Retention in HIV care - Delta Region AIDS Education and Training

Debbie Konkle-Parker, PhD, FNP
June 2012
Desired content
 Methods to teach on the subject: casebased; worksheet, best practices
discussion, panels, brainstorming
 Others?
What makes it difficult to
prepare a training on
retention in care?
Important Content for training
General background: why should I care?
 Describe the extent of the problem of retention
in HIV care and its effect on health outcomes
Specific background: what has research
told us about the problem?
 Describe the factors that have been found to be
associated with retention in HIV care
What can we do about it anyway?
 Describe evidence-based strategies to impact
retention in HIV care
How can we make this real?
 Discuss potential strategies in clinical settings
Why is Retention Important?
Patient Care and Public Health
 Retention has now been proven to correlate with
improved biological outcomes that improve quality
of life for patients [and reduce the likelihood of
further transmission of HIV to others]
National Quality Center
Why is Retention Important?
Healthcare Cost
 If patients are retained in care, they are more
likely to receive preventive care, use emergency
services less and keep overall healthcare
utilization and costs lower, placing less demand
on human and material resources.
National Quality Center
Why is Retention Important for People
Living with HIV?
 Retention in care promotes improved adherence
to treatment which results in lower viral loads,
prevention of drug-resistance and improved
health outcomes, as well as decreased HIV
Is there evidence to support the hypothesis?
Why is Retention Important for People
Living with HIV?
The Evidence Base:
 Rastegar, AIDS Care 2003: Missed appointments associated
with detectable viral load. Chart review 1997-99.
 Lucas, Ann Intern Med 1999: Missed appointments associated
with failure of suppression. JHU. 1996-8.
 Valdez, Arch Intern Med 1999: Missing <2 appts per year
associated with virologic success defined as <400 copies.
 Sethi, Clin Infect Dis 2003: Missed appointments associated
with viral rebound and clinically significant resistance at JHU
 Nemes, AIDS 2004: Missing 2 appointments associated with
decreased adherence among >1900 patients in Brazil.
National Quality Center
Why is Retention Important for People
Living with HIV?
The Evidence Base:
 Giordano, CID, 2007: Less frequent visits associated with
mortality in US veterans starting HIV medicines, even in a system
financial barriers are low.
 Mugavero, CID, 2009: In a community setting in Birmingham, AL,
missed visits within the first year of entering treatment was associated
with mortality
 Park, Journal of Internal Medicine, 2007: In South Korea, even one
missed visit in the first year after starting HAART was associated with
increased mortality, and this doubled with each missed visit
 Mugavero, JAIDS, 2009: The racial disparity in virologic failure
lost significance when adjusted for missed visits.
Why is Retention Important for
People Living with HIV?
1 in 5 do not know their HIV status
 2 in 5 have not seen an HIV primary
care doctor
 3 in 5 don’t regularly see their doctor,
 5 in 5 are not viral load suppressed
Gardner et al, CID 2011
Why is Retention Important for
People Living with HIV?
In a meta-analysis of more than 53,000
people diagnosed with HIV between
1995 – 2009:
 69% entered care within 4 – 6 months and
had subsequent > 2 visits
 Of those, on average, 59% had multiple HIV
medical care visits across different periods
of time
Marks, Gardner, Craw, & Crepaz, 2010
Structural and Personal Issues
“Multiple studies have shown that patients
who access case management,
transportation, mental health support, drug
treatment, and other supportive services
are more likely to be retained in care than
are those who do not.
 “Interventions that assist patients to
develop and maintain a positive
relationship with health care providers and
to improve their knowledge of HIV infection
and dispel negative health beliefs also
improve outcomes.”
Cheever, L.W. (2007). Engaging HIV-infected patients in care: their lives
depend on it. Clinical Infectious Diseases, 44.
Factors Associated with
 Mugavero, JAIDS 2009, CID, 2007, CID 2009 :
higher median Missed Visit Proportion (MVP) seen in
younger patients, females, blacks, those with no
or public health insurance, those with substance
abuse histories;
Giordano, CID 2007: those with better retention in
care had more advanced disease, were older, less
substance abuse, were more adherent to
Gardner, AIDS 2005: more health care utilization
associated with no crack use, older age, use of
assistance programs, recent diagnosis, case
Factors Associated with
Rajabiun, AIDS Pt Care and STDs,
2007: engagement in care was
associated with
 level of acceptance of disease;
 ability to cope with mental illness, substance
abuse, and stigma;
 health care provider relationships;
 presence of support system; and
 ability to overcome practical obstacles to
Factors Associated with
Tobias, AIDS Pt Care and STDs 2007:
predictive factors for less retention included
substance abuse,
number of unmet needs,
negative health belief,
no insurance.
Predictive factors of more care included
 having a case manager,
 having less mental health problems, and
 use of mental health services.
Provider-Patient Relationship
 Patronizing communication by provider
 Connecting, by giving time and attention
 Validating, by treating the patient as an
individual person
 Partnering, by listening to and
acknowledging patient needs
Mallinson, Rajubian, & Coleman (2007). The
provider role in client engagement in HIV care. AIDS
Pt Care & STDs
Barriers and Facilitators of
Engagement in HIV Care at
Thompson MA, Mugavero MJ, Amico KR, Cargill VA,
Chang LW, Gross R et al, epub ahead of print 3/5/2012 in
Grading Scales for Quality of the Body of Evidence and Strength of Recommendations.
Thompson M A et al. Ann Intern Med doi:10.1059/00034819-156-11-201206050-00419
©2012 by American College of Physicians
1. Systematic monitoring of
successful entry into HIV care (IIA)
Collaboration with HIV testing sites
 Creation of process map regarding entry
into care, to identify where loss is
happening and to focus intervention
2. Systematic monitoring of
retention in HIV care (IIA)
In+Care campaign
 Clinic-based monitoring of performance
 Creation of electronic signal when
individual out of care for six months, for
initiation of outreach
3. Brief, strengths-based case
management for individuals
with a new HIV diagnosis (IIB)
Based on data from AntiRetroviral
Treatment and Access Study (ARTAS)
Antiretroviral Treatment Access
Study (ARTAS)
Brief case management protocol
allowed up to 5 contacts: 3 for
development of relationship, identifying
client needs and barriers to health care,
and encouraging contact with the clinic.
 2 other contacts allowed if needed,
including accompaniment to clinic.
Garner, Metsch, Anderson-Mahoney et al (2005) Efficacy of a brief case
management intervention to link recently diagnosed HIV-infected persons to care.
AIDS, 19(4):423-431.
Trained social workers helped clients to
identify their internal strengths and
assets to facilitate successful linkage to
HIV medical care
ARTAS Results
Results showed significantly greater
proportion of case managed individuals
saw an HIV care provider at least once
by 6 and 12 months (RR=1.41, p=.006)
 Those with 2 or more contacts showed a
significant difference from SOC
Average of 2.6 face-to-face contacts
with clients. Estimated cost $600-1200
per client.
4. Intensive outreach for
individuals not engaged in
medical care within 6 months of a
new HIV diagnosis (IIC)
Outreach Initiative
HRSA Special project of National
Significance (SPNS) in 10 US sites
2004-2006 to demonstrate and evaluate
the effectiveness of outreach initiatives
in engaging and retaining underserved
disadvantaged individuals in HIV care
Bradford, J. B. (2007). The promise of outreach for engaging and retaining out-of-care persons
in HIV medical care. AIDS Patient Care and STDs, 21(Suppl1):S85-81.
Cabral, H.J., Tobias, C., Rajabiun, S., Sohler, N., Cunningham, C., Wong, M., et al. (2007).
Outreach program contacts: do they increase the likelihood of engagement and retention in HIV
primary care for hard-to-reach patients? AIDS Patient Care and STDs, 21(Suppl1):59-67.
Findings from Outreach Initiative
Individuals with 9 or more contacts within the
first 3 months of entering care were
significantly less likely to experience a gap in
care, especially when the program included
accompaniment to visits.
5 Use of peer or
paraprofessional patient
navigators (IIC)
Findings from Outreach Initiative
Navigation programs that include skillsbuilding with clients to build skills/
confidence to develop a partnership with
providers significantly improved
engagement scores and retention in
Multidimensional HIV Treatment
Adherence Intervention in MS
Two face-to-face sessions for
 I: HIV education
 M (personal): motivational interviewing
 M (social): video of peers to improve social
 BS: adherence reminder devices
 BS: training on how to improve communication
with the provider during a medical visit
Konkle-Parker, D., Amico, K. R., & McKinney, V. (2012). Effects of a
Multidimensional Intervention on Retention in HIV Care in the Deep South.
Manuscript in preparation.
Major Lessons
Barriers to care can be reduced or
removed with sufficient resources
 Coaching, skills-building, knowledge
gains, and respectful, trusting
relationships with outreach workers can
facilitate better utilization of HIV care
Major Lessons
For the most disadvantaged individuals,
more resources and systemic changes
are needed to provide equitable access
to HIV care
Bradford, J. B. (2007). The promise of outreach for engaging and retaining
out-of-care persons in HIV medical care. AIDS Patient Care and STDs,
Bradford, J. B., Coleman S., Cunningham, W. (2007). HIV System
Navigation: An emerging system to improve HIV care access. AIDS
Patient Care and STDs, 21(Suppl-1):S49-58.
Practical Strategies
Partnerships with community-based agencies
offer great potential
Supportive services, including navigation and
case management, help increase retention by
removing barriers and meeting needs
Provider engagement and behavior affects levels
of engagement and retention and decrease
sporadic use: fortify relationships
HIV Quality Center
Practical Strategies (2)
Use peers
Target new patients
Help patients access needed services to
remove barriers to care: transportation,
mental health support, drug treatment
Reduce drug use
Dispel negative health beliefs
HIV Quality Center
Other ideas from the literature
Co-locating of HIV services
 Medical
 Case management
 Psychiatric services
 Substance use services
 Homelessness services
 Human services addressed at poverty
If impossible, patient navigators can
Reminder Systems
Phone calls
 Text messages
 Letters
Addressing Patient
younger age,
substance abusers,
those with mental health problems,
those with no insurance,
older diagnoses,
earlier disease
What else?
Focusing on special populations
The population of focus might be
different in different clinics
Building on Infrastructure
Making it a clinic-wide program
 Roles and responsibilities for all clinic
 Reinforcement of attendance
 Reminder calls
 Updating of contact information
 Questionnaires to identify important issues
 Data review to identify the target audience
Other roles?
Measure retention prior to intervention
number of missed visits,
missed visit proportion (MVP),
number of intervals with at least one visit
(persistence), or
interval with no arrived visits (gap in care)
Identify problem/target group for an
Develop targeted intervention to address the
problem identified and try it for a small group
or short period of time
Evaluate the results of small pilot study
Based on results of the evaluation, scale up
intervention or go back to the planning stage

similar documents