Early Retention in HIV Care and Viral Load Suppression

This chapter seeks to create further awareness and public health education on the importance of the human immunodeficiency virus (HIV) care continuum as one of the key policy focal areas to significantly reduce the HIV epidemic. Specific efforts were directed into the need to implement comprehensive HIV care continuum. The chapter argues that rolling out HIV counseling and testing, enrolled and linked patients to care, prescribing antiretroviral therapy, viral load testing and monitoring are key to achieve viral load suppression. Recommendations and future research direction have put much emphasis on an effort to address psychosocial factors such as stigma, inadequate healthcare facilities, laboratory testing equipment, social and cultural barriers to testing and treatment, to improve access and overall implementation of HIV care continuum.

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What gaps remain in the HIV cascade of care? Results of a population-based survey in Nsanje District, Malawi

PLoS ONE ◽

10.1371/journal.pone.0248410 ◽

2021 ◽

Vol 16 (4) ◽

pp. e0248410

Author(s):

Nolwenn Conan ◽

Cyrus P. Paye ◽

Reinaldo Ortuno ◽

Alexander Chijuwa ◽

Brown Chiwandira ◽

...

Keyword(s):

Young Adults ◽

Viral Load ◽

Health Facility ◽

Population Based ◽

Hiv Care ◽

Hiv Positive ◽

Viral Load Suppression ◽

Hiv Rna ◽

Hiv Test ◽

Cascade Of Care

Introduction The Malawi Ministry of Health (MoH) has been in collaboration with Médecins sans Frontières (MSF) to increase access to quality HIV care through decentralization of antiretroviral therapy (ART) diagnosis and treatment from hospital to clinics in Nsanje District since 2011. A population-based household survey was implemented to provide information on HIV prevalence and cascade of care to inform and prioritize community-based HIV interventions in the district. Methods A cross-sectional survey was conducted between September 2016 and January 2017. Using two-stage cluster sampling, eligible adult individuals aged ≥15 years living in the selected households were asked to participate. Participants were interviewed and tested for HIV at home. Those tested HIV-positive had their HIV-RNA viral load (VL) measured, regardless of their ART status. All participants tested HIV-positive at the time of the survey were advised to report their HIV test result to the health facility of their choice that MSF was supported in the district. HIV-RNA VL results were made available in this health facility. Results Among 5,315 eligible individuals, 91.1% were included in the survey and accepted an HIV test. The overall prevalence was 12.1% (95% Confidence Interval (CI): 11.2–13.0) and was higher in women than in men: 14.0% versus 9.5%, P<0.001. Overall HIV-positive status awareness was 80.0% (95%CI: 76.4–83.1) and was associated with sex (P<0.05). Linkage to care was 78.0% (95%CI: 74.3–81.2) and participants in care 76.2% (95%CI: 72.4–79.5). ART coverage among participants aware of their HIV-positive status was 95.3% (95%CI: 92.9–96.9) and was not associated with sex (P = 0.55). Viral load suppression among participants on ART was 89.9% (95%CI: 86.6–92.4) and was not statistically different by sex (p = 0.40). Conclusions Despite encouraging results in HIV testing coverage, cascade of care, and UNAIDS targets in Nsanje District, some gap remains in the first 90, specifically among men and young adults. Enhanced community engagement and new strategies of testing, such as index testing, could be implemented to identify those who are still undiagnosed, particularly men and young adults.

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Short-term effectiveness of HIV care coordination among persons with recent HIV diagnosis or history of poor HIV outcomes

10.1101/311597 ◽

2018 ◽

Author(s):

Denis Nash ◽

McKaylee M. Robertson ◽

Kate Penrose ◽

Stephanie Chamberlin ◽

Rebekkah S. Robbins ◽

...

Keyword(s):

New York ◽

New York City ◽

Viral Load ◽

Relative Risk ◽

York City ◽

Hiv Care ◽

Newly Diagnosed ◽

Viral Load Suppression ◽

History Of

AbstractThe New York City HIV Care Coordination Program (CCP) combines multiple evidence-based strategies to support persons living with HIV (PLWH) at risk for, or with a recent history of, poor HIV outcomes. We assessed the comparative effectiveness of the CCP by merging programmatic data on CCP clients with population-based surveillance data on all New York City PLWH. A non-CCP comparison group of similar PLWH who met CCP eligibility criteria was identified using surveillance data. The CCP and non-CCP groups were matched on propensity for CCP enrollment within four baseline treatment status groups (newly diagnosed or previously diagnosed and either consistently unsuppressed, inconsistently suppressed or consistently suppressed). We compared CCP to non-CCP proportions with viral load suppression at 12-month follow-up. Among the 13,624 persons included, 15·3% were newly diagnosed; among the 84·7% previously diagnosed, 14·2% were consistently suppressed, 28·9% were inconsistently suppressed, and 41 ·6% were consistently unsuppressed in the year prior to baseline. At 12-month follow-up, 59·9% of CCP and 53·9% of non-CCP participants had viral load suppression (Relative Risk=1.11, 95%CI:1.08-1.14). Among those newly diagnosed and those consistently unsuppressed at baseline, the relative risk of viral load suppression in the CCP versus non-CCP participants was 1.15 (95%CI:1.09-1.23) and 1.32 (95%CI:1.23-1.42), respectively. CCP exposure shows benefits over no CCP exposure for persons newly diagnosed or consistently unsuppressed, but not for persons suppressed in the year prior to baseline. We recommend more targeted case finding for CCP enrollment and increased attention to viral load suppression maintenance.

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A modified HIV continuum of care: A six-year evaluation of a viral load cascade at a hospital-based clinic in Kingston, Jamaica

International Journal of STD & AIDS ◽

10.1177/0956462419839514 ◽

2019 ◽

Vol 30 (8) ◽

pp. 748-755 ◽

Cited By ~ 1

Author(s):

Geoffrey J Barrow ◽

Margaret L Brandeau

Keyword(s):

Viral Load ◽

Statistical Analysis ◽

Viral Suppression ◽

Care Delivery ◽

Continuum Of Care ◽

Hiv Care ◽

Viral Load Suppression ◽

Outcome Indicators ◽

Care Continuum ◽

Hiv Continuum Of Care

To achieve the goal of HIV viral suppression, provision of medication alone is not sufficient. Concomitant frameworks to evaluate HIV care delivery programmes are needed. This study examined the care continuum at a hospital-based HIV clinic in Kingston, Jamaica using a modified HIV continuum of care, with an increased focus on viral load indicators (viral load samples taken, results returned and viral suppression). A statistical analysis of patient flow through the care continuum to identify gaps in programme delivery was performed. Key programmatic areas for process improvement and the utility of this approach for viral load suppression interpretation were identified. Between 2010 and 2015, more than 1600 patients had been registered for care and more than 1000 had accessed antiretroviral therapy at this location. Consistent trends in programme performance were seen from 2010 to 2012. Although declines in the proportion of viral load samples taken and results returned occurred because of laboratory failures in 2013, the trend of increasing numbers and proportions of virally suppressed patients continued. Statistical analysis indicated that improvements in laboratory quality (fraction of viral load samples returned with accurate test results) could increase viral load suppression among patients at the clinic by up to 17%. Refining care delivery processes can significantly improve HIV viral load suppression rates. Expanding monitoring frameworks to include all of the essential processes that affect final outcome indicators can provide valuable insight into trends of outcome indicators and programme performance.

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1770. The Association of Unmet Needs With Subsequent Retention in Care and HIV Suppression Among Hospitalized Patients With HIV Who Are Out of Care

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy209.155 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S65-S66

Author(s):

Dima Dandachi ◽

Sarah May ◽

Jessica Davila ◽

Jeffrey Cully ◽

K Rivet Amico ◽

...

Keyword(s):

Viral Load ◽

Dental Care ◽

Unmet Needs ◽

Unmet Need ◽

Retention In Care ◽

Hospitalized Patients ◽

Hiv Care ◽

Medical Needs ◽

Retention In Hiv Care ◽

Housing Needs

Abstract Background Unmet needs among hospitalized patients with HIV may prevent engagement in HIV care leading to worse clinical outcomes. Our aim was to examine the role of unmet subsistence needs (e.g., housing, transportation, food) and medical needs (e.g., mental health, substance abuse treatment) as barriers for retention in HIV care and viral load (VL) suppression. Methods We utilized data from the Mentor Approach for Promoting Patients’ Self-Care intervention study, the enrolled hospitalized HIV-patients at a large publicly funded hospital between 2010 and 2013, who were out-of-care. We examined the effect of unmet needs on retention in HIV care (attended HIV appointments within 0–30 days and 30–180 days) and viral load suppression, 6 months after discharge. Results A total of 417 participants were enrolled, 78% reported having ≥1 unmet need at baseline, most commonly dental care (55%), financial (43%), or housing needs (34%). Participants with unmet needs at baseline, compared with those with no needs, were more likely to be African American, have an existing HIV diagnosis, and be uninsured. Among participants who completed a baseline and 3-month survey (n = 320), 45% reported a need for dental care, 42% reported financial needs, and 32% reported housing needs that were unmet at either time point (Figure 1). Having a dental care need at baseline that was met was significantly associated with higher odds of VL improvements at 6-month follow-up (OR: 2.2; 95% CI: 1.04–4.50, P = 0.03) and higher odds for retention in care (OR: 2.06; 95% CI: 1.05–4.07, P = 0.04). An unmet need for transportation was associated with lower odds of retention in care (OR: 0.5; 95% CI: 0.34–0.94, P = 0.03), even after adjusting for other factors. Compared with participants with no need, those who reported ≥3 unmet subsistence needs were less likely to demonstrate viral load improvement (OR: 0.51; 95% CI: 0.28–0.92; P = 0.03) and to be retained in care (OR: 0.52; 95% CI: 0.28–0.95; P = 0.03). Conclusion An important and novel finding in our study is that the number of unmet subsistence needs had a significant effect on retention in care and VL suppression. Broader access to programs that can assist in meeting subsistence needs among hospitalized patients could have significant individual and public health benefits. Disclosures All authors: No reported disclosures.

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Effect and implementation experience of intensive adherence counseling in a public HIV care center in Uganda: a mixed-methods study

BMC Infectious Diseases ◽

10.1186/s12879-021-06862-6 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Zubair Lukyamuzi ◽

Samuel Etajak ◽

Thomas Katairo ◽

David Mukunya ◽

Moses Tetui ◽

...

Keyword(s):

Health Care ◽

Viral Load ◽

Healthcare Workers ◽

Care Center ◽

Hiv Care ◽

Art Adherence ◽

Intervention Period ◽

Viral Load Suppression ◽

Related Factors ◽

Adherence Counseling

Abstract Background Intensive adherence counseling (IAC) is an intervention recommended by the World Health Organization to improve anti-retroviral therapy (ART) adherence among people living with HIV on ART with unsuppressed viral load; and in 2016, the intervention was implemented in Uganda. This study evaluated the effect and experiences of providing IAC in an urban HIV care center in Kampala, Uganda. Methods This was a sequential explanatory mixed-method study that compared viral load suppression during IAC implementation (intervention) to the period before IAC at Kisenyi Health centre IV. Data were abstracted from patient files and viral load register. The effect of IAC on viral load suppression and associated factors were analyzed using modified Poisson regression with robust standard errors. Using in-depth interviews and an inductive analysis approach in Atlas-ti 8. We also explored experiences of providing IAC among healthcare workers. Results A total of 500 records were sampled: 249 (49.8%) in the intervention period and 251 (51.2%) in the pre-intervention period. The mean age was lower during the intervention period 33.1 (± 12.0) than 36.5 (± 13.4) in the pre- intervention period, p = 0.002. More clients were currently on Protease-based regimen in the pre-intervention period 179 (71.3%) than 135 (54.2%) in the intervention period, p ≤ 0.001. In the intervention period, all eligible clients received IAC [249/249 (100.0%)]. Overall, 325 (65.0%) received IAC and of these, 143 (44.1%) achieved viral load suppression compared to 46 (26.3%) who received regular counseling. Receiving IAC significantly increased viral load suppression by 22% (aPR 1.22, 95% CI 1.01–1.47). Clients on Protease-based regimen were less likely to suppress than those on Efavirenz or Nevirapine-based regimens (aPR 0.11, 95% CI 0.08–0.15). All the interviewed healthcare workers lauded IAC for improving ART adherence. However, patient and health care system related factors hindered adherence during IAC. Conclusions The full potential of IAC in achieving viral load suppression in this setting has not been reached due to a combination of the patient and health care system related factors. Provision of adequate IAC necessities and use of patient centered approach should be emphasized to obtain the maximum benefit of the intervention.

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Example Interventions Using Motivational Interviewing to Enhance Engagement in HIV Care

Motivational Interviewing in HIV Care ◽

10.1093/med/9780190619954.003.0008 ◽

2019 ◽

pp. 75-86

Author(s):

Laramie Smith ◽

Riddhi Modi ◽

K. Rivet Amico

Keyword(s):

Clinical Trial ◽

Motivational Interviewing ◽

Self Determination ◽

Hiv Care ◽

Change Talk ◽

Intervention Approach ◽

Retention In Hiv Care ◽

Righting Reflex ◽

Early Retention ◽

Engagement In Hiv Care

Chapter 8 provides examples of programs developed to optimize retention in HIV care that are based on principles of motivational interviewing (MI). Two programs are highlighted: iEngage, a recently evaluated intervention to promote early retention in HIV-care as part of a multi-site clinical trial, and 60-Mintues for Health, a piloted intervention approach for patients tenuously engaged in HIV-care. These programs, their theoretical underpinnings, and use of MI offer some importance insights about mobilizing MI in the context of HIV care. Consistent with MI, both programs are founded on patients’ autonomy and self-determination, with the interventionist acting as a guide to help patients achieve tailored goals while avoiding the righting-reflex and highlighting change talk.

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