Electronic Medical Records Can Help Select HIV PrEP

Candidates
Algorithm identified people most likely to benefit from drug prophylaxis

by Liz Highleyman October 29, 2016

NEW ORLEANS -- A machine learning algorithm used to analyze electronic health records
(EHRs) was able to identify people who are likely to be at elevated risk for HIV infection
and might benefit from pre-exposure prophylaxis, or PrEP.

Out of 800,000 patients at a large medical practice in Boston, the algorithm indicated
that more than 8,000 were potential PrEP candidates, according to Douglas Krakower,
MD, of Beth Israel Deaconess Medical Center.

Investigators concluded that automated analysis of data routinely stored in EHRs can
identify patients at increased risk for HIV infection who are potential candidates for PrEP,
Krakower said at the annual IDWeek meeting, which brings together four organizations
that focus on infectious disease -- the Infectious Diseases Society of America, the HIV
Medicine Association, the Society for Healthcare Epidemiology of America, and the
Pediatric Infectious Diseases Society.

"The vast majority of patients in the general population have very low risk scores, but at
the far end of the curve there's an inflection point. It seems like there might be a
subpopulation, based on the patterns observed in the data, that may benefit from
consideration of PrEP and other more intensive HIV prevention strategies," Krakower
said.

The FDA approved tenofovir/emtricitabine (Truvada) for HIV prevention in July 2012.
Studies of gay and bisexual men have shown that PrEP reduces the risk of HIV infection
by more than 90% if used consistently, with no new infections seen among people who
take it at least four times a week.

PrEP use has increased dramatically in recent years as clinical trials and demonstration
projects continue to confirm its safety and efficacy. However, it has been difficult to
estimate how many people have used PrEP because this information is not centrally
collected.

A survey of retail pharmacies by Gilead Sciences, presented at the International AIDS

Conference in July, found that more than 79,000 people in the U.S. have taken PrEP over
the past 4 years. But the CDC estimates that more than 1.2 million people could
potentially benefit from PrEP, including one in four sexually active gay and bisexual men.

Krakower said that one of the major barriers to getting more people on PrEP is not having
sexual health and risk evaluations done as part of routine care. "We know that providers
are very busy and have competing demands, and taking comprehensive sexual histories
is challenging for several seasons including lack of training and lack of comfort having
discussions about sexual health," he said.

Krakower's team therefore aimed to develop an automated algorithm to identify people

at increased risk for acquiring HIV using routinely collected information in EHRs -- "an
extremely rich data source."

The researchers first extracted potentially relevant data from the EHRs of Atrius Health, a
large practice group in the greater Boston area with approximately 800,000 patients at
27 sites. They looked at more than 100 variables including patient demographics (age,
sex, race/ethnicity), diagnoses, drug prescriptions, laboratory tests, and procedures. A
record of sexually transmitted infection testing or

treatment suggests someone has had condomless sex, while a prescription for
buprenorphine or methadone indicates a substance use disorder, Krakower noted as
examples.

The team then matched each patient who was newly infected with HIV during 2006-2015
with 100 control subjects of the same sex and similar duration of Atrius Health
membership who remained HIV-negative, comparing their characteristics and risk
factors. Looking at more than nine years of data, they identified 138 HIV cases and
selected 13,800 matched controls.

Next they used logistic regression modeling and machine learning to predict incident HIV
infections among cases versus controls. Logistic regression is a more traditional
approach that makes prior assumptions about what the data will look like, while machine
learning is a new approach in which the computer learns to recognize patterns in the
data that might not have been apparent at the outset, Krakower explained.

A comparison of the computer algorithms to each other and to logistic regression showed
that several of the machine learning methods did a good job at predicting incident HIV
infection. One known as Ridge Regression demonstrated the best predictive performance
(area under the receiver-operating characteristic curve 0.76); the LASSO method also
performed well.

As examples of variables that differed between HIV cases and controls, 6.5% of people
who became infected had undergone anal cytology testing to screen for anal cancer,
compared with less than 0.1% of uninfected control subjects. Similarly, 3.6% of HIV cases
had received a recent prescription for benzathine penicillin G (Bicillin) -- used to treat
syphilis -- compared with less than 0.1% of uninfected controls. While 5.8% of HIV cases
had ever had a positive gonorrhea test, this also fell to less than 0.1% among controls.

Finally, the researchers asked if the distribution of HIV prediction scores in the Atrius
Health general population could suggest a subpopulation who might be candidates for
PrEP. While the vast majority of members were at very low or low risk of HIV infection, a
small proportion were found to be at high risk. After excluding 885 patients who were
already HIV-positive and 249 who were currently receiving PrEP, the algorithm indicated
that 8,414 patients, or 1.1% of the general Atrius population, were potential PrEP
candidates.

"When you see 8,000 patients, that's a lot to think about providing PrEP to, but if you
have a primary care provider handling 1,000 patients, this 1.1% would represent 11 of
their patients, or 22 of 2,000 patients," Krakower said. "I think this is a clinically
reasonable and manageable subgroup of the population for more intensive screening."

The investigators next plan to optimize the predictive algorithm and validate it with
patients at Fenway Health in Boston, a community health center that specializes in care
for sexual and gender minorities where PrEP use is much more common. Among
approximately 30,000 patients, 2,200 are HIV-positive and PrEP has been prescribed for
1,500. They then hope to conduct a pilot study with clinicians to see if the algorithm
leads to increased appropriate use of PrEP in a real-world setting, according to Krakower.

"Using STD diagnosis as a predictor of HIV risk is evidence-based, but it assumes that
providers correctly screen patients -- especially men who have sex with men -- to
 actually capture the 70% of gonorrhea and chlamydia missed by urine-only testing,"
Demetre Daskalakis, MD, of the New York City Department of Health and Mental Hygiene,
told MedPage Today. "The first step is still getting a sexual history that allows the data
entering the model to be truly predictive of people at risk of HIV exposure."

"EHR-based screening to remind providers to evaluate for PrEP based on patient

characteristics and diagnosis is an important innovation," Daskalakis added. "I can't wait
to see how this technology evolves to include women and other harder-to-define
populations that could benefit from PrEP."

Source: Highleyman, L. (2016, October 29). Electronic Medical Records Can Help Select HIV
PrEP Candidates. Retrieved from
http://www.medpagetoday.com/meetingcoverage/idweek/61108

Synthesis:

The article talks about electronic health records that can help select HIV pre-
exposure prophylaxis, or PrEP candidates. According to Douglas Krakower, MD, of Beth
Israel Deaconess Medical Center, out of 800,000 patients at a large medical practice in
Boston, the algorithm indicated that more than 8,000 were potential PrEP candidates.
Investigators concluded that automated analysis of data routinely stored in EHRs can
identify patients at increased risk for HIV infection who are potential candidates for PrEP.
According to Demetre Daskalakis, MD, of the New York City Department of Health and
Mental Hygiene, EHR-based screening to remind providers to evaluate for PrEP based on
patient characteristics and diagnosis is an important innovation and they can't wait to see
how this technology evolves to include women and other harder-to-define populations that
could benefit from PrEP.

According to Ojha (2004), there is a fundamental shift in economics of information

due to emerging information and communication technologies (ICTs). This shift has
resulted in what is popularly called the information revolution. According to Hitt, Ireland
and Hoskisson (2011), dramatic changes in information technology have occurred in
recent years. An important outcome of these changes is that the ability to effectively and
efficiently access and use information has become an important source of competitive
advantage in virtually all industries. Information technology advances have given small
firms more flexibility in competing with large firms, if that technology can be efficiently
used.

I think in this situation, the competitive advantage of their company is being able
to select HIV PrEP candidates through electronic health records. Even though this
innovation made the process of selecting such candidates easier, I think they also have
limitations because data on a computer can easily become corrupted for one reason or
another.

Sources:

Highleyman, L. (2016, October 29). Electronic Medical Records Can Help Select
HIV PrEP Candidates. Retrieved from
http://www.medpagetoday.com/meetingcoverage/idweek/61108
 Hitt, M., Ireland, R. & Hoskisson, R. (2011). Strategic Management and
Strategic Competitiveness. Strategic Management Competitiveness & Globalization
(9th ed.). Mason, OH: South-Western Cengage Learning

Ojha, A. (2004). Organizational Forms in the Electronic Age. Retrieved from

http://www.vikalpa.com/pdf/articles/2004/2004_jul_sep_83_95.pdf

Wheelen, T. & Hunger, J. (2012) Basic Concepts of Strategic Management. Strategic

Management and Business Policy TOWARD GLOBAL SUSTAINABILITY (13 th ed.). Upper
Saddle River, NJ: Pearson Education, Inc.