1. Data Integration and Improving HIV Outcomes
Diana L. Jordan, RN, MS
Director, Division of Disease Prevention Virginia Department of Health
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2. Disclosures Presenter has no financial interest to disclose.
This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with HSRA and LRG. PESG, HSRA, LRG and all accrediting organization do not support or endorse any product or service mentioned in this activity.
PESG, HRSA, and LRG staff has no financial interest to disclose.
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3. Learning Objectives
At the conclusion of this activity, the participant will be able to:
Understand how the HIV Care Continuum is a tool for examining data and care issues
Understand how Virginia has merged information across systems and funding streams to improve health outcomes for PLWH
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4. Obtaining CME/CE Credit
If you would like to receive continuing education credit for this activity, please visit:
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5. Data Collaboration Across Work Units
HIV Care
HIV Prevention
HIV Surveillance
STD Surveillance, Operations, and Data Administration TB
Five work units have worked closely on enhancing data sharing. Three are specifically focused on HIV and two others contribute data and provide services to persons at risk for or living with HIV. With the advent of the National HIV/AIDS Strategy and Care Continuum, efforts increased to integrate the programs, including collaborations on quality improvement projects and the development of measures and data systems across units.

6. Initiatives SPNS Systems Linkages (2011-2016)
Care and Prevention in the United States ( )
Black Box, with MD and DC, led by Georgetown (2014-now)
SPNS Health Information Technology ( )
VDH was awarded several initiatives in the past few years to implement and expand the data integration work to better assess health outcomes along the HIV care continuum.
SPNS Systems Linkages: impetus for the Care Markers Database (integrating all data sources together to include additional markers for care)
Care and Prevention in the United States (CAPUS): initiative that progressed the development of the Care Markers Database and the beginning of Data to Care project
Black Box: integration of surveillance data between Maryland, DC, and Virginia, with future expansion to additional jurisdictions
SPNS Health Information Technology: three-year grant from HRSA to integrate and expand health information technology for assessment of HIV care continuum measures; supports expansion of Care Markers Database and development of e2Virginia as well as enhanced/progressed the Data to Care initiative

7. The HIV Continuum of Care
The HIV continuum of care is a model used to look at a person’s health outcomes from diagnosis with HIV to the overall goal of viral suppression. Having a suppressed viral load promotes better health outcomes for persons living with HIV and also reduces the risk of HIV transmission. The HIV continuum of care is used to look at where there might be differences in certain populations living with HIV to implement programs and planning initiatives that address the needs of all persons living with HIV.
To create the HIV care continuum, we have to look at evidence of care. In Virginia, evidence of care is defined through markers for care. A “care marker” is defined as: a CD4 test, a viral load test, an HIV medical care visit, or an antiretroviral prescription.
The HIV continuum of care looks at three different measures of health outcomes. Once a person is newly diagnosed, the HIV care continuum looks at how quickly persons were linked to HIV medical care following diagnosis, if persons stayed in care over time, and if persons were virally suppressed.
What are the definitions of linkage to care, retention in care (staying in care over time), and viral suppression?
Linkage to care is defined as evidence of a care marker (a CD4 or viral load test, an HIV medical care visit, or an ART prescription) within 30 days of initial HIV diagnosis. Timely linkage was previously defined as linkage to care within 90 days, but has since been condensed to 30 days from the 2020 NHAS goals.
Retention in care (staying in care over time) is defined as 2 or more care markers in a 12-month timeframe, at least 3 months apart.
Viral suppression is defined as the last viral load taken in a 12-month timeframe was measured at <200 copies/ml.

8. Care Markers Database: Sources
eHARS
Medical Monitoring Project
HIV Care
STD*MIS
ADAP
Medicaid
HIV Testing
Accurint
The Care Markers Database consists of several data sources that include additional markers for care.
The HIV surveillance system in Virginia, the Enhanced HIV/AIDS Reporting System (eHARS) serves as the foundation for the Care Markers Database.
HIV care data sources
(e2Virginia: Virginia’s new HIV care and prevention data system which includes all lab, medical visit, and antiretroviral prescription information for Ryan White clients)
Virginia Client Reporting System (legacy HIV care system)
CAREWare data (which is imported into e2Virginia)
AIDS Drug Assistance Program (ADAP), which provides labs, ART, and med visit information for ADAP clients
HIV prevention data sources
HIV testing, which includes demographic information and HIV testing history information
Additional HIV surveillance data sources
Medical Monitoring Project (MMP) which includes information on in-care clients’ medical visit, labs, and ART information (will include extracts from most recent cycles of MMP using the new algorithm)
STD*MIS- STD surveillance database that provides updated address and risk information
Other data sources (outside VDH)
Medicaid: quarterly file from Virginia’s Medicaid office that includes information on HIV-related labs, ART prescriptions, and HIV medical care visits for fee-for-service Medicaid client
Accurint (Lexis Nexis): government-based search engine used to update vital status and address information on clients

9. HIV Continuum of Care in Virginia: NHAS Goals
Virginia’s HIV Continuum of Care vs. the National HIV/AIDS Strategy 2020 Goals
First column: most recent estimate of the number of persons living in Virginia and aware of HIV diagnosis (2013); 86% of persons living in Virginia were HIV-positive and aware of their HIV diagnosis; Virginia will need to increase by 4% for the number of persons living with HIV in Virginia who are aware of their HIV status
Second column: this column looks at the denominator of only the newly diagnosed persons in 2015 (929 persons newly diagnosed with HIV in 2015 in Virginia); Of those, 69% were linked to HIV care within 30 days (NHAS goal of 85% by 2020); 81% of the new diagnoses in 2015 were linked to care within 90 days (the former benchmark for linkage to care).
Third column: evidence of a care marker in 2015 (defined as having a CD4 or viral load lab, ART prescription, or HIV medical care visit at least once during the 12-month timeframe in 2015); 56% or 13,945 persons out of the 24,853 persons living with HIV as of 12/31/2015 had evidence of care in 2015.
Fourth column: 43% of all persons living with HIV as of 12/31/2015 were considered retained in HIV care in 2015 (having at least two or more markers for care in 2015 at least 3 months apart); by 2020, retention rates will need to increase by 47% to achieve the NHAS goal of 90%.
Fifth column: 42% of all persons living with HIV as of 12/31/2015 were considered virally suppressed in 2015 (the last viral load measured in 2015 was less than 200 copies/mL); by 2020, viral suppression rates will need to increase by 38% to achieve the NHAS goal of 80%.

10. Ryan White HIV Continuum 2015
In contrast to the HIV continuum of care for all persons living with HIV in Virginia, Virginia also looks at the Ryan White HIV Continuum of Care as well.
The Ryan White HIV continuum of care looks at persons living with HIV as of 12/31/2015 who received a Ryan White service or served through ADAP in calendar year 2015.
Overall, the health outcomes for Ryan White clients show better linkage, retention, and viral suppression rates than the statewide HIV continuum of care.

11. Black Box: Real Time HIV Surveillance
Pilot project from Georgetown, funded by NIH
Involved DC, MD, and VA Departments of Health
Utilized privacy technology for sharing surveillance data among jurisdictions
Black Box Project:
Pilot project from Georgetown University funded through the National Institutes of Health and through data sharing agreements between DC, Maryland, and Virginia
Georgetown implemented “Black Box” or privacy technology to share surveillance data between the three jurisdictions
Matching algorithm returned matches of varying strengths to each jurisdiction
These data were used to assess how many clients were migrating across jurisdictions or were in more than one surveillance system
Data could then be used to update vital status and address information of clients who may no longer reside in Virginia, resulting in updated denominators for the HIV care continuum as well as additional care information for clients living with HIV in Virginia (additional data source for health outcomes)

12. Presentation Title
6/5/2018
Black Box Results
Output of person-matching across DC, MD, and VA eHARS databases:
82% of persons have vital clinical and surveillance data across jurisdictions
Improved Accuracy of Case Numbers
Number of PLWH in Virginia by 12/31/2015 was reduced by 760 persons after address and vital status updates.
Increased Number of Care Markers for Continuum
8% added to 2014 retention rates
9% added t viral suppression rates
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13. e2Virginia
Another initiative to facilitate better data integration across systems was through the development of a new HIV care and prevention data system, e2Virginia, in partnership with RDE Systems, LLC.
E2Virginia includes:
Ryan White data from all Parts
HIV Prevention Data: including CAPUS patient navigation and referrals, CHARLI (corrections program at VDH), and HIV testing data
Patient Navigation process data for SPNS, MAI, and CAPUS funded PN programs
Future implementation will include an electronic bidirectional feed of out of care lists for the Data to Care initiative.

15. e2Virginia: Data Sharing
Another feature of e2Virginia that helps with data integration is the data sharing capability of the system:
For clients who are served by multiple agencies or medical facilities in Virginia, agencies are able to see clinical and service information from other agencies through a data sharing module. An agency will select that they would like to see clinical and/or service information on a client. An is then sent to VDH to approve or deny the request. If the request is approved, the agency will then be able to see clinical (labs, screenings) and service information for the client that may have occurred at another agency.

16. e2Virginia: Email Alerts

17. Future Directions Update HIV Surveillance Data Expand e2Virginia
Public Health Authority for Medical Sites
Data to Care Linkage Coordinator
Future Directions:
Update HIV surveillance data: continuation of Black Box initiative, incorporation of Data to Care results (bidirectional feedback), developing protocols/processes for integrating Lexis Nexis data into HIV surveillance data
e2Virginia: continued expansion of the data system, including electronic out-of-care lists, enhancements to current modules, and integration of Care Markers data into e2Virginia
Public health authority for medical sites: assisting Data to Care activities by permitting medical facilities to follow up on out-of-care clients who are seen outside of their medical facility but are residing in their jurisdiction
DtC Linkage Coordinator: hiring a Linkage Coordinator at the Dept of Health to support Data to Care activities for hard-to-reach out-of-care clients or clients where there is no current information or available provider history

18. Future Directions Improve processes based on stakeholder feedback
Collaborate with other States/Jurisdictions
All of these will improve health outcomes for PLWH
Improve processes based on agency feedback: continuation of stakeholder engagement activities: e2Virginia: feedback via surveys, webinars from agencies as well as ongoing trainings and agency testing of the future modules; Data to Care: feedback via surveys, webinars, ongoing trainings and continued expansion of the project by including Data to Care activities in all HIV care contracts
Collaborate with other states/jurisdictions: expansion of the Black Box project and additional data sharing agreements with neighboring states/jurisdictions and others to better facilitate data sharing across state lines
In closing:
HIV Care Continuum is a framework and tool for examining both data and care issues
Utilizing data for public health action requires merging of multiple sources of information across systems and funding streams
Increased alignment of goals and objectives across agencies that fund HIV prevention, care, and surveillance activities

19. Acknowledgements CDC: Benjamin Laffoon, Dr. Irene Hall
DC Department of Health: Michael Kharfen, Garret Lum, Auntre Hamp
Georgetown University: Jeff Collman, Joanne Michelle Ocampo, Jay Smart, Raghu Pemmaraju
HRSA: Jessica Xavier, John Hannay
Maryland Department of Health: Colin Flynn, Reshma Bhattacharjee
RDE Systems: Jesse Thomas, Anusha Dayananda, RDE Developer Team
Virginia Department of Health: Anne Rhodes, Jeff Stover, Steve Bailey, Elaine Martin, Lauren Yerkes, Kate Gilmore, Sahithi Boggavarapu, Sonam Patel, Amanda Saia