Georgia Leverages Telehealth to Expand HIV Care Management in Underserved Areas

Virtual care pathways for people living with HIV: A mixed-methods systematic review

BACKGROUND

The COVID-19 pandemic prompted an unprecedented surge in virtual services, necessitating a rapid shift to digital healthcare approaches. This review focuses on evaluating the evidence of virtual care (VC) in delivering HIV care, considering the complex nature of HIV and the need for tailored-approaches, especially for marginalized populations.

METHODS

A mixed-methods systematic review was performed with searches on five databases, covering studies from January 1946 to May 2022. Inclusion criteria involved two-way virtual consultations between healthcare workers and people living with HIV (PLHIV), with detailed descriptions and outcomes. Qualitative and quantitative studies were included, and the risk of bias was assessed using the Newcastle-Ottawa score and Stenfors' framework.

RESULTS

Among 4143 identified records, 26 studies met the criteria, with various models of care described. The majority of studies were observational, and videoconferencing was the primary mode of virtual consultation employed. Quantitative analysis revealed PLHIV generally accept VC, with high attendance rates (87%). Mean acceptability and satisfaction rates were 80% and 85%, respectively, while 87% achieved HIV viral suppression. The setting and models of VC implementation varied, with some introduced in response to COVID-19 while others were as part of trials.

CONCLUSIONS

VC for PLHIV is deemed an acceptable and effective approach and is associated with good virological outcomes. Data on other health outcomes is lacking. The review underscores the importance of diverse models of care, patient choice and comprehensive training initiatives for both staff and patients. Establishing a 'gold standard' for VC models is crucial for ensuring appropriate and effective reviews of PLHIV in virtual settings.

Barriers to HIV rapid start among New Jersey providers

BACKGROUND

Rapid Start ensures that persons with HIV initiate antiretroviral therapy in less than seven days after diagnosis. Benefits of Rapid Start include timely linkage to medical care, viral suppression in a shorter time and improved retention to medical care. Despite these benefits, there is a slow uptake of Rapid Start, in New Jersey.

OBJECTIVE

Identify barriers to Rapid Start among New Jersey providers.

METHODS

An electronic survey, consisting of 28 questions, with the following domains was administered to New Jersey providers, using Qualtrics: provider and practice characteristics (10), knowledge (1), barriers (8) and attitudes to diverse patient types (9). The results were analyzed using descriptive statistics due to small numbers over strata. Approval to conduct the survey was obtained from the William Paterson University Institutional Review Board.

RESULTS

There were 69 responses to the survey. Providers were at least 45 years old (48%), female (44/60, 73%), nurse practitioners or physician assistants (41/59, 69%). Overall, 44/63 (70%) providers did not correctly identify that integrase inhibitors had the lowest prevalence of transmitted drug resistance. Newly diagnosed patients were referred for medical care in 37 (65%) of the medical sites. Only providers from Ryan White (federally funded clinics for persons with HIV) (64%) and non-Ryan White (73%) public sites reported co-located HIV testing sites. Seventy percent of medical sites offered same-day medical appointments. However, a lower proportion of private (62%), public Ryan White (55%), and other medical sites (36%) offered same-day appointments compared to public non-Ryan White sites (82%). Despite having staff available 40 h per week (91%), only 55% of Ryan White sites offered extended office hours in the early morning, evenings, or on Saturdays. When compared to providers in public non-Ryan White sites, a lower proportion of providers in Ryan White sites were comfortable doing Rapid Start either on the day of or within one week of diagnosis, 82% and 72%, respectively, or starting antiretroviral therapy before genotype results were available, 55% and 46%, respectively. Overall, providers were not comfortable with Rapid Start for persons engaging in condomless sex (60%).

CONCLUSIONS

Policy and administrative decisions are needed to eliminate barriers at the clinic level. An HIV clinical scholar program, to increase providers knowledge, may increase uptake of Rapid Start.

Human Immunodeficiency Virus in the South: An Epidemic Within an Epidemic

The authors examine the HIV epidemic in the Southern United States, emphasizing its severe impact on minority and young populations. The authors highlight challenges including limited health care access, systemic racism influencing social determinants of health, and lesbian, gay, bisexual, transgender, and queer+ stigma. The South faces a critical human immunodeficiency virus (HIV) workforce shortage, especially in rural areas, and struggles with coexisting syndemics like other sexually transmitted infections and substance-use disorders. The authors describe comprehensive strategies such as Medicaid expansion, workforce enhancement, stigma reduction, and policy reforms to improve HIV prevention and treatment, emphasizing the need for a multifaceted approach to improve health outcomes for those living with HIV in the South.

Evaluating the delivery of care by telemedicine for incarcerated people living with HIV: a cohort study

BACKGROUND

The use of telemedicine has grown significantly since the COVID-19 pandemic and has the potential to improve access to specialized care for otherwise underserved populations. Incarcerated people living with HIV (PLWH) could potentially benefit from expanded access to HIV care through telemedicine.

METHODS

All PLWH who were incarcerated within the Tennessee Department of Corrections and received care through the HIV telemedicine clinic at Regional One Hospital between 5/1/2019 through 2/28/2022 were identified from the electronic health records (EHR). Demographics, laboratory data, vaccine history, and treatment outcomes were abstracted from the EHR. Retention in care and viral suppression were defined using Centers for Disease Control and Prevention definitions.

RESULTS

Of the 283 incarcerated PLWH receiving care from this telemedicine clinic, 78% remained retained in care and 94% achieved or maintaining viral suppression at 12 months. Many preventative care measures remained unperformed or undocumented, including vaccinations and testing for concurrent sexually transmitted infections. There were 56 patients (20%) found to have chronic hepatitis C in this population, with 71% either cured or still on treatment in this study period.

CONCLUSIONS

Retention in care and viral suppression rates were excellent among incarcerated PLWH receiving telemedicine care for their HIV. HIV related primary health care screenings and vaccinations, however, were less consistently documented and represent areas for improvement.

Acceptability, Feasibility, and Preliminary Impact of 4 Remotely-Delivered Interventions for Rural Older Adults Living with HIV

People living with HIV (PLH) who live in rural areas of the United States (US) face more challenges to obtaining medical care and suffer higher mortality rates compared to non-rural PLH. Compared with younger PLH, older PLH (age 50+) also face additional challenges to maintaining their health and wellbeing. Despite the heightened barriers to receiving care and remaining adherent to treatment among older rural PLH, few interventions to increase viral suppression and improve quality of life exist for this population. We pilot-tested four remotely-delivered interventions-group-based social support, group-based stigma-reduction, individual strengths-based case management, and individual technology detailing-aimed to improve care engagement and quality of life in rural older PLH in the southern US. Participants (N = 61, Mage = 58, 75% male) completed surveys and self-collected blood specimens at baseline and 3 months; in between, they were randomized to 0-4 interventions. We assessed feasibility, acceptability, and preliminary impact on medication adherence, viral suppression, quality of life, depressive symptoms, and hypothesized mediating mechanisms. More than 80% participated in assigned intervention(s), and 84% completed the study. Interventions were highly acceptable to participants, with more than 80% reporting they would recommend interventions to peers. More than 80% found the social support and case management interventions to be relevant and enjoyable. We found promising preliminary impact of interventions on quality of life, medication adherence, depressive symptoms, internalized stigma, and loneliness. Remotely-delivered interventions targeting rural older PLH are feasible to conduct and acceptable to participants. Larger scale study of these interventions is warranted.

Leveling Up PrEP: Implementation Strategies at System and Structural Levels to Expand PrEP Use in the United States

PURPOSE OF REVIEW

Despite highly effective biomedical HIV pre-exposure prophylaxis (PrEP) options, suboptimal PrEP uptake impedes progress towards ending the epidemic in the United States of America (USA). Implementation science bridges what we know works in controlled clinical trial settings to the context and environment in which efficacious tools are intended to be deployed. In this review, we focus on strategies that target PrEP use barriers at the system or structural level, exploring the implications and opportunities in the context of the fragmented USA healthcare system.

RECENT FINDINGS

Task shifting could increase PrEP prescribers, but effectiveness evidence is scarce in the USA, and generally focused in urban settings. Integration of PrEP within existing healthcare infrastructure concentrates related resources, but demonstration projects rarely present the resource implications of redirecting staff. Changing the site of service via expanded telehealth could improve access to more rural populations, though internet connectivity, technology access, and challenges associated with determining biomedical eligibility remain logistical barriers for some of the highest burden communities in the USA. Finally, a tailored care navigation and coordination approach has emerged as a highly effective component of PrEP service provision, attempting to directly modify the system-level determinants of PrEP use experienced by the individual. We highlight recent advances and evidence surrounding task shifting, integration, service delivery, and tailoring. With the exception of tailored care navigation, evidence is mixed, and the downstream impact and sustainability of task shifting and care integration require further attention. To maximize PrEP outcomes, research will need to continue to examine the interplay between individuals, clinics, and the healthcare system and associated policies within which they operate.

Telemedicine and HIV Care Quality Measures During the COVID-19 Pandemic

BACKGROUND

During the COVID-19 pandemic, telemedicine was adopted to ensure continuity of HIV care. We examined how introducing televisits affected technical quality of care for people with HIV (PWH) during this time.

METHODS

PWH receiving HIV care at Howard Brown Health Centers and Northwestern University in Chicago, Illinois were included. HIV care quality indicators were calculated using data extracted from electronic medical records during 4 timepoints every 6 months from March, March 1, 2020 to September 1, 2021. Generalized linear mixed models estimated differences in indicators across timepoints within each site while controlling for multiple observations of individuals. Generalized linear mixed models were also used to compare differences in outcomes among PWH who attended all versus a combination of in-person and televisits versus no televisits across the study time periods.

RESULTS

6447 PWH were included in the analysis. Compared with prepandemic levels, there were significant declines in care utilization and processes of care measures. Measures of HIV virologic suppression, blood pressure control, and HbA1C <7% (in both people with and without diabetes) were stable with no significant differences noted across the study timepoints. Similar trends were observed across all age, race, and sex subgroups. In multivariable models, televisits were not associated with decreased HIV viral suppression.

CONCLUSIONS

During the COVID-19 pandemic and rapid implementation of televisits, indicators of care utilization and processes of care decreased compared with prepandemic levels. Among PWH who remained in care, televisits were not associated with worse virologic, blood pressure, and glycemic control in PWH.

HIV Care Meets Telehealth: a Review of Successes, Disparities, and Unresolved Challenges

Purpose of Review

This review summarizes the current state of telehealth utilization in HIV care delivery by highlighting successes, gaps, and unresolved challenges related to access, disparities, care providers in and standardization of policies and protocol.

Recent Findings

Telehealth adoption in HIV care delivery in the USA has been successful. Despite this success, racial minority groups, older adults, and individuals with low telehealth literacy report low preference, dissatisfaction, and experience poorer health outcomes than other groups. Lack of broadband access, compatible devices, standardization, and government regulations of telehealth in HIV care contribute to poor patient-provider experience and utilization.

Summary

Telehealth remains a valuable tool in HIV care. However, disparities exist in access and health outcomes. Telehealth literacy, broadband access, protecting patients’ data, policies, and standardized protocols are critical in sustaining telehealth for HIV care. Further research is needed on preferences and how specific telehealth platforms influence HIV treatment outcomes.

Clinical Effectiveness of Telemedicine-Based Pediatric Genetics Care

BACKGROUND AND OBJECTIVES

Telemedicine may increase access to medical genetics care. However, in the pediatric setting, how telemedicine may affect the diagnostic rate is unknown, partially because of the perceived importance of the dysmorphology physical examination. We studied the clinical effectiveness of telemedicine for patients with suspected or confirmed genetic conditions.

METHODS

We conducted a retrospective cohort study of outpatient encounters before and after the widespread implementation of telemedicine (N = 5854). Visit types, diagnoses, patient demographic characteristics, and laboratory data were acquired from the electronic health record. Patient satisfaction was assessed through survey responses. New molecular diagnosis was the primary end point.

RESULTS

Patients seen by telemedicine were more likely to report non-Hispanic White ancestry, prefer to speak English, live in zip codes with higher median incomes, and have commercial insurance (all P < .01). Genetic testing was recommended for more patients evaluated by telemedicine than in person (79.5% vs 70.9%; P < .001). Patients seen in person were more likely to have a sample collected, resulting in similar test completion rates (telemedicine, 51.2%; in person, 55.1%; P = .09). There was no significant difference in molecular diagnosis rate between visit modalities (telemedicine, 13.8%; in person, 12.4%; P = .40).

CONCLUSIONS

Telemedicine and traditional in-person evaluation resulted in similar molecular diagnosis rates. However, improved methodologies for remote sample collection may be required. This study reveals the feasibility of telemedicine in a large academic medical genetics practice and is applicable to other pediatric specialties with perceived importance of physical examination.