Using Surveillance Data to Drive Cascade-Related Community-Based HIV

Amanda D. Castel, MD, MPH
June 01, 2013

Washington, DC is one of the 12 cities in the U.S that accounts for 44% of all HIV infections nationally. With a 3% prevalence rate, the epidemic is generalized and affects all populations and areas. Measurement of the DC continuum of care suggests that as many as 25-30% of people are unaware of their infections, and despite high linkage to care rates, only 58% of persons are continuously in care with 56% of all HIV-positive persons ever achieving viral suppression. Moreover, the mean community viral load (CVL) in DC, a measure of the potential infectivity of a community, is approximately 33,000 copies/ml, indicative of a high rate of potential onward transmissions and a failure of the HIV care continuum at one or more junctures. Given the high rates of HIV in DC and the potential for new transmissions, examining the potential role of surveillance data to identify the highest-risk geographic areas, identifying HIV-positive persons, and linking those persons to immediate care, is essential in improving rates of viral suppression. The objectives of this pilot study are to assess the feasibility of using surveillance data to identify geographic areas for an intensive HIV testing intervention, coupled with financial incentives to increase retention in care and viral suppression among HIV-positive persons. The study will be implemented in two phases. First we will use surveillance data to identify geographic areas with highest CVL and highest proportions of persons out of care or never in care for HIV testing. We will then partner with Community Education Group, a community-based organization in DC, to conduct intensive HIV testing in these areas. Using HIV- positive persons identified through testing from the first phase, we will then pilot a community-level intervention to determine if intensive outreach using an mHealth application, coupled with financial incentives leads to higher linkage, retention and decreases in viral load. Participants will be followed at 1-, 3-, and 6- months to assess linkage rates, visit adherence, and decreases in viral load. At the conclusion of this pilot study, we would have tested the feasibility and acceptability of a public health department/community-based intervention to address several junctures of the treatment cascade. If the pilot intervention is successful, a larger-scale randomized community-level trial would be conducted to test the efficacy of this intervention.