Improving Engagement in HIV Care: What Can We Do?

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Improving Engagement in HIV Care What Can We Do?
Michael J. Mugavero, MD, MHSc Assistant Professor
of Medicine University of Alabama at Birmingham
The International AIDS SocietyUSA
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Outline

• Conceptual framework
• Linkage to Care
• Retention in Care
• Summary

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Blueprint for HIV Treatment Success
Retention in Care
ARV Receipt
Outcomes
HIV Dx
Linkage to Care
ARV Adherence
Ulett et al. AIDS Pt Care STDS (in press).
Adapted from Giordano et al. Curr HIV/AIDS Rep
20052177-183, Samet et al. AIDS 20011577-85
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Blueprint at a Population Level
Retention in Care
ARV Receipt
Outcomes
HIV Dx
Linkage to Care
ARV Adherence
Glynn Rhodes. National HIV Prevention
Conference 2005, Abstract 595, Gardner et al.
AIDS 200519423-431, Mugavero et al. Clin
Infect Dis 200745127-130, Gay et al. AIDS
200620775-78, Mugavero et al. Am J Med
2007120370-373, Fleming et al. 9th CROI 2002,
abstract 11
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HRSA Continuum of Engagement
Not in Care
Fully engaged
Cheever. Clin Infect Dis 2007441500-1502
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• Contextual factors
• Rural vs. Urban
• Neighborhood

• Predisposing
• Age
• Race / ethnicity
• Sex
• Mental illness
• Substance abuse
• Stigma
• Self efficacy

• Clinic factors
• Clinic distance
• Appointments
• Waiting time

Linkage to Care Retention in Care ARV
Receipt Adherence

• Outcomes
• HRQOL
• CD4
• Viral load
• OIs
• Death

• Enabling
• Insurance status
• Transportation
• Housing
• Social support

• System factors
• MH services
• SA services
• SW / Case
• management

• Perceived Need
• Symptoms
• Health beliefs

• Provider factors
• Trust
• Experience

Environment Pt. characteristics
Behavior Outcomes
Ulett et al. AIDS Pt Care STDS (in press).
Adapted from Andersen RM. J Health Soc Behav
1995361-10
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Implications of Engagement

• Individual Level
• ART receipt adherence
• Immunologic and virologic outcomes
• Survival
• Population Level
• Mediator of disparities
• Role in transmission
• Changes in risk behaviors
• Impact of ART

Keruly et al. AJPH 200292852-857, Robbins et.
al. JAIDS 20074430-37, Park et al. J Intern Med
2007261268-275, Giordano et al. CID
2007441493-1499, Marks et al. AIDS
2006201447-1450, Metsch et al. Clin Infect Dis
200847577-584, Quinn et al. N Engl J Med
2000342921-9, Cohen at al. Ann Intern Med
2007146591-601
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Blueprint for HIV Treatment Success
Retention in Care
ARV Receipt
Outcomes
HIV Dx
Linkage to Care
ARV Adherence
Ulett et al. AIDS Pt Care STDS (in press).
Adapted from Giordano et al. Curr HIV/AIDS Rep
20052177-183, Samet et al. AIDS 20011577-85
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Linkage to Care

• Revised CDC HIV testing recommendations advocate
  routine opt-out HIV testing
• An estimated 25-50 increase in patients in need
  of outpatient HIV care anticipated in response to
  implementation
• CDC guidelines highlight the importance of
  linkage to medical services

CDC. MMWR 200655(RR14)1-17, Mugavero Saag.
MedGenMed. 2007958
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Linkage to Care

• Newly diagnosed patients frequently delay or fail
  to establish outpatient HIV care
• CDC ARTAS Multi-site RCT to test a case
  management (CM) intervention to improve linkage
  to care
• Empowerment self efficacy
• Asks clients to identify internal strengths
  assets
• Up to 5 CM contacts allowed in 90 days

Samet et al. AIDS 20011577-85, del Rio et al.
8th CROI 2001 AbstractS21, Gardner et al. AIDS
200519423-431
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CDC ARTAS

• 1o HIV provider visit attended w/in 6 mo. in 78
  CM arm vs. 60 SOC (Plt0.01)
• Second visit w/in first 12 months in 64 CM arm
  vs. 49 SOC arm (Plt0.01)
• Cost 599 per client, 3,993 per additional
  client linked to care beyond SOC
• Intervention is efficacious, but additional steps
  needed to improve linkage to HIV care

Gardner et al. AIDS 200519423-431
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Linkage to Care UAB 1917 Clinic

• Problem identified Scheduled new patient
  appointments often not attended (no show)
• Study of patients calling to establish HIV care
  at UAB 1917 Clinic, 2004-2006
• 31 of patients (160 of 522) failed to attend a
  clinic visit within 6 mos. of initial call

Mugavero et al. Clin Infect Dis 200745127-130
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No Show Phenomenon
Data presented as mean SD or n (column )
Age
OR per 10 years, Days from call OR per 10 days
Mugavero et al. Clin Infect Dis 200745127-130
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Project CONNECT
Client- Oriented New Patient Navigation
to Encourage Connection to Treatment
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Project CONNECT

• Program launched January 1, 2007
• New patients have orientation visit within 5 days
  of their initial call to the clinic
• Semi-structured interview, psychosocial
  questionnaire baseline labs
• Uninsured patients meet with clinic SW
• Prophylactic antibiotics initiated more quickly
• Expedited referral for SA / MH services

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CONNECT Questionnaire
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Project CONNECT

• Program evaluation 2007 calendar year
• 82 of pts attended orientation visit (299 / 364)
• 81 of pts attended 1o HIV provider visit (296 /
  364)
• Drop in no show from 31 ? 19 (Plt0.01)
• Cost 200 per client, 1,628 per additional
  client linked to care beyond SOC
• Reimbursement through RW Part B

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Blueprint for HIV Treatment Success
Retention in Care
ARV Receipt
Outcomes
HIV Dx
Linkage to Care
ARV Adherence
Ulett et al. AIDS Pt Care STDS (in press).
Adapted from Giordano et al. Curr HIV/AIDS Rep
20052177-183, Samet et al. AIDS 20011577-85
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Retention in Care

• After establishing outpatient HIV care, missed
  visits are common
• Associated with delayed ARV receipt, emergence of
  ARV resistance, and virologic failure
• Relationship between missed visits (no show)
  and mortality after linkage to care unknown
• Study of 543 UAB 1917 Clinic patients initiating
  outpatient HIV care, 2000 2005

Ulett et al. AIDS Pt Care STDS (in press).
Giordano et al. JAIDS 200332399-405, Lucas et
al. Ann Intern Med 199913181-87, Sethi et al.
Clin Infect Dis 2003371112-1118, Robbins et al.
JAIDS 20074430-37, Mugavero et al. 3rd
International Conference on HIV Treatment
Adherence 2008 Abstract 70
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Missed Visit ? Mortality

• Missed visits in the first year following initial
  linkage to outpatient HIV care are common
• Observed in 60 of patients!
• More common in younger patients, African
  Americans, and patients with public insurance
• Missed visits in the first year of HIV care
  associated with long-term mortality
• 2.3 per 100 patient-years f/u for missed visit
• 1.0 per 100 patient-years f/u for no missed
  visit

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Retention in Care Methodology
Patient A
Patient B
Patient C
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Expanding the Spectrum of Adherence
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Expanding the Spectrum of Adherence
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Appt. Non-Adherence ? VF (gt50c/mL)
Mugavero et al. 29th Society of Behavioral
Medicine 2008 Symposium
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Retention A Challenge to Survival

• Study of US Veterans with HIV starting ART
• Identified relationship b/t number of quarters
  with arrived visit in first year (persistence)
  and
• 1-Year CD4 outcomes
• 1-Year plasma HIV RNA outcomes
• ARV adherence
• Long-term survival

Giordano et al. CID 2007441493-1499, CheeverCID
2007441500-1502
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Retention A Challenge to Survival
Giordano et al. CID 2007441493-1499
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Retention in Care Intervention

• HRSA Ancillary Service Use Studies
• Case management
• Transportation
• Housing
• Substance abuse services
• Mental health services
• HRSA SPNS Outreach Initiative
• CDC / HRSA Retention in Care RCT underway

AIDS Care 200214Supplement 1, AIDS Pt Care
STDS 2007 Supplement
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Summary

• Linkage to care and retention in care are
  distinct processes
• Engagement in care is vital for HIV treatment
  success at individual population level
• Early missed visits may identify patients at risk
  for poor health outcomes
• Engagement worse in groups bearing a
  disproportionate burden of US HIV epidemic
• Critical role of ancillary services in improving
  linkage and retention in care

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What Can We Do?

• Partner with local RW, HDs, CBOs, EDs, in
  implementing HIV testing linked with ARTAS
• Evaluate no show phenomenon in your clinic
  consider revising new patient orientation
• Implement routine screening for barriers to
  engagement in care
• Strengthen MH, SA, SW / CM programs
• Develop partnerships to implement / strengthen
  outreach / peer navigation programs

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Thanks

• UAB
• 1917 Clinic Patients
• 1917 Clinic Staff
• Michael Saag
• James Raper
• James Willig
• Jeroan Allison
• Hui-Yi Lin
• Pei-Wen Chang
• Malcolm Marler
• 1917 Clinic Cohort Team

• Baylor
• Thomas Giordano
• UNC Chapel Hill
• Stephen Cole

Support UAB 1917 Clinic Cohort UAB CFAR
(P30-AI27767), CNICS (R24-AI067039), and the Mary
Fisher CARE Fund MJM K23MH082641 from the NIMH
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Thanks
www.uab1917cliniccohort.org