Through an HIV heatmap, as well as an extensive survey and customized web-based software to connect social determinants with viral suppression rates, an HIV primary care program is working to reduce the number of new HIV diagnoses and increase viral suppression rates in Long Island and Queens.
In a continuous push to reduce the number of new HIV diagnoses and increase viral suppression rates in Long Island and Queens, clinicians from an HIV primary care program are using data and technology to identify HIV hot spots and facilitate prevention and treatment efforts in those areas.
A team from Northwell Health’s Center for AIDS Research and Treatment (CART) at North Shore University Hospital has a multidisciplinary program—complete with social workers, nurse case managers, health educators, and dietitians—and has a 93.6% viral suppression rate. “But, we wanted to look forward and say, ‘Is everyone doing well?’ We wanted to see if there were some people not benefitting equally," explained Joseph McGowan, MD, medical director, CART, in an interview with The American Journal of Managed Care® (AJMC®).
So, the team created a 2-fold initiative. They first collected information on incidence of sexually transmitted infections from the state health department and results of viral loads being sent to the health system. Laying out the data, the team was able to create a heat map that identified where new diagnoses and high-risk behavior was occurring as well as where people with unsuppressed viral loads were residing.
“Long behold, there were certain areas where all of these elements were overlapping,” said McGowan. “So, we called these hot zones. If you looked within these communities, they were at risk for all of these components.”
From there, the team reached out to and worked with these communities. In addition to identifying stakeholders within the community to alert them of their high risk, a community liaison worked with people in the community to identify where they were getting their medical information and where they go to meet people—venues they go to or apps they use—and used these venues to educate people.
“Most people know about HIV. They’ve heard about it, they know how it’s transmitted, but for whatever reason, people don’t necessarily apply that message to themselves, or they may not realize that they’re living in a community of high risk,” said McGowan.
The second component of the initiative is an extensive survey and customized web-based software, RED Cap, through which the team collected and analyzed patient data. Through years of surveying patients on mental health status, housing status, and other psychosocial characteristics, the social workers were able to come up with a vast survey done with patients twice a year.
The meta-driven survey creates branching logic for the questions, so patient questions are based on their previous answers. Through these answers and logged data, the team is able to identify various disparities, explained Richard Varghese, who is part of the CART team, in an interview with AJMC®. The survey is able to recognize the relationship between variables, such as housing status, depression, insurance type, and food access, and viral suppression load.
“This information is given to the social worker in real-time so as the patient is having a discussion with the social worker, the social worker is immediately able to identify barriers facing the patient and make referrals for any needs,” said Varghese.