Engagement and Retention in HIV Care: A Work in Progress

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1 Engagement and Retention in HIV Care: A Work in Progress Kenneth Mayer, MD Fenway Health Beth Israel Deaconess Medical Center Harvard Medical School ACTHIV May 12 th, 2012

2 Learning Objectives Upon completion of this presentation, learners should be better able to: Be familiar with the relevant epidemiology of HIV in the US, including: knowing which patients engage, or are less likely to engage, in care, and who are retained in care Incorporate techniques in your practice which have been shown to encourage HIV testing, linkage to care, engagement, and retention

3 Faculty and Planning Committee Disclosures Please consult your program book. Off-Label Disclosure There will be no off-label/investigational uses discussed in this presentation.

5 What is your current practice regarding HAART initiation? 1. I discuss HAART with all my new patients in the first visit in order to increase rapid uptake 2. I wait to discuss HAART until I feel we have a rapport, but then try to get them to start, independent of CD4 count 3. I would only discuss HAART if I know the patient s mental health is stable and that substance use will not be barrier to adherence 4. I only start HAART if the CD4 count is less than 500 cells/mm3

7 HIV Care/Prevention Continuum Link ART Eligible el-sadr, CROI 2012

8 The Continuum of HIV Care--US Percentage 80% 77% 66% 89% 77% Engagement in HIV care Of all with HIV infection, 850,000 individuals do not have suppressed HIV RNA (72%) MMWR (60), 2011

9 21% Undiagnosed 31% Not linked 41% Not retained 19% VL<50 c/ml Adapted from: Gardner et al. Clin Infect Dis 2011;52:793, Greenberg et al. Health Affairs 2009;28:1677, Marks et al. AIDS 2010;24:2665

10 HRSA Continuum of Engagement Not in Care Fully engaged Unaware of HIV status Aware of HIV status May be receiving other medical care but not HIV care Entered HIV medical care but dropped out In and out of HIV care or infrequent user Fully engaged in HIV medical care Cheever. Clin Infect Dis 2007;44:1500, Eldred & malitz AIDS Pt Care STDS 2007;21:S1

Adapted from: Ulett et al. AIDS Pt Care STDS 2009;23:41-49 and Mugavero. Top HIV Med 2008;16:156-61.

11 Adapted from: Ulett et al. AIDS Pt Care STDS 2009;23:41-49 and Mugavero. Top HIV Med 2008;16: Based upon behavioral Model of Health Services Utilization: Andersen RM. J Health Soc Behav 1995;36:1-10

12 Social Cognitive Model Pleasure reduction Depression, anxiety, mental health problems Disease prevention Self efficacy Safer Sex Adherence Social Models Wulfert, Safren, et al., 1999; Journal of Applied Social Psychology

Early retention in care (Mugavero et al) The first year in outpatient HIV medical care is a dynamic, formative & vulnerable time Poor early retention in care associated with: Delayed / failed

13 Early retention in care (Mugavero et al) The first year in outpatient HIV medical care is a dynamic, formative & vulnerable time Poor early retention in care associated with: Delayed / failed antiretroviral therapy (ART) receipt Delayed time to VL suppression and greater cumulative HIV burden Increased sexual risk transmission behaviors Increased risk of clinical events & mortality Worse ART adherence, CD4 & VL response and increased long-term mortality following ART start Ulett et al. AIDS Pt Care STDS 2009;23, Giordano et al. JAIDS 2003;32, Metsch et al. Clin Infect Dis 2008;47, Mugavero et al. Clin Infect Dis 2009;48, Tripathi et al. AIDS Res Hum Retrovirus 2011;e-pub, Giordano et al. Clin Infect Dis 2007;44

14 What types of supports do you have to help manage your HIV-infected patients? 1. Medical Social Worker/Case Manager 2. Peer Health System Navigator 3. Psychologist/Psychiatrist or other MH professional 4. Two or three of the above 5. None of the above

15 HRSA SPNS Outreach Initiative Study sites: Community based organizations = 7 Community based health centers = 2 Hospital based clinic = 1 Heterogeneous approaches & samples: Behavioral interventions Intensive case management Health literacy and life skills Outreach in provision of medical services Supportive services included in 8 of 10 programs Tobias et al. AIDS Pt Care STDS 2007;21:S3, Rajabuin et al. AIDS Pt Care STDS 2007;21:S9

16 HRSA SPNS Outreach Initiative Barriers to HIV care can be reduced or removed with sufficient resources Coaching, skill-building, knowledge gains, respectful trusting relationships b/t client and outreach worker facilitate HIV care utilization Additional resources and system changes needed for most disadvantaged persons Outreach interventions can be implemented to comply with research standards Bradford. AIDS Pt Care STDS 2007;21:S85

17 HIV System Navigation Patient navigation shares features w/ advocacy, health education & case management Distinctive features: Concerned with individuals vs. system as a whole Less pro-active in addressing knowledge gaps Use principles of CM but don t have a home agency Usually do not have nursing or SW degrees, although apply strengths-based principles Navigators often peers or near-peers with shared cultural background Bradford. AIDS Pt Care STDS 2007;21:S49

18 HIV System Navigation Bradford. AIDS Pt Care STDS 2007;21:S49

19 Linkage to Care: CDC ARTAS 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 ARTAS II effectiveness study at health departments & CBOs with similar effect size Gardner et al. AIDS 2005;19, Craw et al. J Acquir Immune Defic Syndr 2008;47

20 Linkage to Care: CDC ARTAS Outcome: 1 o HIV provider visit attended w/in: Case Management Standard of Care P-value 6 months 78% 60% < months 64% 49% <0.01 Intervention is efficacious, but additional steps needed to promote linkage to care Gardner et al. AIDS 2005;19

21 No Show Phenomenon Characteristic Show Group (n=362, 69%) No Show Group (n=160, 31%) OR (95%CI) for No Show Age (years) ( ) White male Minority male White female Minority female 125 (80%) 154 (67%) 31 (61%) 52 (62%) 32 (20%) 76 (33%) 20 (39%) 32 (38%) 1.0 (Reference) 1.75 ( ) 2.72 ( ) 2.39 ( ) Private insurance Public insurance Uninsured 127 (83%) 77 (69%) 158 (61%) 26 (17%) 34 (31%) 100 (39%) 1.0 (Reference) 1.91 ( ) 2.62 ( ) Days from call to appointment ( ) Data presented as mean + SD or n (row %) Age OR per 10 years, Days from call OR per 10 days Mugavero et al. Clin Infect Dis 2007;45:

22 Project CONNECT Client- Oriented New Patient Navigation to Encourage Connection to Treatment New Challenges Emerge Make a plan Empower Others to Join You Identify a Need Name It Celebrate

23 Project CONNECT (UAB) Program launched January 1, 2007 New patients have orientation visit within 5 days of their initial call to the clinic Coordinated by SW services: replaced intake visit conducted on date of 1 st medical visit Semi-structured interview, psychosocial questionnaire & baseline labs Prophylactic antibiotics initiated more quickly Expedited referral for SA / MH services

24 Mugavero, IAPAC-NIMH, 2011

25 CONNECT: Program evaluation Time Period No Show Unadjusted OR (95%CI) Pre-CONNECT (n=522) 30.7% 1.0 Adjusted OR (95%CI) a 1.0 Post-CONNECT (n=361) 17.7% 0.48 ( ) 0.54 ( ) a Multivariable model controls for age, race, sex, insurance, location of residence and time from call to scheduled visit.

26 What do we know about Engagement in Care? Medical Monitoring Project (MMP) (Skarbinksi, CROI 2012) Supplemental surveillance system Created in response to 2004 Institute of Medicine report Need for population-based, nationally representative data on HIV-infected persons in care 17 states and territories 76% of all PLHIV Estimate 421K in care

27 Who is Prescribed ART and Who Achieves Viral Suppression (MMP)? Characteristic Age in years Prescribed ART % (95% CI) Virally suppressed % (95% CI) (64-80)* 56 (49-62)* (82-89)* 62 (57-67)* (88-92) 72 (67-76)* (91-94) 79 (77-82) Gender Male 90 (88-92) 74 (70-77) Female 86 (83-89) 66 (62-70) Transgender 94 (88-100) 68 (53-83) Total 89 (87-91) 72 (68-75) Population total 373, ,626 * P value <0.05

28 Who is Prescribed ART and Who Achieves Viral Suppression (MMP)? Characteristic Race/ethnicity Prescribed ART % (95% CI) Virally suppressed % (95% CI) Non-Hispanic White 92 (90-94) 80 (76-83) Non-Hispanic Black 86 (83-88)* 64 (60-68)* Hispanic 89 (86-92) 74 (71-78) Other 87 (81-94) 69 (63-76) Sexual risk behavior MSM 89 (87-91) 76 (72-79) MSW 91 (88-93) 70 (66-75) WSM 86 (83-89) 66 (62-70)* * P value <0.05

29 Who is Prescribed ART and Who Achieves Viral Suppression (MMP)? Characteristic Education Prescribed ART % (95% CI) Virally suppressed % (95% CI) < High school 90 (88-93) 66 (62-70)* High school 89 (87-91) 69 (65-74) > High school 88 (86-90) 75 (72-79) Household income at or below poverty line Yes 89 (86-91) 67 (64-71)* No 89 (87-91) 77 (74-81) Health insurance Any public 91 (88-93) 71 (68-74) Private only 88 (86-90) 76 (73-80) * P value <0.05

30 SMS Messaging and Adherence Randomized clinical trial of SMS versus Standard of Care Three clinics, 538 patients initiating ART Weekly SMS messaging, with response by patient within 48 hours Follow-up call by nurse if not response received SMS SOC RR (95% CI) P value Adherence (>95%) 168 (62%) 132 (50%) 0.81 ( ) HIV RNA (<400 copies/ml) 156 (57%) 128 (48%) 0.85 ( ) 0.04 Lester et al. Lancet 2010

HPTN 065 (TLC-Plus): Test, Link to Care Plus Treat Study Observational Social Mobilization 16 hospitals Site Randomized 38 Testing sites Financial incentive vs SOC Site Randomized 39 Care sites

31 HPTN 065 (TLC-Plus): Test, Link to Care Plus Treat Study Observational Social Mobilization 16 hospitals Site Randomized 38 Testing sites Financial incentive vs SOC Site Randomized 39 Care sites Financial incentive vs SOC Expanded HIV Testing Linkage to Care Viral Suppression Individual Randomized 660 patients in two communities 1320 patients Prevention for Positives Cross sectional (pre and post) Care providers Provider and Patient Surveys

32 Treatment as Prevention, 2012 Interventions to Increase Testing HIV Negative Risk Assessment PrEP, Adherence Counseling Test HIV Positive Positive Prevention Linkage To Care Address concomitant concerns, e.g. depression, substance use, relationship dynamics Enroll in Care Treat ART Initiation Adherence to ART Maintain Viral Suppression Modified from Decrease in HIV Transmission

33 Thank You Fenway Clinical, Epidemiological and Behavioral Research Teams Fenway Medical Department Steve Safren Wafaa El-Sadr Jacek Skarbinski Michael Mugavero NIAID, NIMH, NIDA, NICHD, CDC, HRSA, Mass DPH, Gilead

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