yes/no documentation of HIV-infected individuals are D • ate of HIV diagnosis/treatment diagnosed HIV infection who pneumococcal immunization considered to be at greater risk for or documentation of infection have received a pneumococcal in medical record or yes/no contracting and developing serious prior to immunization immunization at least once documentation of pneumococcal complications from pneumococcal D • ate of pneumococcal since HIV diagnosis immunization within reporting pneumonia. CDC recommends immunization period can be used if specific prophylactic vaccination as soon as dates of HIV diagnosis and possible following diagnosis, followed pneumococcal immunization are by a one-time revaccination 5 years not available.
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From page 117... ...
available. Additional Indicators for Mental Health, Substance Abuse, and Supportive Services Indicator Data Elements Needed Proxy/Alternative Data Elements Rationale Proportion of people with Yes/no evidence of screening for Undiagnosed, and therefore D • ate of mental health screening diagnosed HIV infection who mental health disorders or referral untreated, mental health disorders were screened for mental for treatment during reporting can negatively affect adherence to health disorders at least once period can be used if dates of treatment and health outcomes for during the preceding 12 mental health screening are not PLWHA and increase their risk of months available.
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From page 118... ...
Proportion of people with Yes/no evidence of assessment for Assessment of transportation need D • ate of transportation needs diagnosed HIV infection transportation need or referral is important because an unmet need assessment who were assessed for need for transportation services during for transportation to access clinical for transportation at least reporting period can be used if HIV care and related services can once during the preceding 12 specific dates of assessment are negatively affect treatment access and months not available. health outcomes for PLWHA and increase the risk of transmitting the virus to others.
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119 APPENDIX TABLE 2-2 follows on next page
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From page 120... ...
received two or more viral load • roportion in P tests continuous care for 12 or • roportion P more months screened for with CD4+ cell chlamydia, count ≥350 gonorrhea, and cells/mm3 syphilis • roportion P screened for hepatitis C • roportion P immunized for influenza Since diagnosis: • roportion P screened for tuberculosis • roportion P screened for hepatitis B • roportion P immunized for hepatitis B (if needed) • roportion P immunized for pneumococcal pneumonia • roportion who P received drug resistance testing (genotypic)
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121 Virologic Treatment Suppression Mediators Disparities • rocess P • utcome O • rocess/Outcome P • rocess/Outcome P • roportion with a • P P roportion on ART • roportion with P • ll indicators A measured CD4+ cell for 12 or more mental health related to count <500 cells/ months who have disorder referred diagnosis, linkage, mm3 who are not an undetectable for mental health engagement and on ART viral load services who retention, primary received these care, treatment, • ll-cause mortality A services within 60 • roportion with P and virologic rate days HIV-associated suppression, nephropathy, stratified by • roportion with P hepatitis B (when subpopulation substance use treatment is disorder referred indicated) , or active • ll mediators, A for substance abuse tuberculosis who stratified by services who receive subpopulation are not on ART these services within 60 days • roportion of HIV P infected pregnant • roportion with an P women who are not unmet need for on ART • housing • food • transportation In the preceding 12 months: • roportion screened P for mental health disorders • roportion screened P for substance use disorders • roportion assessed P for need for • housing • food • transportation continued
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From page 122... ...
• ates of D chlamydia, gonorrhea, and syphilis screenings • ate of hepatitis D C screening • ate and results D of tuberculosis screening • ate hepatitis B D screening or date of documented immunity • ate of influenza D immunization • ate of D pneumococcal immunization • ate of hepatitis D vaccine/date of documented immunity • ate of drug D resistance testing • ate of ART D initiation
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From page 123... ...
123 Virologic Treatment Suppression Mediators Disparities • ates of CD4 D • ates of ART D • ate of diagnosis D • ll data elements A tests prescription or or evidence of for indicators and dispensing mental health mediators • esults of CD4 R disorder tests • ates of viral D • dditional data A load tests • ate of referral D elements pertaining • ates of ART D for mental health to subpopulations: prescription or • esults of viral R services • Race dispensing load tests • Ethnicity • ate of first visit D • Sex • iagnosis or D • ate of death D for mental health • Gender identity test results for services • Sexual orientation HIV-associated • Date of birth nephropathy, • ate of diagnosis D • Zip code/other hepatitis B, and or evidence of geographic marker tuberculosis substance use disorder • regnancy status P • ate of referral D for substance abuse services • ate of first visit D for substance abuse services • ousing status H • ood security F status • ransportation T need • ate of mental D health screening • ates of D screening for substance use • ates of D housing, food security, and transportation needs assessment
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From page 124... ...
-Infected Adults Receiving Antiretroviral Therapy: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America and the Adult AIDS Clinical Trials Group (http://cid. oxfordjournals.org/content/37/5/613.full)
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From page 125... ...
Hypogonadism Advanced HIV • Primary Care Guidelines for the disease Management of Persons Infected with Human Immunodeficiency Virus: 2009 Update by the HIV Medicine Association of the Infectious Diseases Society of America (http://cid.oxfordjournals.org/ content/49/5/651.full) Hepatitis Chronic hepatitis B • Primary Care Guidelines for the or C; antiretroviral Management of Persons Infected with hepatotoxicity Human Immunodeficiency Virus: 2009 Update by the HIV Medicine Association of the Infectious Diseases Society of America (http://cid.oxfordjournals.org/ content/49/5/651.full)
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From page 126... ...
126 MONITORING HIV CARE IN THE UNITED STATES APPENDIX TABLE 2-3 Continued Condition Etiological Cofactors Guidance for Optimal Management Mental health Anxiety, depression, • HIV and Mental Health (http://www. disorders post-traumatic stress; hivguidelines.org/clinical-guidelines/ stigma; discrimination hiv-and-mental-health/)
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