Download Retaining HIV-Infected Patients in Care

John W. Hogan, M.D.
Howard University College of Medicine
Upon completion of this training the
participants will be able to:
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Identify services offered by the National
HIV/AIDS Clinicians Consultation Center.
Discuss the problems associated with delayed
linkage to care.
Understand the rationale behind test and
treat strategies.
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The National HIV/AIDS Clinicians Consultation Center
(NCCC) which is part of the AIDS Education and
Training Centers (AETC), provides clinical consultation
with HIV experts about:
 Indeterminate tests,
 HIV diagnosis,
 HIV management and
 Referral issues.
Clinicians with questions about HIV are encouraged
to call the NCCC Warmline at 1-800-933-3413.
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The National HIV/AIDS Clinicians’ Consultation Center’s
(NCCC) Warmline is a confidential and free service that can
be especially helpful for those clinicians identifying new
cases of HIV infection when HIV experts are unavailable or
referrals to HIV experts have not yet been identified.
This service provides free expert consultation on HIV testing
(e.g., interpreting indeterminate tests and false positive
tests) and can help guide the initial steps in workup and
management of newly diagnosed patients.
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NCCC consultation services include:
 The National Clinicians' Post-Exposure Prophylaxis
Hotline (PEPline 1-888-HIV-4911) for advice on
managing occupational exposures to HIV and
hepatitis;
 The National Perinatal Consultation and Referral
Service (Perinatal HIV Hotline 1-888-448-8765) for
consultation on preventing mother-to-child
transmission of HIV. The NCCC website is
www.nccc.ucsf.edu .
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On July 13, 2010, the White House released
the National HIV/AIDS Strategy (NHAS).
This ambitious plan is the nation’s first-ever
comprehensive coordinated HIV/AIDS
roadmap with clear and measurable targets
to be achieved by 2015.
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Goals of the National HIV/AIDS Strategy
 By 2015, increase from 79% to 90% the percentage of
people living with HIV who know their serostatus (from
948,000 to 1,080,000 people).
 By 2015, increase the proportion of newly diagnosed
patients linked to clinical care within three months of their
HIV diagnosis from 65% to 85% (from 26,824 to 35,078
people).
 Improve access to prevention and care services for all
Americans.
Reporting and Notification
Connecting to Services
Document HIV
Test Result
Clinical Care
+
Report HIV to
Health
Department
Support
Services
Partner
Notification
HIV
Prevention
Services
HIV-Infected
Source: CDC. MMWR. 2006;55(RR-14):1-17.
Never
Later than 3 Months
17%
19%
64%
Within 3 Months
Analysis: Time to Initiation of Care
Source: Torian LV, et al. Arch Intern Med. 2008;168:1181-7.
Linkage To Care:
 The large majority of people newly diagnosed with HIV in
2010 (89%) were linked to care within 12 months of their
initial diagnosis.
 76% were linked to care within three months of their
diagnosis.
 The share of people entering care has increased since 2006,
yet there are still people with HIV who are not getting the
care and treatment they need.
Fact Sheet-The HIV/AIDS Epidemic in Washington, D.C.; The Henry J. Kaiser Family Foundation
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The International Association of Physicians in AIDS Care
(IAPAC) convened an expert panel to develop evidencebased recommendations to optimize entry into and
retention in care and ART adherence and to monitor these
processes.
These guidelines aim to define best practices that can be
used by practitioners and health systems to improve
adherence and, in turn, health outcomes.
The recommendations are based on the best published
science; however, the evidence base remains insufficient in
many areas.
Guidelines for Improving Entry Into and Retention in Care and
Antiretroviral Adherence for Persons With HIV: Evidence-Based
Recommendations From an International Association of Physicians in
AIDS Care Panel: M Thompson et al: Ann Intern Med. 5 June 2012;
156(11):817-833
1-Systematic monitoring of successful entry into HIV care is
recommended for all individuals diagnosed with HIV.
 2-Systematic monitoring of retention in HIV care is
recommended for all patients
 3-Brief, strengths-based case management for individuals with
a new HIV diagnosis is recommended.
 4-Intensive outreach for individuals not engaged in medical
care within 6 months of a new HIV diagnosis may be
considered.
 5-Use of peer or paraprofessional patient navigators may be
considered.
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Guidelines for Improving Entry Into and Retention in Care and Antiretroviral
Adherence for Persons With HIV: Evidence-Based Recommendations From
an International Association of Physicians in AIDS Care Panel: M Thompson
et al: Ann Intern Med. 5 June 2012;156(11):817-833
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Providers who offer HIV tests to their patients should be
prepared to play a role in helping assure their patients newly
diagnosed with HIV infection are linked to appropriate care.
The patient should be immediately connected with the case
worker, who then addresses any unique barriers to care that
the patient may face.
Clinicians cite strong provider relationships with an open
dialog as the most important part of their testing and
referral systems.
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There have been major advances in the development of
effective antiretroviral treatments (ARTs) that have reduced
morbidity and improve survival for patients infected with
human immunodeficiency virus type 1 (HIV-1).
These advances in medicine have allowed HIV infection to
become a chronic, manageable condition and have already
resulted in millions of years of life saved.
Despite the availability of highly active antiretroviral therapy
(HAART), there still are hundreds of thousands of Americans
living with HIV infection who are undiagnosed, not in
medical care, or not receiving HIV treatment.
Introduction: Linkage, Engagement, and Retention in HIV Care:
Essential for Optimal Individual- and Community-Level Outcomes in the
Era of Highly Active Antiretroviral Therapy; K Mayer et al. Clinical Infectious
Diseases;2011, 52(6), S205-S207
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A large number of HIV-infected Americans are aware of their
status but not engaged in care.
Delayed entry into care is defined as care entry >3 months after
HIV diagnosis.
Many patients present beyond the clinical period recommended
by current guidelines, which advocate initiating ART when CD4
cell counts fall below 500 cells/mm3.
Longer delays in linkage with medical care are associated with
greater likelihood of progression to AIDS by CD4 cell criteria.
Similar to individuals with undiagnosed infection, HIV-infected
individuals not engaged in care pose a greater risk of ongoing HIV
transmission.
Introduction: Linkage, Engagement, and Retention in HIV Care: Essential
for Optimal Individual- and Community-Level Outcomes in the Era of Highly
Active Antiretroviral Therapy; K Mayer et al. Clinical Infectious Diseases;
2011, 52(6), S205-S207
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HIV-infected individuals who are engaged in care have 4
main barriers to successful treatment with antiretroviral
medications:
 delay or failure to initiate therapy,
 lack of persistence with therapy,
 poor adherence to therapy, and
 viral resistance to antiretroviral medication.
Introduction: Linkage, Engagement, and Retention in HIV Care: Essential for
Optimal Individual- and Community-Level Outcomes in the Era of Highly Active
Antiretroviral Therapy; K Mayer et al. Clinical Infectious Diseases;2011, 52(6),
S205-S207
In 2009, Bristol-Myers Squibb commissioned a national
survey to assess perceived barriers to HIV testing, care,
and treatment.
 Interviews were conducted over the telephone, online,
and in person with healthcare providers and HIV-infected
patients to assess reasons why people living with HIV were
not receiving care or treatment.
 The survey revealed that healthcare providers generally
underestimate the impact of emotional rather than
circumstantial barriers that prevent people from seeking
testing, care, and treatment for HIV infection.
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“Barriers to accessing HIV testing, care, and treatment in the
United States”. Presented at XVIII International AIDS
Conference. Vienna, Austria, 18–23 July 2010. D Seekins et al.
Healthcare providers were more likely to view:
 structural barriers (finances, transportation, family care) and
 substance abuse
as important barriers to patients seeking care.
 Emotional barriers such as:
 fear of HIV medication side effected,
 fear of people knowing, and
 Stigma
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were the most commonly reported reasons for not seeking
care by HIV-infected patients.
“Barriers to accessing HIV testing, care, and treatment in the United
States”. Presented at XVIII International AIDS Conference. Vienna,
Austria, 18–23 July 2010. D Seekins et al.
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Opportunistic illnesses, such as Pneumocystis jirovecii pneumonia,
are most common in individuals with unknown HIV serostatus and
in those who are not receiving HIV care.
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Three population-based studies from the United States have
found that 45%–55% of known HIV-infected individuals fail to
receive HIV care during any year.
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Over longer periods, approximately one-third of HIV-infected
individuals fail to access care for 3 consecutive years in some
communities.
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Multiple cohort studies have found that 25%–44% of HIV-infected
individuals are entirely lost to follow-up in many settings ,
although these individuals may eventually re-establish care.
The Spectrum of Engagement in HIV Care and its Relevance to Test-andTreat Strategies for Prevention of HIV Infection: E Gardner et al;Clinical
Infectious Diseases-2011,52(6),793-800
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Nonadherence to antiretroviral therapy and antiretroviral
medication resistance were long viewed as barriers to
controlling the HIV epidemic.
The advent of more potent regimens has shifted the
challenge toward earlier steps in the process of recognition
and treatment of HIV infection.
The Spectrum of Engagement in HIV Care and its Relevance to
Test-and-Treat Strategies for Prevention of HIV Infection: E
Gardner et al;Clinical Infectious Diseases-2011,52(6),793-800
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A series of studies funded through a US Health Resources
and Services Administration (HRSA) Special Programs of
National Significance (SPNS) found that greater
engagement in HIV care was associated with greater use of:
 case-management services,
 mental health services,
 substance abuse treatment,
 transportation assistance, and
 housing assistance.
The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat
Strategies for Prevention of HIV Infection: E Gardner et al;Clinical Infectious
Diseases-2011,52(6),793-800
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Some localities have developed peer intervention programs
that have demonstrated meaningful results.
Peer intervention programs educate, train and employ staff
who have similar socioeconomic and health characteristics
as the patients being served.
Trained peers work to build trusting relationships with
patients and help them improve their understanding of how
to successfully access services.
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Peers also work as Health Systems Navigators. Health
Systems Navigators support case management services by
helping patients follow through with referrals.
HSNs use a variety of strategies including:
 accompanying patients to appointments,
 helping them learn how to be their own advocates,
 coaching patients on how to effectively talk with their
clinicians, and
 providing translation services.
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Antiretroviral therapy has become more potent therefore
better treatment outcomes can be achieved despite lower
adherence.
With modern initial antiretroviral regimens, 70%–80%
adherence leads to durable viral suppression in most
individuals.
In 2 recent studies from large North American cohorts, 60%–
80% of individuals achieved adequate levels of adherence by
this new standard.
The Spectrum of Engagement in HIV Care and its Relevance to Test-andTreat Strategies for Prevention of HIV Infection: E Gardner et al;Clinical
Infectious Diseases-2011,52(6),793-800
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Nonpersistence occurs when therapy is halted prematurely.
Patients may stop their medications as a result of
medication adverse effects or competing priorities.
Providers may recommend cessation of therapy in response
to clinical or laboratory adverse events or barriers to
adherence.
In 3 large cohort studies, 4 %–6% of individuals who
remained in care discontinued their antiretroviral regimen
each year.
The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat
Strategies for Prevention of HIV Infection: E Gardner et al;Clinical Infectious
Diseases-2011,52(6),793-800
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Nonpersistence, nonadherence, and antiretroviral
resistance are barriers to effective antiretroviral therapy,
contributing to detectable HIV viremia in 15%–25% of
individuals receiving therapy.
The majority of individuals receiving antiretroviral therapy in
2010 have undetectable viral loads.
Therefore, most HIV-infected individuals receiving therapy
are at low risk for clinical progression and low risk to transmit
HIV to others.
The Spectrum of Engagement in HIV Care and its Relevance to Test-andTreat Strategies for Prevention of HIV Infection: E Gardner et al;Clinical
Infectious Diseases-2011,52(6),793-800
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Mathematical models have been published which suggest
that widespread use of antiretroviral therapy in HIV-infected
individuals could reduce the incidence of HIV infection.
Epidemiological data have suggested that antiretroviral
therapy reduces the risk of HIV transmission in heterosexual
sero-discordant couples by 92%–98%.
Ecological data have revealed that the incidence of HIV
infection decreases in communities with high treatment
coverage.
The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat
Strategies for Prevention of HIV Infection: E Gardner et al; Clinical Infectious
Diseases-2011,52(6),793-800
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The most widely cited transmission study entailed a retrospective
analysis of nearly 15,000 persons living in the Rakai District of
Uganda.
HIV transmission was studied among couples retrospectively
assembled through careful analysis of the data.
The probability of an HIV transmission was reflected in the blood
viral burden in the index patient.
No transmission events occurred among individuals with a blood
HIV RNA level <3500 copies/ mL.
Nearly half of the transmission events could be traced to infected
persons with a blood HIV RNA level >35,000 copies/mL.
Treatment to Prevent Transmission of HIV-1: M Cohen et al; Clinical Infectious
Diseases:2010;50,S85-S90
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Linkage and retaining individuals in care is an
essential part of the National HIV/AIDS
Strategy.
The team approach is incorporated in linkage
and retaining patients in care
There are many patient and public benefits of
retaining patients in care.
The test and treat model has the potential
benefit of decreasing the number of new
patients acquiring HIV.
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A 31 yo Latina female was diagnosed HIV+ 4 mo ago. She
initially presented with a complaint of a rash on her vagina x
3 days which was treated as genital herpes and her Oraquick
was positive. She returned 1 wk later for her confirmatory
results and has missed 3 FU appointments. She is a single
mother of 2 and has a job as a store clerk. She is in a
committed relationship. She always promises to keep her
appointment but doesn’t show.
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Discuss linkage to care strategies for this patient.
Do you feel any urgency?
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A 57 yo AA man is accompanied by his 28 yo daughter for his
FU visit. He was dx HIV+ 9 mo ago. His most recent CD4
count was 389 so last visit (he has missed the following 2
visits) you discussed starting him on ARV’s. Today he smells
of ETOH as he has on subsequent visits. He insists that he
does not drink ”that much” and states he has cut back after
you questioned him about his drinking last visit. His daughter
has remained quiet.
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How do you proceed?
Howard University HURB 1
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Washington, DC 20001
202-865-8146 (Office)
202-667-1382 (Fax)
www.capitolregiontelehealth.org
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