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TechniquesandInterventionstoImproveAdherencetoHIVCare
AadiaRana,MDAssociateProfessorofMedicine
UABSchoolofMedicineAdvancedManagementIssuesinHIVCareConference
Cleveland,OhioSeptember13,2018
Acknowledgements
• Conflictsofinterests:Nofinancialconflictsofinterest• Acknowledgements:Dr.MichaelMugavero,Dr.JulieDombrowski
LearningObjectives
• DefinetheNationalHIV/AIDSStrategyGoalsforlinkagetoandretentioninHIVmedicalcare
• ReviewtheimportanceofretentioninHIVcare• PresenttheepidemiologyoftheHIVCarecontinuum• Reviewevidence-basedinterventionstoimprovelinkageto&retentionincare• DescribewaysthatHIVclinicscanimproveretentioninHIVcare
TermsforthisPresentation
• Engagementincare-anumbrellatermfortheongoingrelationshipbetweenapatientandacareprovider
• Linkagetocare-completionofaninitialvisitwithanHIVmedicalproviderafterdiagnosis(aone-timeevent)
• Retention-keepingpatientsincare
• Relinkage-bringingpatientswhohavefallenoutofcarebacktoHIVmedicalcare
• PLWH–peoplelivingwithHIV
AudiencePoll1
Towhatextentareyoucurrentlyworkingoninterventionstoimprovelinkagetoandretentionincareatyourclinic?• Ourclinicdoesnothavelinkageandretentionactivities• Iamawareoftheseactivitiesoccurringbutdonotworkonthem• Iproduceorreviewdatawithateam• Ihelpdetermineinterventions• Iparticipateintheinterventions
NationalHIV/AIDSStrategyTargets
• IncreasethepercentageofnewlydiagnosedpersonslinkedtoHIVmedicalcarewithinonemonthoftheirHIVdiagnosisto85%
• IncreasethepercentageofpersonswithdiagnosedHIVwhoareretainedinmedicalcaretoatleast90%
• IncreasethepercentageofpersonswithdiagnosedHIVinfectionwhoarevirallysuppressedtoatleast80%
Source:CDC.HIVSurveillanceReport.SupplementalReport.2017;22(2)
EngagementinCareisDynamic
Powersetal,LongitudinalHIVCareTrajectoriesinNorthCarolinaJAIDS2017;74(S2)
“Consistently High” (26%)
“Steadily Declining” (16%)
“Consistently Low” (26%)
“Early Increasing” (17%)
“Late Increasing” (15%)
WhyisRetentioninCareimportant?
SuccessofHIVTreatment
57% Reduced Risk of Death or Serious Events with Immediate Therapy
INSIGHTSTARTStudyGroup,InitiationofAntiretroviralTherapyinEarlyAsymptomaticHIVInfection.NEJM2015RodgerAetal,SexualActivityWithoutCondomsandRiskofHIVTransmissioninSerodifferentCouplesWhentheHIV-PositivePartnerIsUsingSuppressiveAntiretroviralTherapy2016;316(2):171-181.
ImplicationsofMissedHIVMedicalCareVisits
PLWH initiating outpatient HIV medical care at UAB Clinic, 2000 – 2005 (N=543)
Characteristic HR (95%CI)a “No show” visit in 1st year 2.90 (1.28- 6.56) Age (HR per 10 years) 1.58 (1.12-2.22) CD4 count <200 cells/mL 2.70 (1.00-7.30) Log10 plasma HIV RNA 1.02 (0.75-1.39) ART started in 1st year 0.64 (0.25-1.62)
a Cox proportional hazards (PH) analysis also adjusts for sex, race/ethnicity, insurance, affective mental health disorder, alcohol abuse, and substance abuse.
Missed HIV medical care visits associated with: • Delayed ART initiation
• Poor retention in care
• Longer time to VS
• Greater cumulative VL burden (viremia copy-years)
• Racial disparities in VS
• Declines in CD4 count • Inpatient hospitalization
• Mortality
MugaveroM,etalCID2014;Horberg2013;Colubi,2012 Mugaveroetal.ClinInfectDis2009;48
ImportanceofNo-ShowVisits
No-showvisitsareanindependentpredictorofmortality
MugaveroM,etalCID2014
RetainedincarebyDHHScoreindicator(N=2166)
NotretainedincarebyDHHScoreindicator(N=1506)
Skarbinskietal.JAMAInternMed2015;175
WhoisatriskforpoorRetentioninCare?
AssessingBarrierstoCareandTreatment
AdherenceDemographics
SubstanceUse
MentalHealth
Poverty
Stigma
Forgetting!
MedicationSideEffects
Predictorsforlowerretention
Bulsara,etal;AIDSBehav2016 345studiesreviewed,30included
PersonsLivingwithDiagnosedorUndiagnosedHIVInfection,HIVCareContinuumOutcomes,
2014
Source:CDC.HIVSurveillanceReport.SupplementalReport.2017;22(2)
AudiencePoll2• 22year-oldmantestsHIV+atahealthfairboothhostedbyalocalAIDSServiceorganization
• Hehasnoinsuranceorprimarycaredoctor
• Assuminghelinkstomedicalcarethroughstandardproceduresinyourarea,howmanypeoplewillhebeaskedtotalkwithbeforehemeetshisHIVmedicalprovider?
1. One
2. Two
3. Threeormore
4. Dependsonwhereheisdiagnosed
5. Idon’tknow
ModelsofLinkagetoCare48hoursto≥6weeks
+HIVTest
+HIVTest
+HIVTest
PartnerServicesInterview
LinkageAssistance& PartnerServices
Interview
MedicalVisit EligibilityAssessment
LinkageAssistance
MedicalVisit
CaseManagementIntake
CENTRALELIGIBILITY
LinkageAssistance
PartnerServicesInterview
MedicalVisit EligibilityAssessment
+/-Casemanagement
intake
Wecannotconcludethatpatients“aren’tready”toengageinHIVcareiftheprocesstogetcareistoocomplicated
SlidecourtesyJulieDombrowskiMD
AudiencePoll3
▪ Whatisthewaittimeforanewpatientappointmentinyourclinic?
• (or,ifyoudonotworkinaclinic,fortheaverageclinicinyourarea)
1. <1week2. 1-2weeks3. 2-4weeks4. >4weeks
TheValueofNewPatientOrientation:ProjectCONNECT
• Within5daysofcallingtoschedulefirstappointment
• Questionnaire• Baselinelabtesting• Socialworker• Prophylacticmeds
• Mentalhealthandsubstanceabusereferrals
• Clinicnoshowrate31%→16%
Sources:MugaveroMJ,etal.TopHIVMed.2008;16:156-61; UABwebsite:http://www.uab.edu/medicine/1917clinic/becoming-a-new-patient
SanFranciscoRAPID:SameDayARTInitiation
PilcherC,etal;JAIDS,2017;74,2RosenS,etal.PLoSMed2016;13(5),3KoenigS,etal.PLoSMed2017;14(7)
TimefromHIVDxto:
SOC(n=47)
RAPID(n=39)
ART 22(14-48) 1(0-7) Clinicreferral 11(3-4) 6(2-11) VL<200c/mL 170(79-363) 65(52-119)
Prospectivecohort(consecutiveptswithnewHIVdiagnosis,2013-2014). Same-dayARTinitiationcohort:ptswithacuteorrecentinfection(<6months)orCD4<200cells/mm3. GlobalrapidARTstarttrials: RapITRCT(n=377,SouthAfrica):RR1.36(95%CI:1.24,1.49)forART,1.26(1.05,1.50)forVSw/rapidARTinitiation2 GHESKIOCentersRCT(n=703,Haiti):improved12-moincarew/VS(53%vs44%,p=0.008)andmortality(3%vs6%,p=0.03)insamedayARTgroup3
AtlantaRapidEntryandARTClinicforHIV(REACH)pilotprogram
DaysfromHIVDxto:
Pre-Reach(n=117)
Post-Reach(n=90)
p
ART 22(13,38) 4(1,6) <0.0001 Clinicreferral 12(6,23) 2(1,4) <0.0001
VL<200c/mL 67(34,126) 41(21,72) <0.0001
Adjustedforage,race,gender,andARTnaive
Colasantietal.CROIMarch2018.Poster#1109
SuggestionstoImproveLinkagetoCare
1. Eligibilitydeterminationshouldbeintegratedintoclinicswhereverpossible
2. Allowpatientstoaccesscasemanagersbeforemedicalproviderstoaddressbarrierstoattendingclinic
3. Implementanorientationvisitifmedicalprovidernotavailableinshorttime(5-7days)
4. ConsiderationforaSameDay/RapidStartARTprogram
5. Set-upaformalsystemtoaddressnewpatientno-shows-Differentthanroutinereschedulingoradministrativecall-Seekoutandengagethepatient
AudiencePoll4• Your22yolinkedtolocalRWclinicandobtainedaprescriptionforARTthroughADAP
• Hehasbeendepressedsincehisdiagnosisandhasnotdisclosedtoanyone,norisheouttohisfamily
• Heoccasionallyusescrystalmethbut‘onlywhenhewantstohaveagoodtime’ontheweekends
• HedoesnotanticipateanybarrierstotakinghisART.Hehasnevertakenmedicationsregularlypriortothis.
Whatservicescouldhebelinkedtoinyourareathatcouldsupporthisadherencetocareandtreatment? 1. Casemanagement 2. Mentalhealthcounseling 3. Patientnavigators
4. Substanceuseprograms
5. LGBTQfriendlyclinic
6. Someoftheabove
7. Alloftheabove
8. Idon’tknow
9. Hedoesn’tneedanyservices
Addressingbarrierstoretention
• Substanceuse:AA/NA,MAT,casemanagement
• Demographics:youth,LGBTQ,andPOC-friendlyaccess
• Physicalhealth:treatHCV,pain,comorbidities
• MentalHealth:integratebehavioralhealth
• Support:navigateinsurance,transport,childcare
• Healthbeliefs:addressstigmaandbias,cultivateempathy,trauma-informedandstrengths-basedcare,ARTAS,MotivationalInterviewing
Low-Effort,Clinic-WideInterventiontoImproveAttendancewithHIVPrimaryCare
• SixHIV-specialtyclinicsparticipatedinacross-sectionallysampledpretest-posttestevaluationofbrochures,posters,andmessagesthatconveyedtheimportanceofregularclinicattendance
• Clinicattendanceforprimarycarewassignificantlyhigherintheinterventionversuspreintervention
Gardneretal.CID2012
We have good evidence that people with HIV who come to their appointments do better than those who don’t. When you miss your appointments, we can’t work together to keep you healthy. Thank you for doing such a good job of keeping your appointments. It makes it easier for all of us to work together to keep you healthy.
Sample Messages:SampleMessages:
“WehavegoodevidencethatpeoplewithHIVwhocometotheirappointmentsdobetterthanthosewhodon’t.When youmissyourappointments,wecan’tworktogethertokeepyouhealthy.”
“Thankyoufordoingsuchagoodjobofkeepingyourappointments.Itmakesiteasierforallofustoworktogethertokeepyouhealthy.”
CDC/HRSAREPCEfficaciousforHIVCareEngagement
GardnerLIetal.ClinInfectDis2014;59;ShresthaRKetal.JAIDS2015;68 SlidecourtesyMichaelMugavero
• RCTat6HIVclinics
• N=1838
• 3studyarms(1:1:1) *EnhancedContact(EC) *EC+skills(EC+) *SOC
• Outcomes@12-months: *Visitadherence
*4-monthvisitconstancy
• EC&EC+superiortoSOC
• Efficacyinsubgroups
• Notefficaciouswithyouth,substanceuse,unmetneeds
ProjectHOPETrial–RCTin11Hospitals
Metschetal,JAMA2016
HIV+adultsadmittedtothehospital • VL>200&CD4<500
• Substanceuse
Navigationintervention
Navigationintervention+
Financialincentives
Treatmentasusual
EffectofPatientNavigation+/-FinancialIncentivesonViralSuppressionamongHospitalizedPatientswithHIV&SubstanceUse
ProjectHopeRCT
p=0.30
p=0.03
p=0.81
p=0.70
MetschLR,etal,JAMA2016
%ofp
articipantswith
VL<200
OpenArmsCenterinJackson,MS
Source:CourtneySims(UMMC)
SuggestionstoImproveRetentiontoCare• Ongoingassessmentsofbarrierstocare
• Systematicidentificationofthoseathighestriskofdisengagement–missedvisits
• Integrationofmentalhealth,substanceuse,navigationandsupportservicesintoclinicalcare
TheProvider’sRoleinRetentioninCare
• Ongoingassessmentofpotentialbarrierstocare
• “Whatcanwedotomakethiseasierorbetterforyou?”
• Connectiontoservicesforcurrentoranticipatedbarriers.
• PositiveMessagingforstayingconnected
• InquireaboutbarriersMakeaconcreteplantoaddressthebarriers
RelinkagetoCare:BeyondtheClinic
AudiencePoll5
• Yourpatientattended2visitsintheyearafterhisdiagnosisbuthasnowmissedallofhisscheduledandrescheduledvisitsforthepast12months
• Hisphonenumberisdisconnectedandnoalternativecontactsarelisted
• Whatdoyoudonow?
1. Keepcalling,maybehejustranoutofminutes
2. Mailacertifiedletter
3. Seeifyoucanstalkhimonsocialmedia
4. Somepeoplejustaren’treadyforcare
5. OutreachfromCommunityBasedOrganizations
6. HealthDepartmentprograms?
7. Someoftheabove
8. Alloftheabove
DatatoCare
• LaboratoriesreportCD4&VLresultstothehealthdepartmentinmostU.S.states
• HealthdepartmentscanuseHIVsurveillancedatatomonitorthecontinuum&todirectinterventionstoimprovethecontinuum
• CDCnowencouragesallhealthdepartmentstoimplementa“DatatoCare”strategy
• Usessurveillancedatatoidentify&re-engageout-of-carePLWH
• Mayormaynotinvolvecoordinationwithmedicalproviders
Effectiveinterventions.org
ExamplesofDatatoCarePrograms
HealthDepartment
HIVClinic Patient
HealthDepartment HIVClinic
Check-in
Datain
Databack
Patient
HealthDepartment Patient
1.
2.
3.
Withmostcurrentrelinkagetocareefforts,weareworkingtoreturnpatientsbacktothesamesystemthatfailedtoengagetheminthefirstplace.
Forthehardest-to-reachpatients,canwechangethestructureofcareweoffer?
TheMaxClinic:MedicalCareDesignedtoEngagetheHardest-to-ReachPersonsLiving
withHIVinSeattleandKingCounty,Washington
Dombrowskietal.AIDSPatientCareandSTDs.2018Apr;32(4):149-156.
Identification of Potential MAX Patients
Case Coordinators [Disease Intervention Specialists (DIS)] • Intensive support & outreach • Single point of contact for patients & providers • Calls, text messages • Meet patients in hospital, clinic, home, or jail
• Walk-in medical care, 5 afternoons per week (in STD Clinic) • Snacks and meal vouchers (each visit, up to once weekly) • Cell phones and bus passes (contingent renewal) • Cash incentives (q2 months)
• $25 for visit + lab draw • $100 for suppressed VL & 1x bonus for 3 in a row ($100)
Enrollment of Patients in MAX Clinic
Dombrowskietal.AIDSPatientCareandSTDs.2018Apr;32(4):149-156.
SuggestionstoImproveRe-linkagetoCare• Designateastaffpersontore-engagepatientsincare
• Systematicallyidentifypoorlyengagedpatients• Calltocheckin,scheduleappointment,coordinatewithCM
• Takereferralsfromproviders&CMforoutreach
• Ifyourclinichascapacity,considersettingupspecialproceduresforthehardest-to-reachpatients
• Walk-incare• Intensivecasemanagementandoutreachsupport• ConsideropportunitiestoworkwithHD
TheProvider’sRoleinRelinkagetoCare
• Assessthepatient’sperceptionofthetime“outofcare”
• Inquireaboutbarriers(withattentiontohealthcaresystembarriers)
• “Whatcanwedotomakethiseasierorbetterforyou?”
• Makeaconcreteplantoaddressthebarriers
• ConsiderationforrestartingARTiskey
• Don’tcreatetoohighathreshold
UnansweredQuestions&AreasforFutureWork• Roleoflong-actinginjectableantiretrovirals
• Effectivenessoftargetedincentives
• Roleofcommunityhealthworkers
• Novelservicedeliverymodels
CouldLAARThavearoleinaddressingsomeofthesebarriers?
• Directly-ObservedTherapy• Intolerantoforalmedications• CompetingResponsibilities• Stigma
• AtthebeginningIthought…OhmyGod…IhopeIgetoverthisdepression.But,myGod…IhopeIwon’tbetakingthesepillsallmylife.ThenIwentontotheinjectablephase…anditwaslikeIsawthelight.AndIsaid,God…howeasyandconvenientthisis.Itwaslikeseeingthelight.-Spain,Maletrialparticipant
• IloveitbecauseIdon'thavetotakeadailymedication,sothat'sjustonelessthingonmyplatethatIhavetoworryabout…Idefinitelyfeelthere'slesspressure.Iliketheinjectionbecauseit'snotadaily,inmyface,Ihavetodothis.–U.S.,Femaletrialparticipant-
• Inreality,takingthepilleverydaykeepsit[HIV]present…andtheshotisjustonceamonth…yourememberitwhenyoucomeinandtherestofthetimeyoucanbasicallyforgetit.–Spain,Maletrialparticipant
KerriganDetal.ExperienceswithLAART:AqualitativestudyamongPLHIVparticipatinginLatte-2intheUSandSpain.PLOSOne.2018.
ACTG5359APhaseIIIRandomized-ControlTrialtoEvaluate
Long-ActingAntiretroviralTherapyinNon-adherentHIV-InfectedIndividuals
Co-Chairs:AadiaRana,JoseCastillo-MancillaCo-ViceChairs:RaphaelJ.Landovitz,KarenTashima Investigators: OmarGalárraga(BehavioralEconomist),MichaelStirratt(NIMH),SteveShoptaw(NIDA),DavidWohl
• ART-experienced,HIV-infectedmalesandnon-pregnantfemales≥18yearsofagewith:• HIV-1RNA>200copies/mL • Evidenceofnon-adherenceaccordingtoatleastoneofthefollowingcriteria:
• Poorvirologicresponsewithin18monthspriortostudyentry(definedas<1log10decreaseinHIV-1RNAorHIV-1RNA>200copies/mLattwotimepointsatleast4weeksapart)inindividualswhohavebeenprescribedARTforatleast6consecutivemonths.
• Losstoclinicalfollow-upwithin18monthspriortostudyentrywithARTnon-adherencefor≥6consecutivemonths.Losttoclinicalfollow-upisdefinedaseithernocontactwithproviderormissed2ormoreappointmentsina6-monthperiod.ARTnon-adherenceisdefinedasalapseinART≥7days(consecutiveornon-consecutive),inthe6-monthperiodwheretheywerelosttoclinicalfollow-upperparticipantreport.
• NoevidenceofanyclinicallyrelevantRPVorINSTIresistance-associatedmutations(historicallyoruponscreening).
• Abilityofsiteclinician,inconjunctionwithparticipant,toconstructa≥3-drugARTregimenwith≥2drugspredictedtobefullyactive,includingaboostedPI/cobiand/oranINSTI.
DataforCareAlabama(D4CAL)7RyanWhiteClinicsinAlabama
|7daysprior|1-3daysprior|Atmedicalvisit|MedicalvisitMISSED|
StayConnected
EPC:LRC*
1-2MissedVisits(MediumRisk)
EPC:FrontDeskorLRC*forinitialvisits
EPCwithin2daysbyLRC*+Healthcareteam
|7daysprior|1-3daysprior|Atmedicalvisit|MedicalvisitMISSED|
EPC:FrontDeskorLRC*forinitialvisits
≥3MissedVisits(HighRisk)
EPC:LRC*;SocialWorkerforpatientsonICM**
StayConnected
EPCwithin2daysbyLRC*+Healthcareteam
*LRC=Linkage&RetentionCoordinator **IntensiveCaseManagement
KeyTakeaways
• NHASgoalby2020=85%linkedtocarewithin1month
• RyanWhiteeligibilitydeterminationshouldbeintegratedintoclinicswhereverpossible
• Orientationvisitswithlabscanhelpfacilitatelinkagetocare• ConsiderationforRapidStart/SameDayStartprogram
• Assessingandaddressingrisksforpoorretentionincareshouldbeongoingandintegratedintoclinicalcare.
• Collaborationbetweenclinicsandhealthdepartmentscanwork
• Implementsystematicretentionandre-engagementprocedures
• Considernovelservicedeliveryforthehardest-to-reachpatients
Resources▪ Bulsara,etal;AIDSBehav2016▪ CDC.Compendiumofevidence-basedinterventionsandbestpracticesforHIVprevention.Centersfor
DiseaseControlandPrevention.http://www.cdc.gov/hiv/research/interventionresearch/compendium/index.html.
▪ CDC.HIVSurveillanceReport.SupplementalReport.2017;22(2)▪ Colasantietal.CROIMarch2018.Poster#1109▪ Dombrowskietal.AIDSPatientCareandSTDs.2018Apr;32(4):149-156.▪ Effectiveinterventions.org▪ Gardneretal.CID2012▪ GardnerLIetal.ClinInfectDis2014;59;ShresthaRKetal.JAIDS2015;68▪ INSIGHTSTARTStudyGroup,InitiationofAntiretroviralTherapyinEarlyAsymptomaticHIVInfection.
NEJM2015373(9):795-807▪ KoenigS,etal.PLoSMed2017;14(7)▪ Metschetal,JAMA2016▪ Mugaveroetal.ClinInfectDis2009;48▪ MugaveroM,etalCID2014;Horberg2013;Colubi,2012▪ MugaveroMJ,etal.TopHIVMed.2008;16:156-61;▪ PilcherC,etal;JAIDS,2017;74▪ Powersetal,LongitudinalHIVCareTrajectoriesinNorthCarolinaJAIDS2017;74(S2)▪ RodgerAetal,SexualActivityWithoutCondomsandRiskofHIVTransmissioninSerodifferentCouples
WhentheHIV-PositivePartnerIsUsingSuppressiveAntiretroviralTherapy2016;316(2):171-181.▪ RosenS,etal.PLoSMed2016;13(5)▪ Skarbinskietal.JAMAInternMed2015;175