Impact of an HIV Care Coordination Program on Durable Viral Suppression

Abstract Background Health departments utilize HIV surveillance data to identify people with HIV (PWH) who need re-linkage to HIV care as part of an approach known as Data to Care (D2C.) The most accurate, effective, and efficient method of identifying PWH for re-linkage is unknown. Methods We evaluated referral and care continuum outcomes among PWH identified using 3 D2C referral strategies: health care providers, surveillance, and a combination list derived by matching an electronic medical record registry to HIV surveillance. PWH who were enrolled in the re-linkage intervention received short-term case management for up to 90 days. Relative risks and 95% confidence intervals were calculated to compare proportions of PWH retained and virally suppressed before and after re-linkage. Durable viral suppression was defined as having suppressed viral loads at all viral load measurements in the 12 months after re-linkage. Results After initial investigation, 233 (24%) of 954 referrals were located and enrolled in navigation. Although the numbers of surveillance and provider referrals were similar, 72% of enrolled PWH were identified by providers, 16% by surveillance, and 12% by combination list. Overall, retention and viral suppression improved, although relative increases in retention and viral suppression were only significant among individuals identified by surveillance or providers. Seventy percent of PWH who achieved viral suppression after the intervention remained durably virally suppressed. Conclusions PWH referred by providers were more likely to be located and enrolled in navigation than PWH identified by surveillance or combination lists. Overall, D2C re-linkage efforts improved retention, viral suppression, and durable viral suppression.

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Progress Toward Achieving the UNAIDS 90-90-90 Goals in HIV Care From Diagnosis to Durable Viral Suppression in the Country of Georgia

AIDS Research and Human Retroviruses ◽

10.1089/aid.2016.0103 ◽

2017 ◽

Vol 33 (10) ◽

pp. 999-1003 ◽

Cited By ~ 2

Author(s):

Nikoloz Chkhartishvili ◽

Otar Chokoshvili ◽

Akaki Abutidze ◽

Natia Dvali ◽

Carlos del Rio ◽

...

Keyword(s):

Viral Suppression ◽

Hiv Care ◽

Country Of Georgia ◽

Durable Viral Suppression

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Despite Early Medicaid Expansion, Decreased Durable Virologic Suppression Among Publicly Insured People with HIV in Washington, DC

10.21203/rs.2.10459/v2 ◽

2020 ◽

Author(s):

Deborah Goldstein ◽

David Hardy ◽

Anne Monroe ◽

Qingjiang Hou ◽

Rachel Hart ◽

...

Keyword(s):

Viral Suppression ◽

Hiv Care ◽

Virologic Suppression ◽

Washington Dc ◽

Community Clinics ◽

Logistic Regression Models ◽

Hiv Rna ◽

Durable Viral Suppression ◽

Publicly Insured ◽

Privately Insured

Abstract Background: Despite widely available access to HIV care in Washington, DC, inequities in HIV outcomes persist. We hypothesized that laboratory monitoring and virologic outcomes would not differ significantly based on insurance type. Methods: We compared HIV monitoring with outcomes among people with HIV (PWH) with private (commercial payer) versus public (Medicare, Medicaid) insurance receiving care at community and hospital clinics. The DC Cohort follows over 8,000 PWH from 14 clinics. We included those ≥18 years old enrolled between 2011-2015 with stable insurance. Outcomes included frequency of CD4 count and HIV RNA monitoring (> 2 lab measures/year, >30 days apart) and durable viral suppression (VS; HIV RNA <50 copies/mL at last visit and receiving antiretroviral therapy (ART) for ≥12 months). Multivariable logistic regression models examined impact of demographic and clinical factors. Results: Among 3,908 PWH, 67.9% were publicly-insured and 58.9% attended community clinics. Compared with privately insured participants, a higher proportion of publicly insured participants had the following characteristics: female sex, Black race, heterosexual, unemployed, and attending community clinics. Despite less lab monitoring, privately-insured PWH had greater durable VS than publicly-insured PWH (ART-naïve: private 70.0% vs public 53.1%, p=0.03; ART-experienced: private 80.2% vs public 69.4%, p<0.0001). Privately-insured PWH had greater durable VS than publicly-insured PWH at hospital clinics (AOR=1.59, 95% CI: 1.20, 2.12; p=0.001). Conclusions: Paradoxical differences between HIV monitoring and durable VS exist among publicly and privately-insured PWH in Washington, DC. Programs serving PWH must improve efforts to address barriers creating inequity in HIV outcomes.

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Social determinants of health and care outcomes among people living with HIV in the United States

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab330 ◽

2021 ◽

Author(s):

Timothy W Menza ◽

Lindsay K Hixson ◽

Lauren Lipira ◽

Linda Drach

Keyword(s):

United States ◽

Social Determinants ◽

Viral Suppression ◽

The United States ◽

Hiv Care ◽

Economic Disadvantage ◽

People Living With Hiv ◽

Care Outcomes ◽

Durable Viral Suppression ◽

Living With Hiv

Abstract Background Fewer than 70% of people living with HIV (PLHIV) in the United States have achieved durable viral suppression. To end the HIV epidemic in the United States, clinicians, researchers, and public health practitioners must devise ways to remove barriers to effective HIV treatment. To identify PLHIV who experience challenges to accessing healthcare, we created a simple assessment of social determinants of health (SDOH) among PLHIV and examined the impact of cumulative social and economic disadvantage on key HIV care outcomes. Methods We used data from the 2015-2019 Medical Monitoring Project, a yearly cross-sectional survey of PLHIV in the United States (N=15,964). We created a ten-item index of SDOH and assessed differences in HIV care outcomes of missed medical appointments, medication adherence, and durable viral suppression by SDOH using this index using prevalence ratios with predicted marginal means. Results Eighty-three percent of PLHIV reported at least one SDOH indicator. Compared to PLHIV who experienced none of the SDOH indicators, people who experienced one, two, three, and four or more SDOH indicators, were 1.6, 2.1, 2.6 and 3.6 as likely to miss a medical appointment in the prior year; 11%, 17%, 20% and 31% less likely to report excellent adherence in the prior 30 days; and, 2%, 4%, 10% and 20% less likely to achieve durable viral suppression in the prior year, respectively. Conclusions Among PLHIV, cumulative exposure to social and economic disadvantage impacts care outcomes in a dose-dependent fashion. A simple index may identify PLHIV experiencing barriers to HIV care, adherence, and durable viral suppression in need of critical supportive services.

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STEPS to Care: Translating an Evidence-Informed HIV Care Coordination Program Into a Field-Tested Online Practice Improvement Toolkit

AIDS Education and Prevention ◽

10.1521/aeap.2020.32.4.296 ◽

2020 ◽

Vol 32 (4) ◽

pp. 296-310

Author(s):

Lydia O'Donnell ◽

Mary K. Irvine ◽

Aisha L. Wilkes ◽

Julie Rwan ◽

Athi Myint-U ◽

...

Keyword(s):

New York ◽

Care Coordination ◽

Viral Suppression ◽

Lessons Learned ◽

Hiv Care ◽

Coordinated Care ◽

Team Coordination ◽

Practice Improvement ◽

Ryan White ◽

Wide Scale

Increasing care engagement is essential to meet HIV prevention goals and achieve viral suppression. It is difficult, however, for agencies to establish the systems and practice improvements required to ensure coordinated care, especially for clients with complex health needs. We describe the theory-driven, field-informed transfer process used to translate key components of the evidence-informed Ryan White Part A New York City Care Coordination Program into an online practice improvement toolkit, STEPS to Care (StC), with the potential to support broader dissemination. Informed by analyses of qualitative and quantitative data collected from eight agencies, we describe our four phases: (1) review of StC strategies and key elements, (2) translation into a three-part toolkit: Care Team Coordination, Patient Navigation, and HIV Self-Management, (3) pilot testing, and (4) toolkit refinement for national dissemination. Lessons learned can guide the translation of evidence-informed strategies to online environments, a needed step to achieve wide-scale implemention.

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PROMISE (Program Refinements to Optimize Model Impact and Scalability based on Evidence): a cluster-randomised, stepped-wedge trial assessing effectiveness of the revised versus original Ryan White Part A HIV Care Coordination Programme for patients with barriers to treatment in the USA

BMJ Open ◽

10.1136/bmjopen-2019-034624 ◽

2020 ◽

Vol 10 (7) ◽

pp. e034624

Author(s):

Mary K Irvine ◽

Bruce Levin ◽

McKaylee M Robertson ◽

Katherine Penrose ◽

Jennifer Carmona ◽

...

Keyword(s):

New York ◽

Care Coordination ◽

Viral Suppression ◽

Treatment Effectiveness ◽

Scale Up ◽

Hiv Care ◽

Detectable Effect ◽

Hiv Viral Load ◽

Ryan White ◽

White Part

IntroductionGrowing evidence supports combining social, behavioural and biomedical strategies to strengthen the HIV care continuum. However, combination interventions can be resource-intensive and challenging to scale up. Research is needed to identify intervention components and delivery models that maximise uptake, engagement and effectiveness. In New York City (NYC), a multicomponent Ryan White Part A-funded medical case management intervention called the Care Coordination Programme (CCP) was launched at 28 agencies in 2009 in order to address barriers to care and treatment. Effectiveness estimates based on >7000 clients enrolled by April 2013 and their controls indicated modest CCP benefits over ‘usual care’ for short-term and long-term viral suppression, with substantial room for improvement.Methods and analysisIntegrating evaluation findings and CCP service-provider and community-stakeholder input on modifications, the NYC Health Department packaged a Care Coordination Redesign (CCR) in a 2017 request for proposals. Following competitive re-solicitation, 17 of the original CCP-implementing agencies secured contracts. These agencies were randomised within matched pairs to immediate or delayed CCR implementation. Data from three 9-month periods (pre-implementation, partial implementation and full implementation) will be examined to compare CCR versus CCP effects on timely viral suppression (TVS, within 4 months of enrolment) among individuals with unsuppressed HIV viral load newly enrolling in the CCR/CCP. Based on current enrolment (n=933) and the pre-implementation outcome probability (TVS=0.54), the detectable effect size with 80% power is an OR of 2.75 (relative risk: 1.41).Ethics and disseminationThis study was approved by the NYC Department of Health and Mental Hygiene Institutional Review Board (IRB, Protocol 18–009) and the City University of New York Integrated IRB (Protocol 018–0057) with a waiver of informed consent. Findings will be disseminated via publications, conferences, stakeholder meetings, and Advisory Board meetings with implementing agency representatives.Trial registration numberRegistered with ClinicalTrials.gov under identifier: NCT03628287, V.2, 25 September 2019; pre-results.

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HIV Care Coordination promotes care re-engagement and viral suppression among people who have been out of HIV medical care: an observational effectiveness study using a surveillance-based contemporaneous comparison group

AIDS Research and Therapy ◽

10.1186/s12981-021-00398-0 ◽

2021 ◽

Vol 18 (1) ◽

Author(s):

Mary K. Irvine ◽

McKaylee M. Robertson ◽

Denis Nash ◽

Sarah G. Kulkarni ◽

Sarah L. Braunstein ◽

...

Keyword(s):

Viral Load ◽

Medical Care ◽

Care Coordination ◽

Odds Ratio ◽

Viral Suppression ◽

Comparison Group ◽

Safety Net ◽

Hiv Care ◽

Term Care

Abstract Background Medical care re-engagement is critical to suppressing viral load and preventing HIV transmission, morbidity and mortality, yet few rigorous intervention studies address this outcome. We assessed the effectiveness of a Ryan White Part A-funded HIV Care Coordination Program relative to ‘usual care,’ for short-term care re-engagement and viral suppression among people without recent HIV medical care. Methods The Care Coordination Program was launched in 2009 at 28 hospitals, health centers, and community-based organizations in New York City. Designed for people with HIV (PWH) experiencing or at risk for poor HIV outcomes, the Care Coordination Program provides long-term, comprehensive medical case management utilizing interdisciplinary teams, structured health education and patient navigation. The intervention was implemented as a safety-net services program, without a designated comparison group. To evaluate it retrospectively, we created an observational, matched cohort of clients and controls. Using the HIV surveillance registry, we identified individuals meeting program eligibility criteria from December 1, 2009 to March 31, 2013 and excluded those dying prior to 12 months of follow-up. We then matched clients to controls on baseline status (lacking evidence of viral suppression, consistently suppressed, inconsistently suppressed, or newly diagnosed in the past 12 months), start of follow-up and propensity score. For this analysis, we limited to those out of care at baseline (defined as having no viral load test in the 12 months pre-enrollment) and still residing within jurisdiction (defined as having a viral load or CD4 test reported to local surveillance and dated within the 12-month follow-up period). Using a GEE model with binary error distribution and logit link, we compared odds of care re-engagement (defined as having ≥ 2 laboratory events ≥ 90 days apart) and viral suppression (defined as having HIV RNA ≤ 200 copies/mL on the most recent viral load test) at 12-month follow-up. Results Among 326 individuals out of care at baseline, 87.2% of clients and 48.2% of controls achieved care re-engagement (Odds Ratio: 4.53; 95%CI 2.66, 7.71); 58.3% of clients and 49.3% of controls achieved viral suppression (Odds Ratio: 2.05; 95%CI 1.30, 3.23). Conclusions HIV Care Coordination shows evidence of effectiveness for care and treatment re-engagement.

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Impact of an HIV Care Coordination Program on the Timeliness of Viral Suppression and Immune Recovery Among Clients Newly Diagnosed with HIV

AIDS and Behavior ◽

10.1007/s10461-019-02732-0 ◽

2019 ◽

Vol 24 (4) ◽

pp. 1237-1242

Author(s):

McKaylee M. Robertson ◽

Kate Penrose ◽

Denis Nash ◽

Graham Harriman ◽

Sarah L. Braunstein ◽

...

Keyword(s):

Care Coordination ◽

Viral Suppression ◽

Hiv Care ◽

Immune Recovery ◽

Newly Diagnosed

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PROMISE (Program Refinements to Optimize Model Impact and Scalability based on Evidence): A cluster-randomized, stepped-wedge trial assessing effectiveness of the revised versus original Ryan White Part A HIV Care Coordination Program for patients with barriers to treatment

10.1101/19012427 ◽

2019 ◽

Author(s):

Mary K. Irvine ◽

Bruce Levin ◽

McKaylee Robertson ◽

Katherine Penrose ◽

Jennifer Carmona ◽

...

Keyword(s):

New York ◽

Care Coordination ◽

Viral Suppression ◽

Service Providers ◽

Hiv Care ◽

List Type ◽

Matched Pairs ◽

Stepped Wedge ◽

Link Type ◽

Ryan White

AbstractIntroductionGrowing evidence supports combining social, behavioral and biomedical strategies to strengthen the HIV care continuum. However, combination interventions can be resource-intensive and challenging to scale up. Research is needed to identify intervention components and delivery models that maximize uptake, engagement and effectiveness. In New York City (NYC), a multi-component Ryan White-funded medical case management intervention called the Care Coordination Program (CCP) was launched at 28 agencies in 2009 to address barriers to care and treatment. Effectiveness estimates based on >7,000 clients enrolled by April 2013 and their controls indicated modest CCP benefits over ‘usual care’ for short- and long-term viral suppression, with substantial room for improvement.Methods and analysisIntegrating evaluation findings and CCP service-provider and community-stakeholder input on modifications, the NYC Health Department packaged a Care Coordination Redesign (CCR) in a 2017 request for proposals. Following competitive re-solicitation, 17 of the original CCP-implementing agencies secured contracts. These agencies were randomized within matched pairs to immediate or delayed CCR implementation. Data from three nine-month periods (pre-implementation, partial implementation and full implementation) will be examined to compare CCR versus CCP effects on timely viral suppression (TVS, within four months of enrollment) among individuals with unsuppressed HIV viral load newly enrolling in the CCR/CCP. Based on estimated enrollment (n=824) and the pre-implementation outcome probability (TVS=0.45), the detectable effect size with 80% power is an odds ratio of 2.90 (relative risk: 1.56).Ethics and disseminationThis study was approved by the NYC Department of Health and Mental Hygiene Institutional Review Board (IRB, Protocol 18-009) and the City University of New York Integrated IRB (Protocol 018-0057) with a waiver of informed consent. Findings will be disseminated via publications, conferences, stakeholder meetings, and Advisory Board meetings with implementing agency representatives.Trial registrationRegistered with ClinicalTrials.gov under identifier: NCT03628287, Version 2, 25 September 2019; pre-results.ARTICLE SUMMARYStrengths and limitations of this studyThe PROMISE trial, conducted in real-world service settings, leverages secondary analyses of programmatic and surveillance data to assess the effectiveness of a revised (CCR) versus original HIV care coordination program to improve viral suppression.To meet stakeholder expectations for rapid completion of the CCR rollout, the study applies a stepped-wedge design with a nine-month gap between implementation phases, prompting use of a short-term (four-month) outcome and a brief (five-month) lead-in time for enrollment accumulation.Randomization is performed at the agency level to minimize crossover between the intervention conditions, since service providers would otherwise struggle logistically and ethically with simultaneously delivering the two different intervention models to different sets of clients, especially given common challenges related to reaching agreement on clinical equipoise.1–3The use of agency matching, when followed by randomization within matched pairs, offers advantages akin to those of stratified random assignment: increasing statistical power in a situation where the number of units of randomization is small, by maximizing equivalency between the intervention and control groups on key observable variables, thus helping to isolate the effects of the intervention.3In addition, nuisance parameters are removed through the conditional analytic approach, which accounts and allows for the unavoidably imperfect matching of agencies and arbitrary variation of period effects across agency pairs.4

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Despite Early Medicaid Expansion, Decreased Durable Virologic Suppression Among Publicly Insured People with HIV in Washington, DC: a retrospective analysis

10.21203/rs.2.10459/v3 ◽

2020 ◽

Author(s):

Deborah Goldstein ◽

David Hardy ◽

Anne Monroe ◽

Qingjiang Hou ◽

Rachel Hart ◽

...

Keyword(s):

Viral Suppression ◽

Hiv Care ◽

Virologic Suppression ◽

Washington Dc ◽

Community Clinics ◽

Logistic Regression Models ◽

Hiv Rna ◽

Durable Viral Suppression ◽

Publicly Insured ◽

Privately Insured

Abstract Background: Despite widely available access to HIV care in Washington, DC, inequities in HIV outcomes persist. We hypothesized that laboratory monitoring and virologic outcomes would not differ significantly based on insurance type. Methods: We compared HIV monitoring with outcomes among people with HIV (PWH) with private (commercial payer) versus public (Medicare, Medicaid) insurance receiving care at community and hospital clinics. The DC Cohort follows over 8,000 PWH from 14 clinics. We included those ≥18 years old enrolled between 2011-2015 with stable insurance. Outcomes included frequency of CD4 count and HIV RNA monitoring ( > 2 lab measures/year, > 30 days apart) and durable viral suppression (VS; HIV RNA <50 copies/mL at last visit and receiving antiretroviral therapy (ART) for ≥12 months). Multivariable logistic regression models examined impact of demographic and clinical factors. Results: Among 3,908 PWH, 67.9% were publicly-insured and 58.9% attended community clinics. Compared with privately insured participants, a higher proportion of publicly insured participants had the following characteristics: female sex, Black race, heterosexual, unemployed, and attending community clinics. Despite less lab monitoring, privately-insured PWH had greater durable VS than publicly-insured PWH (ART-naïve: private 70.0% vs public 53.1%, p=0.03; ART-experienced: private 80.2% vs public 69.4%, p<0.0001). Privately-insured PWH had greater durable VS than publicly-insured PWH at hospital clinics (AOR=1.59, 95% CI: 1.20, 2.12; p=0.001). Conclusions: Paradoxical differences between HIV monitoring and durable VS exist among publicly and privately-insured PWH in Washington, DC. Programs serving PWH must improve efforts to address barriers creating inequity in HIV outcomes.

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