Making the connection: the importance of engagement and retention in HIV medical care

A Focus on Aging, HIV/AIDS, and Neurocognitive Challenges: Examining Southern Nevada HIV Sector Providers' Awareness and Prospective Roles

Although abundant research has been carried out to investigate the underlying mechanisms that may cause neurocognitive challenges among middle-aged and older people living with HIV/AIDS (PLWH), to monitor the prevalence rates of HIV-related neurocognitive deficits, and to identify factors related to the improvement of diagnostic screening tools, classification and nosology, and clinical and rehabilitative treatment of HIV-Associated Neurocognitive Disorder (HAND); to date, there have been only a few studies that have explored and examined the awareness and work experiences HIV sector healthcare and service providers have related to HAND. To address this research gap, we conducted a qualitative, community-based participatory research study and interviewed 12 HIV sector providers in Southern Nevada, USA, from January to April 2022. After performing a thematic analysis of our interviews, we were able to identify two major themes and several sub-themes. Under our first major theme, provider awareness and knowledge, we identified four sub-themes: (1) prior knowledge and current awareness; (2) lived experiences of patients and clients with neurocognitive challenges; (3) lack of knowledge as a barrier to providing needed care; and (4) continuing education and professional development. Under our second major theme, prospective provider roles, we identified three sub-themes: (1) early detection; (2) direct and practical support; and (3) appropriate and timely referrals. In this article, we discuss our findings and lessons learned from our study, as well as their implications for the future work of researchers and providers in the HIV sector related to improving care and support for people aging with HIV/AIDS and experiencing neurocognitive challenges.

Does the Relationship Between HIV Stigma Subtypes and Viral Suppression Differ by Age?: A Stratified Analysis of Data from the Florida Medical Monitoring Project

HIV-related stigma is recognized as a top barrier to achieve viral suppression in the United States, but data describing who is most affected by HIV stigma is limited. The study sought to (1) identify the relationships between HIV-related stigma and unsuppressed viral load and (2) examine whether the association between HIV stigma subtypes and unsuppressed viral load differ by age group (i.e., 18-34, 35-49, and 50+ years-old) using surveillance data from the Florida Medical Monitoring Project (n = 1195). Most participants were 50+ years-old (55%), male (71%), and Black (51%). Enacted stigma was significantly associated with unsuppressed viral loads among the 18-34-year-old age group (OR 1.68, CI 1.09-2.60). After adjusting for potential confounders, only enacted stigma was independently associated with unsuppressed viral load in the 18-34-year-old age group. Results highlight the need for targeted interventions to reduce enacted stigma among younger persons with HIV to achieve viral suppression.

Strategies to improve HIV care outcomes for people with HIV who are out of care

OBJECTIVE

The aim of this study was to evaluate the effectiveness of five intervention strategies: patient navigation, appointment help/alerts, psychosocial support, transportation/appointment accompaniment, and data-to-care on HIV care outcomes among persons with HIV (PWH) who are out of care (OOC).

DESIGN

A systematic review with meta-analysis.

METHODS

We searched CDC's Prevention Research Synthesis (PRS) Project's cumulative HIV database to identify intervention studies conducted in the U.S., published between 2000 and 2020 that included comparisons between groups or prepost, and reported at least one relevant outcome (i.e. re-engagement or retention in HIV care, and viral suppression). Effect sizes were meta-analyzed using random-effect models to assess intervention effectiveness.

RESULTS

Thirty-nine studies reporting on 42 unique interventions met the inclusion criteria. Overall, intervention strategies are effective in improving re-engagement in care [odds ratio (OR) = 1.79;95% confidence interval (95% CI): 1.36-2.36, k = 14], retention in care (OR = 2.01; 95% CI: 1.64-2.64, k = 22), and viral suppression (OR = 2.50;95% CI: 1.87-3.34, k = 27). Patient navigation, appointment help/alerts, psychosocial support, and transportation/appointment accompaniment improved all three HIV care outcomes. Data-to-care improved re-engagement and retention but had insufficient evidence for viral suppression.

CONCLUSION

Several strategies are effective for improving HIV care outcomes among PWH who are OOC. More work is still needed for consistent definitions of OOC and HIV care outcomes, better reporting of intervention and cost data, and identifying how best to implement and scale-up effective strategies to engage and retain OOC PWH in care and reach the ending the HIV epidemic goals.

Patient Co-Participation in Narrative Medicine Curricula as a Means of Engaging Patients as Partners in Healthcare: A Pilot Study Involving Medical Students and Patients Living with HIV

This paper describes a pilot study of a new model for narrative medicine training, "community-based participatory narrative medicine" (CBPNM), which centers on shared narrative work between healthcare trainees and patients. Nine medical students and eight patients participated in one of two, five-week-long pilot workshop series. A case study of participants' experiences of the workshop series identified three major themes: (1) the reciprocal and collaborative nature of participants' relationships; (2) the interplay between self-reflection and receiving feedback from others; and (3) the clinical and pedagogical implications of the CBPNM model. Principles and proposed outcomes of the CBPNM model are presented.

Linking racism and homonegativity to healthcare system distrust among young men of color who have sex with men: Evidence from the Healthy Young Men's (HYM) study

BACKGROUND

Experiences with racism predict healthcare system distrust among people of color, but Black and Latino young men who have sex with men (YMSM) also experience overlapping forms of stigma associated with their sexual identities and behaviors (i.e., homonegativity and internalized homonegativity). These forms of minority stress may drive healthcare system distrust among Black and Latino YMSM but have received far less attention.

OBJECTIVES

To examine the associations of racism, homonegativity, and internalized homonegativity with healthcare system distrust among a community sample of Black and Latino YMSM.

METHODS

Data came from waves 2-4 (years 2017-2018) of the Healthy Young Men's study, a longitudinal cohort study of Black and Latino YMSM living in Los Angeles County. Data across waves (n = 424, nobs = 1272) were combined and analyzed using a fixed effects approach and adjusting for repeated measures across participants. A series of regression models that added sets of covariates (demographics, syndemic indicators, and health-related factors) were tested to examine associations of racism, homonegativity, and internalized homonegativity with healthcare system distrust.

RESULTS

Adjusting for demographics and syndemic indicators, racism, but not homonegativity or internalized homonegativity, was associated with healthcare system distrust. Adjustment for health-related factors had little impact on results.

CONCLUSIONS

Among Black and Latino YMSM, greater exposure to racism is associated with greater healthcare system distrust. Efforts to strengthen healthcare system trust should explicitly target the institutional policies that disproportionately harm people of color.

Sociocultural Contexts of Access to HIV Primary Care and Participant Experience with an Intervention Project: African American Transgender Women Living with HIV in Alameda County, California

The baseline data of the intervention project for African American transgender women living with HIV showed that more than one-third of the participants having ever enrolled in HIV care had not received ART and that among those in ART, more than half reported their adherence to ART was poor. Those who had engaged in sex work, sold drugs, or experienced higher levels of transphobia were less likely to have enrolled in care. The qualitative interviews with participants who had completed the intervention or dropped out revealed barriers to enroll in care, such as community stigma and transphobia.

Measuring Unmet Needs among Persons Living with HIV at Different Stages of the Care Continuum

Unmet needs can impede optimal care engagement, impacting the health and well-being of people living with HIV (PLWH); yet, whether unmet needs differ by care engagement status is not well understood. Using surveys and qualitative interviews, we examined and compared unmet needs for PLWH (n = 172) at different levels of care engagement. Unmet needs varied only slightly by care status. Survey findings revealed that provision of housing, emergency financial assistance, employment assistance, and food security were the greatest unmet need; for those in care, housing was the greatest unmet need, whereas for those sporadically in care or out of care, employment assistance was the greatest unmet needs. Qualitative interviews likewise illustrated that a lack of financial resources including insurance, housing, employment, and transportation presented barriers to care engagement across all care groups. Our findings indicate that unmet needs among PLWH are complex and multi-faceted across care engagement status.

Health information technology interventions and engagement in HIV care and achievement of viral suppression in publicly funded settings in the US: A cost-effectiveness analysis

BACKGROUND

The US National HIV/AIDS Strategy (NHAS) emphasizes the use of technology to facilitate coordination of comprehensive care for people with HIV. We examined cost-effectiveness from the health system perspective of 6 health information technology (HIT) interventions implemented during 2008 to 2012 in a Ryan White HIV/AIDS Program (RWHAP) Special Projects of National Significance (SPNS) Program demonstration project.

METHODS/FINDINGS

HIT interventions were implemented at 6 sites: Bronx, New York; Durham, North Carolina; Long Beach, California; New Orleans, Louisiana; New York, New York (2 sites); and Paterson, New Jersey. These interventions included: (1) use of HIV surveillance data to identify out-of-care individuals; (2) extension of access to electronic health records (EHRs) to support service providers; (3) use of electronic laboratory ordering and prescribing; and (4) development of a patient portal. We employed standard microcosting techniques to estimate costs (in 2018 US dollars) associated with intervention implementation. Data from a sample of electronic patient records from each demonstration site were analyzed to compare prescription of antiretroviral therapy (ART), CD4 cell counts, and suppression of viral load, before and after implementation of interventions. Markov models were used to estimate additional healthcare costs and quality-adjusted life-years saved as a result of each intervention. Overall, demonstration site interventions cost $3,913,313 (range = $287,682 to $998,201) among 3,110 individuals (range = 258 to 1,181) over 3 years. Changes in the proportion of patients prescribed ART ranged from a decrease from 87.0% to 72.7% at Site 4 to an increase from 74.6% to 94.2% at Site 6; changes in the proportion of patients with 0 to 200 CD4 cells/mm3 ranged from a decrease from 20.2% to 11.0% in Site 6 to an increase from 16.7% to 30.2% in Site 2; and changes in the proportion of patients with undetectable viral load ranged from a decrease from 84.6% to 46.0% in Site 1 to an increase from 67.0% to 69.9% in Site 5. Four of the 6 interventions-including use of HIV surveillance data to identify out-of-care individuals, use of electronic laboratory ordering and prescribing, and development of a patient portal-were not only cost-effective but also cost saving ($6.87 to $14.91 saved per dollar invested). In contrast, the 2 interventions that extended access to EHRs to support service providers were not effective and, therefore, not cost-effective. Most interventions remained either cost-saving or not cost-effective under all sensitivity analysis scenarios. The intervention that used HIV surveillance data to identify out-of-care individuals was no longer cost-saving when the effect of HIV on an individual's health status was reduced and when the natural progression of HIV was increased. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess sites against themselves at baseline and not against standard of care during the same time period.

CONCLUSIONS

These results provide additional support for the use of HIT as a tool to enhance rapid and effective treatment of HIV to achieve sustained viral suppression. HIT has the potential to increase utilization of services, improve health outcomes, and reduce subsequent transmission of HIV.

Are missed- and kept-visit measures capturing different aspects of retention in HIV primary care?

The literature recognizes six measures of retention in care, an integral component of the HIV Continuum of Care. Given prior research showing that different retention measures are differentially associated with HIV health outcomes (e.g., CD4 count and viral suppression), we hypothesized that different groups of people living with HIV (PLWH) would also have differential retention outcomes based on the retention measure applied. We conducted a cross-sectional analysis of multisite patient-level medical record data (n = 10,053) from six academically-affiliated HIV clinics using six different measures of retention. Principal component analysis indicated two distinct retention constructs: kept-visit-measures and missed-visit measures. Although black (compared to white) PLWH had significantly poorer retention on the three missed-visit measures, race was not significantly associated with any of the three kept-visit measures. Males performed significantly worse than females on all kept-visit measures, but sex differences were not observed for any missed-visit retention measures. IDU risk transmission group and younger age were associated with poorer retention on both missed- and kept-visit retention measures. Missed- and kept-visit measures may capture different aspects of retention, as indicated in the observed differential associations among race, sex, age, and risk transmission group. Multiple measures are needed to effectively assess retention across patient subgroups.

Antiretroviral Adherence Trajectories Among Black Americans Living with HIV

Black people living with HIV (BPLWH) are less likely to adhere to antiretroviral treatment than are members of other racial/ethnic groups. Data were combined from two studies of BPLWH (n = 239) to estimate adherence trajectories using a semiparametric, group-based modeling strategy over three time-points (spanning 6 months). Analyses identified three groups of individuals (high-stable, moderately low-stable, low-decreasing). Multinomial logistic regressions were used to predict trajectory membership with multiple levels of socio-ecological factors (structural, institutional/health system, community, interpersonal/network, individual). Older age was associated with being in the high-stable group, whereas substance use, lower perceived treatment effectiveness, and lower quality healthcare ratings were related to being in the moderately low-stable group. In sum, multiple socio-ecological factors contribute to adherence among BPLWH and thus could be targeted in future intervention efforts.

A Focus on the HIV Care Continuum Through the Healthy Young Men's Cohort Study: Protocol for a Mixed-Methods Study

BACKGROUND

No group is at greater risk for acquiring HIV than young men who have sex with men (YMSM), particularly black or African American (AA) and Hispanic or Latino (L) YMSM living in inner cities, who account for the largest number of new HIV infections each year. Although pre-exposure prophylaxis (PrEP), postexposure prophylaxis (PEP), and treatment as prevention hold enormous promise for changing the course of the epidemic, AA/L-YMSM are the least likely population to be receiving primary health care and HIV prevention/care and are the least likely to be using PrEP and PEP.

OBJECTIVE

The overarching aim of the Healthy Young Men's (HYM) cohort study is to conduct longitudinal research with a cohort of AA/L-YMSM to prevent new HIV infections, reduce transmission, and reduce HIV/AIDS-related disparities by focusing on successful engagement in care. Findings from this research will be used to inform the development of new interventions designed to engage AA/L-YMSM in the HIV prevention and care continua.

METHODS

Longitudinal research (baseline and follow-up assessments every 6 months for a total of 8 waves of data collection) is ongoing with a new cohort of 450 high-risk AA/L-YMSM in Los Angeles. Participants were recruited using a venue-based and social media sampling design. In addition to self-report surveys, the study protocol includes the collection of urine to assess recent use of illicit drugs and the collection of blood and rectal/throat swabs to test for current sexually transmitted infection (STI)/HIV infection. An additional sample of blood/plasma (10 mL for 4 aliquots and 1 pellet) is also collected and stored in the HYM cohort study biorepository for future research. By design, we recruited 400 HIV-negative participants and 50 HIV-positive (HIV+) participants. This mixed-methods study design includes collection and triangulated analysis of quantitative, qualitative, and biological measures (ie, drug use, STI/HIV testing, and adherence to antiretroviral therapy among HIV+ participants) at baseline and every 6 months. The HYM cohort study will provide a platform from which new and emerging biomedical prevention strategies (eg, PrEP, rectal microbicides, and PEP) and other HIV prevention and care engagement interventions can be developed and evaluated with AA/L-YMSM.

RESULTS

To date, all participants in the HYM cohort study have been recruited and baseline assessment has been conducted.

CONCLUSIONS

The findings from this research will be used to inform the development of new and/or adaptation of existing evidence-based HIV prevention interventions and interventions designed to engage this population in the HIV prevention and care continua.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/10738.

'Drug adherence levels are falling down again': health worker perceptions of women's service utilization before and after integration of HIV/AIDS services into general care in India

Integrated models of HIV/AIDS service delivery are believed to have advantages over stand-alone models of care from health planners' and providers' perspectives. Integration models differ, yet there is little information about the influence of differing models on workers' beliefs about models' efficacy. Here, we examine the effect of integration of HIV care into the general health system in India. In 2014, India replaced its stand-alone model of HIV service delivery-Community Care Centers (CCCs)-with a purported integrated model that delivers HIV medical services at general hospitals and HIV psychosocial services at nearby Care and Support Centers (CSCs). We examine 15 health workers' perceptions of how change from the earlier stand-alone model to the current model impacted women's care in a district in Uttar Pradesh, India. Results indicate that (1) Women's antiretroviral (ART) adherence and utilization of psychosocial support service for HIV/AIDS suffered when services were not provided at one site; (2) Provision of inpatient care in the CCC model offered women living in poverty personal safety in accessing HIV health services and promoted chances of competent ART usage and repeat service utilization; and (3) Although integration of HIV services with the general health system was perceived to improve patient anonymity and decrease chances of HIV-related stigma and discrimination, resource shortages continued to plague the integrated system while shifting costs of time and money to the patients. Findings suggest that integration efforts need to consider the context of service provision and the gendered nature of access to HIV care.

Randomized Trial of a Health Coaching Intervention to Enhance Retention in Care: California Collaborative Treatment Group 594

Poor linkage, engagement and retention remain significant barriers in achieving HIV treatment goals in the US. HIV-infected persons entering or re-entering care across three Southern California academic HIV clinics, were randomized (1:1) to an Active, Linkage, Engagement, Retention and Treatment (ALERT) specialist for outreach and health coaching, or standard of care (SOC). The primary outcome of time to loss to follow up (LTFU) was compared using Cox proportional hazards regression modeling. No differences in the median time to LTFU (81.7 for ALERT versus 93.6 weeks for SOC; HR 1.27; p = 0.40), or time to ART initiation was observed (N = 116). Although, ALERT participants demonstrated worsening depressive symptomatology from baseline to week 48 compared to SOC (p = 0.02). The ALERT intervention did not improve engagement and retention in HIV care over SOC. Further studies are needed to determine how best to apply resources to improve retention and engagement.

Effectiveness of a Peer Navigation Intervention to Sustain Viral Suppression Among HIV-Positive Men and Transgender Women Released From Jail: The LINK LA Randomized Clinical Trial

IMPORTANCE

Diagnosis of human immunodeficiency virus (HIV) infection, linkage and retention in care, and adherence to antiretroviral therapy are steps in the care continuum enabling consistent viral suppression for people living with HIV, extending longevity and preventing further transmission. While incarcerated, people living with HIV receive antiretroviral therapy and achieve viral suppression more consistently than after they are released. No interventions have shown sustained viral suppression after jail release.

OBJECTIVE

To test the effect on viral suppression in released inmates of the manualized LINK LA (Linking Inmates to Care in Los Angeles) peer navigation intervention compared with standard transitional case management controls.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted from December 2012 through October 2016 with people living with HIV being released from Los Angeles (LA) County Jail. All participants were (1) 18 years or older; (2) either men or transgender women diagnosed with HIV; (3) English speaking; (4) selected for the transitional case management program prior to enrollment; (5) residing in LA County; and (6) eligible for antiretroviral therapy.

MAIN OUTCOMES AND MEASURES

Change in HIV viral suppression (<75 copies/mL) over a 12-month period.

INTERVENTIONS

During the 12-session, 24-week LINK LA Peer Navigation intervention, trained peer navigators counseled participants on goal setting and problem solving around barriers to HIV care and adherence, starting while the participants were still in jail. After their release, they continued counseling while they accompanied participants to 2 HIV care visits, then facilitated communication with clinicians during visits.

RESULTS

Of 356 participants randomized, 151 (42%) were black; 110 (31%) were Latino; 303 (85%) were men; 53 (15%) were transgender women; and the mean (SD) age was 39.5 (10.4) years. At 12 months, viral suppression was achieved by 62 (49.6%) of 125 participants in the peer navigation (intervention) arm compared with 45 (36.0%) of 125 in the transitional case management (control) arm, for an unadjusted treatment difference of 13.6% (95% CI, 1.34%-25.9%; P = .03). In the repeated measures, random effects, logistic model the adjusted probability of viral suppression declined from 52% at baseline to 30% among controls, while those in the peer navigation arm maintained viral suppression at 49% from baseline to 12 months, for a difference-in-difference of 22% (95% CI, 0.03-0.41; P = .02).

CONCLUSIONS AND RELEVANCE

The LINK LA peer navigation intervention was successful at preventing declines in viral suppression, typically seen after release from incarceration, compared with standard transitional case management. Future research should examine ways to strengthen the intervention to increase viral suppression above baseline levels.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01406626.

Factors that Motivated Otherwise Healthy HIV-Positive Young Adults to Access HIV Testing and Treatment in South Africa

The World Health Organization recommends early initiation of HIV antiretroviral therapy (ART) for all those infected with the virus at any CD4 count. Successfully reaching individuals with relatively high CD4 counts depends in large part on healthy individuals seeking testing and treatment; however, little is known about factors motivating this decision. We conducted a qualitative study to explore this issue among 25 young HIV-positive adults (age 18-35) with a CD4 count >350 cells/mm³ who recently started or made the decision to start ART in Gugulethu, South Africa. Using an inductive content analytical approach, we found that most individuals sought testing and treatment early in the disease progression because of a desire to appear healthy thereby avoiding stigma associated with AIDS. Other factors included social support, responsibilities and aspirations, normalcy of having HIV, and accessible services. These findings suggest that maintenance of physical appearance should be included in the development of novel testing and treatment interventions.

Competing subsistence needs are associated with retention in care and detectable viral load among people living with HIV

Competing priorities between subsistence needs and health care may interfere with HIV health. Longitudinal data from the Los Angeles-based HIV Outreach Initiative were analyzed to examine the association between competing subsistence needs and indicators of poor retention-in-care among hard-to-reach people with HIV. Sacrificing basic needs for health care in the previous six months was associated with a 1.55 times greater incidence of missed appointments (95% CI 1.17, 2.05), 2.32 times greater incidence of emergency department visits (95% CI 1.39, 3.87), 3.66 times greater incidence of not receiving ART if CD4 < 350 (95% CI 1.60, 8.37), and 1.35 times greater incidence of detectable viral load (95% CI 1.07, 1.70) (all p < 0.01). Among hard-to-reach PLHIV, sacrificing basic needs for health care delineates a population with exceptional vulnerability to poor outcomes along the HIV treatment cascade. Efforts to identify and reduce competing needs for this population are crucial to HIV health outcomes.

Linkage between HIV diagnosis and care: Understanding the role of gender in a Northern Province in Vietnam

Early linkage to HIV care is associated significantly with improved patient outcomes and reduced the risk of HIV transmission. However, delays between HIV diagnosis and registering for care have prevailed in Vietnam. The aim of researchers in this study is to examine linkages to care for individuals newly diagnosed with HIV in 2014, especially to highlight the impact of gender upon these linkages in a Northern Province of Ninh Binh. We collected secondary data of all 125 eligible HIV positive people diagnosed in 2014 and conducted a gender-based descriptive analysis of their registration to care within 6 months. Nineteen in-depth interviews and two focus group discussions were completed. We found that women accounted for one-third of newly diagnosed cases (42/125), but initiated HIV treatment at an earlier stage of HIV disease than men (65% women at stage 1, 2 versus 31% in men). Stigma and discrimination was greater among women while inadequate awareness of treatment was greater for men. Dissatisfaction with HIV testing and counseling and no or passive referral to treatment were other barriers for both the genders for enrolling in care services after diagnosis.

Barriers and facilitators of the HIV care continuum in Southern New England for people with drug or alcohol use and living with HIV/AIDS: perspectives of HIV surveillance experts and service providers

BACKGROUND

Contemporary studies about HIV care continuum (HCC) outcomes within substance using populations primarily focus on individual risk factors rather than provider- or systems-level influences. Over 25% of people living with HIV (PLWH) have substance use disorders that can alter their path through the HCC. As part of a study of HCC outcomes in nine small cities in Southern New England (population 100,000-200,000 and relatively high HIV prevalence particularly among substance users), this qualitative analysis sought to understand public health staff and HIV service providers' perspectives on how substance use may influence HCC outcomes.

METHODS

Interviews with 49 participants, collected between November 2015 and June 2016, were analyzed thematically using a modified social ecological model as the conceptual framework and codes for substance use, HCC barriers and facilitators, successes and failures of initiatives targeting the HCC, and criminal justice issues.

RESULTS

Eight themes were identified concerning the impact of substance use on HCC outcomes. At the individual level, these included coping and satisfying basic needs and could influence all HCC steps (i.e., testing, treatment linkage, adherence, and retention, and viral load suppression). The interpersonal level themes included stigma issues and providers' cultural competence and treatment attitudes and primarily influenced treatment linkage, retention, and viral load suppression. These same HCC steps were influenced at the health care systems level by organizations' physical environment and resources as well as intra-/inter-agency communication. Testing and retention were the most likely steps to affect at the policy/society level, and the themes included opposition within an organization or community, and activities with unintended consequences.

CONCLUSIONS

The most substantial HCC challenges for PLWH with substance use problems included linking and retaining in treatment those with multiple co-morbidities and meeting their basic living needs. Recommendations to improve HCC outcomes for PLWH with substance use problems include increasing easy access to effective drug and mental health treatment, expanding case management and peer navigation services, training staff about harm reduction, de-stigmatizing, and culturally competent approaches to interacting with patients, and increasing information-sharing and service coordination among service providers and the social service and criminal justice systems.

Effects of a Laboratory Health Information Exchange Intervention on Antiretroviral Therapy Use, Viral Suppression, and Racial/Ethnic Disparities

BACKGROUND

Although antiretroviral therapy (ART) is available to treat HIV+ persons and prevent transmission, ineffective delivery of care may delay ART use, impede viral suppression (VS), and contribute to racial/ethnic disparities along the continuum of care. This study tested the effects of a bi-directional laboratory health information exchange (LHIE) intervention on each of these outcomes.

METHODS

We used a quasi-experimental, interrupted time-series design to examine whether the LHIE intervention improved ART use and VS, and reduced racial/ethnic disparities in these outcomes among HIV+ patients (N = 1181) in a comprehensive HIV/AIDS clinic in Southern California. Main outcome measures were ART pharmacy fill and HIV viral load laboratory data extracted from the medical records over 3 years. Race/ethnicity and an indicator for the intervention (after vs. before) were the main predictors. The analysis involved 3-stage, multivariable logistic regression with generalized estimating equations.

RESULTS

Overall, the intervention predicted greater odds of ART use (odds ratio [OR] = 2.50; 95% confidence interval: 2.29 to 2.73; P < 0.001) and VS (OR = 1.12; 95% confidence interval: 1.04 to 1.21; P < 0.05) in the final models that included sociodemographic, behavioral, and clinical covariates. Before the intervention, there were significant black/white disparities in ART use OR = 0.75 (0.58-0.98; P = 0.04) and VS OR = 0.75 (0.61-0.92; P = 0.001). After the intervention, the black/white disparities decreased after adjusting for sociodemographics and the number of HIV care visits, and Latinos had greater odds than whites of ART use and VS, adjusting for covariates.

CONCLUSIONS

The intervention improved overall ART treatment and VS, and reduced black/white disparities. LHIE interventions may hold promise if implemented among similar patients.

Feasibility of identifying out of care HIV-positive patients in a hospital setting and enrolling them in a retention intervention

BACKGROUND

The hospital setting provides an opportunity to re-engage people living with HIV (PLWH) in HIV care. We developed and implemented a protocol to identify PLWH in a hospital setting. The aim of the current study was to report on our strategy to recruit hospitalized HIV patients into an intervention study, and to report on lessons learned for future studies.

METHODS

Our protocol was developed based on experience of our research staff in recruiting HIV patients as well as clinical input from providers and administrators on delivering care in hospitalized settings. We identified hospitalized PLWH between 2010 and 2013 who were potentially eligible for an intervention study. Patients were identified by review of electronic medical records and clinician referral, followed by in-person screening to confirm eligibility. We examined factors related to identifying and enrolling hospitalized patients, and documented lessons learned.

RESULTS

Key strategies included systematic medical record review followed by in-person screening, collaboration with staff, and flexibility in recruitment logistics. We identified 1801 PLWH hospitalized during the 3-year study period. Eighty-four percent (n = 1514) met the met the inclusion criteria based on medical record review. Of these, 48% (n = 733) were ineligible. Among eligible patients, 59% (n = 460) were enrolled. Only 3% (n = 23) of eligible patients declined; 84% (n = 321) were not enrolled because they were discharged before enrollment. Lessons learned included (1) needing to identify patients and deliver the intervention before hospital discharge, (2) limiting the complexity of the intervention, and (3) having research staff available on weekends and after hours.

CONCLUSIONS

Targeted recruitment of hospitalized populations is a feasible and productive approach for finding and engaging PLWH who are newly diagnosed or out of routine care.

Using Path Analysis to Evaluate the Healthcare Empowerment Model Among Persons Living with HIV for Antiretroviral Therapy Adherence

Healthcare empowerment (HCE) is patient controlled and includes the process and state of being engaged, informed, collaborative, committed, and tolerant of uncertainty. Understanding psychosocial factors that impact HCE for persons living with HIV is critical for their treatment and care. A sample of 1494 male and female participants living with HIV in the United States with a mean age of 45.6 (standard deviation = 11.4) completed a one-time online survey about their demographic characteristics, social support, healthcare provider relationship, HIV treatment knowledge, perceived HIV-related stigma, lifetime trauma, depressive symptoms, HCE, and antiretroviral therapy (ART) adherence. A path analysis was conducted using structural equation modeling software to fit a theory-based model of HCE. Results included statistically significant direct pathways between depressive symptoms, healthcare provider relationship, lifetime trauma, and ART adherence, as well as between healthcare provider relationship, HIV treatment knowledge, and HCE. Specifically, ART adherence was positively linked to healthcare provider relationship and negatively linked to depressive symptoms and lifetime trauma. In addition, healthcare provider relationship and HIV treatment knowledge were positively associated with HCE. The indirect effects of healthcare provider relationship and HIV treatment knowledge on adherence through HCE were also significant. In particular, ART adherence was indirectly and positively affected by healthcare provider relationship and HIV treatment knowledge through HCE. Multi-level interventions are urgently needed to address the effects of these psychosocial factors on ART adherence.

Creating Systems Change to Support Goals for HIV Continuum of Care: The Role of Community Coalitions to Reduce Structural Barriers for Adolescents and Young Adults

Routine population-wide HIV screening, early linkage and long-term retention in healthcare for HIV-infected individuals are key nodes of the HIV continuum of care and are essential elements of the National HIV/AIDS Strategy. Despite this, up to 80% of youth are unaware of their HIV infection status and only 29% are linked to HIV healthcare; less than half are engaged in long-term HIV healthcare, and far fewer maintain viral suppression. To fill this gap and to address the national call to action to establish a seamless system for immediate linkage to continuous and coordinated quality healthcare after diagnosis, this paper describes the processes and mechanisms by which the SMILE Program worked within the infrastructure of the ATN-affiliated Connect to Protect^® (C2P) community coalitions to address structural barriers that hindered youth in their communities from being tested for HIV infection or linked and engaged in healthcare after an HIV positive diagnosis.

Welcome back survey: exploring concerns impacting HIV care engagement and retention

The current study describes the development of a short pre-clinic survey that helped multidiscipline providers to elicit patient perspective on barriers to HIV primary care. The survey was piloted with 318 patients returning to care after being lost to care for at least 12 months. Reasons for breaks in care were dependent on age, gender, and race. Concerns about confidentiality in care were more commonly reported by African-American, Latino, and younger patients, while concerns relating to acceptance of diagnosis and side effects were greater for women, African-American, and Latino participants. Further, Intimate Partner Violence (IPV) and transportation were greater concerns for women and younger patients in the sample.

Veterans' Perspectives on Interventions to Improve Retention in HIV Care

Poor retention in HIV medical care is associated with increased mortality among patients with HIV/AIDS. Developing new interventions to improve retention in HIV primary care is needed. The Department of Veteran Affairs (VA) is the largest single provider of HIV care in the US. We sought to understand what veterans would want in an intervention to improve retention in VA HIV care. We conducted 18 one-on-one interviews and 15 outpatient focus groups with 46 patients living with HIV infection from the Michael E. DeBakey VAMC (MEDVAMC). Analysis identified three focus areas for improving retention in care: developing an HIV friendly clinic environment, providing mental health and substance use treatment concurrent with HIV care and encouraging peer support from other Veterans with HIV.

Barriers and Facilitators of Linkage to and Engagement in HIV Care Among HIV-Positive Men Who Have Sex with Men in China: A Qualitative Study

Linking and engaging HIV-positive patients in care is the key bridging step to glean the documented health and prevention advantages of antiretroviral therapy (ART). In China, HIV transmission among men who have sex with men (MSM) is surging, yet many HIV-positive MSM do not use HIV care services. We conducted a qualitative study in order to help positive interventions to promote linkage-to-care in this key population. Four focus group discussions (FGD) were held among HIV-positive MSM in Beijing, China, to ascertain knowledge, beliefs, attitudes, and practices related to HIV care. FGD participates highlighted six major barriers of linkage to/engagement in HIV care: (1) perceived discrimination from health care workers; (2) lack of guidance and follow-up; (3) clinic time or location inconvenience; (4) privacy disclosure concerns; (5) psychological burden of committing to HIV care; and (6) concerns about treatment. Five major sub-themes emerged from discussions on the facilitators of linkage to/engagement in care: (1) peer referral and accompaniment; (2) free HIV care; (3) advocacy from HIV-positive MSM counselors; (4) extended involvement for linking MSM to care; and (5) standardization of HIV care (i.e., reliable high quality care regardless of venue). An understanding of the barriers and facilitators that may impact the access to HIV care is essential for improving the continuum of care for MSM in China. Findings from our study provide research and policy guidance for how current HIV prevention and care interventions can be enhanced to link and engage HIV-positive MSM in HIV care.

Outcomes of a Clinic-Based Surveillance-Informed Intervention to Relink Patients to HIV Care

BACKGROUND

Improving patient retention in HIV care is crucial to improving the HIV care continuum. We instituted and evaluated a relinkage program that uses clinical data to identify potentially out-of-care patients, matches those data to public health surveillance, and employs a linkage specialist (LS) to coordinate care relinkage.

METHODS

The intervention began November 1, 2012, in the largest HIV clinic in Washington State. We evaluated program outcomes and compared patient outcomes in the year after initiation of the intervention to a historical control cohort of patients. Cox proportional hazard ratios were used to compare time to relinkage to care between cohorts, and regression models using generalized estimated equations were preformed to examine secondary outcomes of relinkage to care, engagement in care, and viral suppression.

RESULTS

A total of 753 patients were identified as "out of care" on November 1, 2012. Matching with surveillance data and initial LS investigations found that 596 (79%) of these patients had moved, transferred care, or were incarcerated. Of the 157 remaining patients, 40 (25%) relinked to care before LS contact, and the LS successfully contacted 38 (24%). A total of 116 (15%) patients in the intervention cohort relinked to care and 24 (20%) were contacted by the LS. Compared with the historical cohort, the time to relinkage was shorter among patients in the intervention cohort [adjusted hazard ratio = 1.7 (1.2-2.3)] and a greater proportion relinked (15% vs. 10%).

CONCLUSIONS

This clinic-based surveillance-informed relinkage intervention showed statistically significant but modest effectiveness in returning out-of-care patients to HIV care compared with historical controls.

Open Trial of an Acceptance-Based Behavior Therapy Intervention to Engage Newly Diagnosed HIV Patients in Care: Rationale and Evidence of Feasibility and Acceptability

Successful linkage and retention in care of newly diagnosed individuals in the United States remains a significant gap in the HIV care continuum. This study assessed the acceptability and feasibility of an acceptance-based behavior therapy (ABBT) intervention to engage patients newly diagnosed with HIV in medical care. Nine patients were recruited over 4 months for this brief ABBT intervention, which consisted of two brief sessions, each lasting less than 20 min. The intervention was developed to promote psychological acceptance of the HIV diagnosis, thereby increasing patients' willingness to make informed disclosure of their status. Eight patients completed a 1-month follow-up assessment, and all approved of the intervention and its components. Over the 1-month period, participants showed increased acceptance, reduced perceptions of HIV stigmatization, and increased disclosure of HIV status to social supports. This pilot study provided support for the continued investigation of ABBT as an adjunctive intervention for newly diagnosed HIV patients who are at high-risk of dropping out of HIV care.

Sorting through the lost and found: are patient perceptions of engagement in care consistent with standard continuum of care measures?

BACKGROUND

Indicators for determining one's status on the HIV care continuum are often measured using clinical and surveillance data but do not typically assess patient perspectives. We assessed patient-reported care status along the care continuum and whether it differed from medical records and surveillance data.

METHODS

Between June 2013 and October 2014, a convenience sample of clinic-attending HIV-infected persons was surveyed regarding care-seeking behaviors and self-perceived status along the care continuum. Participant responses were matched to DC Department of Health surveillance data and clinic records. Participants' care patterns were classified using Health Resources Services Administration-defined care status: in care (IC), sporadic care (SC), or out of care (OOC). Semistructured qualitative interviews were analyzed using an open coding process to elucidate relevant themes regarding participants' perceptions of engagement in care.

RESULTS

Of 169 participants, most were male participants (64%) and black (72%), with a mean age of 50.7 years. Using self-reported visit patterns, 115 participants (68%) were consistent with being IC, 33 (20%) SC, and 21 (12%) OOC. Among OOC participants, 52% perceived themselves to be fully engaged in HIV care. In the previous year, among OOC participants, 71% reported having a non-HIV-related medical visit and 90% reported current antiretroviral use. Qualitatively, most SC and OOC persons did not see their HIV providers regularly because they felt healthy.

CONCLUSIONS

Participants' perceptions of HIV care engagement differed from actual care receipt as measured by surveillance and clinical records. Measures of care engagement may need to be reconsidered as persons not receiving regular HIV care maybe accessing other health care and HIV medications elsewhere.

Barriers and facilitators to the implementation of SPNS interventions designed to engage and retain HIV positive women of color in medical care

The use of evidence-based strategies to increase access to medical care and improve health outcomes for people living with HIV is a major public health priority in the United States. As part of a multi-site evaluation funded under the Health Resources and Services Administration (HRSA), a process evaluation was conducted with the goal of understanding barriers and facilitators to the implementation of eleven heterogeneous interventions designed to engage and retain HIV positive women of color (WoC) in medical care. Findings identified barriers and facilitators to program implementation at five levels: (1) program; (2) team; (3) agency; (4) partner network; and (5) the larger socio-ecological context. We conclude with a series of recommendations that may be useful for the implementation of similar interventions focused on recruitment and retention of WoC in HIV medical care.

Factors associated with retention and viral suppression among a cohort of HIV+ women of color

Access to sustained HIV medical care is critical to achieving viral suppression. However, a variety of factors may impede or facilitate retention in care or becoming virally suppressed. Though retention and suppression are often treated separately, this study examined both in a cohort of 921 HIV+ women of color who participated in eight demonstration programs across the US. For women who met the inclusion criteria, 83% (n = 587) were retained and 73% (n = 357) were virally suppressed. Average age of women retained was 40.9, and 41.9 for those virally suppressed. The majority were African American/Black or Hispanic/Latina, single, and had no children less than 18 years of age, had health insurance, a high school degree or higher, were stably housed, and unemployed. Some factors associated with retention in care were indecision about seeking HIV medical care (AOR = 0.42) and having children under the age of 18 (AOR = 0.59). Some factors associated with being virally suppressed were living with others (AOR = 0.58), current substance abuse (AOR = 0.38), and fair/poor health (AOR = 0.40). The findings suggest different processes and social mechanisms may influence retention and viral suppression. Interventions seeking to improve retention in care may require tailored program components and strategies that focus on improving viral suppression.

Interventions that retain African Americans in HIV/AIDS treatment: implications for social work practice and research

Social workers play an important role in recognizing and addressing barriers to retention in HIV care. Although there is a large body of literature and research supporting interventions that promote medication adherence, there is limited intervention research that addresses retention in care, the precursor to adherence. Despite many advances in HIV treatment, many African Americans are not engaged in regular care. In a systematic review, the literature was critically appraised to examine intervention research designed to retain HIV-infected African Americans in treatment. Only peer-reviewed studies published from January 2002 through October 2012 were examined. The initial search generated a total of 798 studies. However, of these, only 13 met the inclusion criteria. Results highlight interventions that can be replicated by social workers--such as the use of ancillary support services, the use of adherence manuals, and theory-based interventions--to engage this population in care. Policy implications are also discussed.

Acceptability of self-conducted home-based HIV testing among men who have sex with men in Brazil: data from an on-line survey

The Brazilian HIV/AIDS epidemic is concentrated among men who have sex with men (MSM), however HIV testing rates among MSM are not commensurate with their risk. Strategies to expand early diagnosis may include use of self-conducted home-based testing kits, which are now available for purchase in the US. In April 2011 we conducted a survey with Brazilian MSM using Facebook to assess HIV testing preferences and acceptability of home-based testing. Among 356 previously tested, HIV-negative MSM, 47% reported a preference for home-based testing, 27% preferred clinic-based testing, and 26% had no preference. Less frequent testers and those who had considered testing but failed to test were more likely to prefer home-based testing. Close to 90% reported that they would use self-test kits; 62% and 54% said they would use home-based testing to make choices about unprotected sex with regular and new partners, respectively. Concerns included difficulty to understand the tests (32%) and receiving results alone (23%). Overall, home-based testing may appeal to MSM and result in increased testing frequency. Research on feasibility and utilization of self-tests in practice is needed.

Health information technology interventions enhance care completion, engagement in HIV care and treatment, and viral suppression among HIV-infected patients in publicly funded settings

BACKGROUND

The National HIV/AIDS Strategy (NHAS) emphasizes the use of technology to facilitate coordination of comprehensive care for people with HIV. We examined the effect of six health information technology (HIT) interventions in a Ryan White-funded Special Projects of National Significance (SPNS) on care completion services, engagement in HIV care, and viral suppression.

METHODS

Interventions included use of surveillance data to identify out-of-care individuals, extending access to electronic health records to support service providers, use of electronic laboratory ordering and prescribing, and development of a patient portal. Data from a sample of electronic patient records from each site were analyzed to assess changes in utilization of comprehensive care (prevention screening, support service utilization), engagement in primary HIV medical care (receipt of services and use of antiretroviral therapy), and viral suppression. We used weighted generalized estimating equations to estimate outcomes while accounting for the unequal contribution of data and differences in the distribution of patient characteristics across sites and over time.

RESULTS

We observed statistically significant changes in the desired direction in comprehensive care utilization and engagement in primary care outcomes targeted by each site. Five of six sites experienced statistically significant increases in viral suppression.

DISCUSSION

These results provide additional support for the use of HIT as a valuable tool for achieving the NHAS goal of providing comprehensive care for all people living with HIV. HIT has the potential to increase utilization of services, improve health outcomes for people with HIV, and reduce community viral load and subsequent transmission of HIV.

High Mortality Among Human Immunodeficiency Virus (HIV)-Infected Individuals Before Accessing or Linking to HIV Care: A Missing Outcome in the Cascade of Care?

BACKGROUND

The "cascade of care" displays the proportion of individuals who are infected with human immunodeficiency virus (HIV), diagnosed, linked, retained, on antiretroviral treatment, and HIV suppressed. We examined the implications of including death in the use of this cascade for program and public health performance metrics.

METHODS

Individuals newly diagnosed with HIV and living in Calgary between 2006 and 2013 were included. Through linkage with Public Health and death registries, the deaths (ie, all-cause mortality) and their distribution within the cascade were determined. Mortality rates are reported per 100 person-years.

RESULTS

Estimated new HIV infections were 680 (543 confirmed and 137 unknown cases). Forty-three individuals, after diagnosis, were never referred for HIV care. Despite referral(s), 88 individuals (18%) never attended the clinic for HIV care. Of individuals retained in care, 87% received antiretroviral therapy and 76% achieved viral suppression. Thirty-six deaths were reported (mortality rate, 1.50/100 person-years). One diagnosis was made posthumously. Deaths (20 of 35; 57%) occurred for individuals linked but not retained in care (6.93/100 person-years), and 70% were HIV-related. Mortality rate for patients in care was 0.79/100 person-years. Retained patients with detectable viremia had a death rate of 2.49/100, which contrasted with 0.28/100 person-years in those with suppressed viremia. Eight of these 15 deaths (53%) were HIV-related.

CONCLUSIONS

Over half of deaths occurred in those referred but not effectively linked or retained in HIV care, and these cases may be easily overlooked in standard HIV mortality studies. Inclusion of deaths into the cascade may further enhance its value as a public health metric.

Site migration in seeking care services from multiple providers is associated with worse clinical outcomes among HIV-infected individuals in Washington, DC

Washington, DC, is a metropolitan city with a severe HIV epidemic and faces challenges in retaining people living with HIV (PLWH) in quality care. This study assessed site migration in seeking care services and its correlates among PLWH in DC. PLWH diagnosed before 2008 and living through the end of 2010 were analyzed. Six scenarios of site migration were examined as patients visited =2, =3, and =4 different providers for their CD4 cell count and/or viral load (VL) tests in the past 3 years from 2008 to 2010 and 2 years from 2009 to 2010, respectively. Of 6480 patients analyzed from 2008 to 2010, 18.4% had CD4 < 200 cells/mm(3), 30.5% had VL > 400 copies/mL, and 76.6% were retained in same care sites; 23.4%, 5.0%, and 0.9% visited =2, =3, and =4 sites in the past 3 years from 2008 to 2010, respectively. Of 5954 patients analyzed from 2009 to 2010, 16.8% had CD4 < 200 cells/mm(3), 29.4% had VL > 400 copies/mL, and 81.9% were retained in same care sites; 18.1%, 3.1%, and 0.6% visited =2, =3, and =4 sites in the past 2 years from 2009 to 2010, respectively. Multivariable logistic regression analyses revealed that migration across six scenarios are consistently associated with CD4 < 200 cells/mm(3) and VL > 400 copies/mL. Site migration was common and associated with lower CD4 and higher VL among PLWH in DC. Frequent migration might be a factor in achieving optimal health outcomes for a subset of patients. Site migration might potentially limit effective delivery of high quality care and treatment services. The preliminary findings underscore the need for further research to assess the predictors of migration and its impact on stage of care.

Assessing the overall quality of health care in persons living with HIV in an urban environment

Ensuring high quality primary care for people living with HIV (PLWH) is important. We studied factors associated with meeting Health Resources and Services Administration-identified HIV performance measures, among a population-based sample of 376 PLWH in care at 24 Philadelphia clinics. Quality of care was assessed by a patient-level composite of 15 performance measures, focusing on HIV-specific care, vaccinations, and co-morbid condition screening. Adjusted incidence rate ratios (IRR) demonstrated relationships between patient and clinic factors and the performance measures score. The mean number of measures met was 8.52. Older age groups met more measures than 18- to 29-year-olds (age 40-49: adjusted IRR: 1.19, 95% CI: 1.05-1.35; age ≥50: adjusted IRR: 1.19, 95% CI: 1.03-1.35). Higher CD4 counts were associated with meeting more measures compared to CD4 <200 cells/μL (CD4 350-499 cells/μL: adjusted IRR: 1.14, 95% CI: 1.02-1.28; ≥500 cells/μL: adjusted IRR: 1.12, 95% CI: 1.01-1.26). PLWH attending clinics that provide adherence counseling or case management met more measures (adjusted IRR: 1.12, 95% CI: 1.04-1.21; adjusted IRR: 1.08, 95% CI: 1.02-1.14; respectively) than those attending clinics without these services. Limitations include potentially poor performance measure documentation and equal treatment of measures. Future work should focus on improving compliance with performance measures.

Physician communication behaviors from the perspective of adult HIV patients in Kenya

OBJECTIVE

We describe perceived physician communication behaviors and its association with adherence to care, among HIV patients in Kenya.

DESIGN

This cross-sectional study was conducted between July and August 2011.

SETTING

The study was conducted in three adult HIV clinics within the Academic Model Providing Healthcare program in western Kenya.

PARTICIPANTS

HIV adult patients.

MAIN OUTCOME MEASURES

Patient's predisposition to attend clinic, missed appointment and missed combined antiretroviral therapy (cART) medication.

RESULTS

A total of 400 patients were enrolled and participated in the study; the median age was 38 years (IQR = 33-44) and 56.5% were female. Patients perceived physicians engaged in a high number of communication behaviors (mean = 3.80, range 1-5). A higher perceived general health status (P = 0.01), shorter distance to the health facility (P = 0.03) and lesser time spent at the health facility (P = 0.02) were associated with a higher number of perceived physician communication behaviors. Physician-patient relationship factors were not associated with physician communication behaviors. In addition, a higher number of perceived physician communication behaviors was associated with a very high likelihood of patients' attending the next HIV clinic [adjusted odds ratio (AOR): 1.89, 95% confidence interval (CI): 1.49-2.40], a lower likelihood of patients' missing an appointment (AOR: 0.75, 95% CI: 0.61-0.92) and missing cART medication (AOR: 0.68, 95% CI: 0.52-0.87).

CONCLUSION

Patients' perception of physician communication behaviors was found to be associated with their adherence to HIV care.

Retention in care within 1 year of initial HIV care visit in a multisite US cohort: who's in and who's out?

Biannual attendance at medical visits is an established measure of retention in HIV care. We examined factors associated with attending at least 2 clinic visits at least 90 days apart among HIV-infected, antiretroviral therapy (ART)-naive HIV Outpatient Study participants entering care during 2000 to 2011. Of 1441 patients, 85% were retained in care during the first year of observation. Starting ART during the year was the strongest correlate of retention (adjusted odds ratio [aOR] 6.4, 95% confidence interval [CI] 4.4-9.4). After adjusting for starting ART, publicly insured patients (aOR 0.6, 95% CI 0.4-1.0), and patients with baseline CD4 counts <200 cells/mm(3) (aOR 0.5, 95% CI 0.3-0.9) or missing CD4 counts (aOR 0.3, 95% CI 0.2-0.6) were less likely to be retained in care. Although most patients had recommended biannual care visits, some ART-naive individuals may require additional interventions to remain in care. Promptly initiating ART may facilitate engagement in care.

Higher quality communication and relationships are associated with improved patient engagement in HIV care

Patient retention in HIV care may be influenced by patient-provider interactions. In an urban, academic HIV clinic, 1363 patients rated the quality of communication and relationships with their providers on 5 domains. We used linear regressions to investigate associations between these 5 domains and appointment adherence. In multivariate analysis, patients kept more appointments if providers treated them with dignity and respect, listened carefully to them, explained in ways they could understand, and knew them as persons. Being involved in decisions was not significantly associated with appointment adherence. Enhancing providers' skills in effective communication and relationship building may improve patient retention in HIV care.

"Taking a half day at a time:" patient perspectives and the HIV engagement in care continuum

The HIV treatment continuum, or "cascade," outlines key benchmarks in the successful treatment of HIV-infected individuals. However, the cascade fails to capture important dimensions of the patient experience in that it has been constructed from a provider point of view. In order to understand meaningful steps in the HIV care cascade for individuals diagnosed with HIV through expanded, more routine testing, we conducted in-depth interviews (n=34) with three groups of individuals: those diagnosed with HIV in the emergency department/urgent care clinic who linked to HIV care and exhibited 100% appointment adherence in the first 6 months of HIV care; those diagnosed in the emergency department/urgent care clinic who linked to HIV care and exhibited sporadic appointment adherence in the first 6 months of HIV care, and; hospitalized patients with no outpatient HIV care for at least 6 months. This last group was chosen to supplement data from in-care patients. The engagement in care process was defined by a changing perspective on HIV, one's HIV identity, and the role of health care. The linkage to care experience laid the groundwork for subsequent retention. Interventions to support engagement in care should acknowledge that patient concerns change over time and focus on promoting shifts in perspective.

Psychometric Assessment of a Physician-Patient Communication Behaviors Scale: The Perspective of Adult HIV Patients in Kenya

Introduction. There have been no scales specifically developed to assess physician-patient communication behaviors (PPCB) in the sub-Saharan population. Aim. We revised an existing PPCB scale and tested its psychometric properties for HIV patients in Kenya. Methods. 17 items (five-point scale) measuring PPCB were initially adopted from the Matched Pair Instrument (MPI). Between July and August 2011, we surveyed a convenient sample of 400 HIV adult patients, attending three Academic Model Providing Healthcare program (AMPATH) clinics in Eldoret, Kenya. Of these 400, eight also participated in cognitive interviews, and 200 were invited to return after one week for follow-up interviews; 134 (67%) returned and were interviewed. Construct and content validity were established using an exploratory factor analysis, bivariate analyses, internal consistency, test-retest reliability and cognitive interviews. Results. Construct and content validity supported a one-dimensional measure of 13 PPCB items. Items assessed physicians' effort to promote a favorable atmosphere for interaction with HIV patients. Biases associated with encoding and comprehension of specific terms, such as "discussion, involvement or concerns," were noted. Internal consistency (Cronbach's alpha = .81) and one-week retest reliability scores (.82) supported the reliability of the 13-item scale. Discussion. The revised PPCB scale showed acceptable validity and reliability in Kenya.

African-Americans' perceptions of health care provider cultural competence that promote HIV medical self-care and antiretroviral medication adherence

Most studies of cultural competence in healthcare examine healthcare providers' definitions of cultural competence practices. This study is unique in that it examines the relationship between African-American patients' perceptions of the cultural competence of their HIV healthcare providers and the adherence of these patients to medical self-care and antiretroviral therapy (ART). This cross-sectional, exploratory, descriptive study was conducted at the Ruth Rothstein CORE Center in Chicago, Illinois. The sample consisted of 202 HIV-positive African-Americans who completed surveys during clinic visits. Multiple measures were used, including the Patient Assessments of Cultural Competency survey instrument developed by the Department of Health and Human Services Agency for Healthcare Research and Quality. Medical self-care was measured using the advice and instructions scale and the self-care symptom management for people living with HIV/AIDS categorical scale. ART adherence was measured using the Adherence Behaviors Self-Report and Adherence Self-Report scales. The data revealed many significant correlations between variables. The more patients believed that providers should integrate culture in HIV treatment; the better their reported health (F1,138=0.151, P=0.05) and the more they followed their provider's advice and instructions (medical self-care; F1,138=0.029, P=0.05). Participants who trusted their providers engaged in more medical self-care (F1,138=0.280, P=0.01). More shared treatment decisions were reported among participants who had higher levels of education (F1,127=0.337, P=0.05). Findings of this study indicate the need for increased attention to the role of cultural competence in HIV/AIDS care. Understanding patient perceptions of provider cultural competence has the potential to improve HIV treatment adherence and health outcomes.

The impact of African Americans' beliefs about HIV medical care on treatment adherence: a systematic review and recommendations for interventions

Disparities in access to and retention of regular HIV medical treatment persist among African Americans living with HIV. Many scholars believe that the mistrust of health care held by many African Americans stems from a legacy of abuse, from medical experimentation on slaves to the unethical practices with patients in the Tuskegee Syphilis study. We performed a systematic appraisal of the literature, using several key terms, in order to understand how attitudes about HIV-related health care influence African Americans' engagement in care. We examined peer-reviewed studies published during the period January 2001 through May 2012. An initial search generated 326 studies. Sixteen descriptive studies met our inclusion criteria. Experiences of racism, conspiracy beliefs and the quality of provider relationships appeared to impact engagement. Providers should openly investigate personal beliefs that adversely affect their treatment decisions, listen to patient narratives, and share treatment decisions in order to create a transparent environment.

The role of multiple identities in adherence to medical appointments among gay/bisexual male adolescents living with HIV

Adolescents living with HIV require engagement with care providers in order to access the critical medical and psychosocial services they need. The current study sought to explore developmental determinants of adherence to medical appointments as one aspect of engagement in care among a geographically diverse sample of 200 gay/bisexual male adolescents (16-24 years) living with HIV, with a specific focus on ethnic identity, sexual orientation identity, and identity as a young man living with HIV. Ethnic identity affirmation (OR = 0.6; 95% CI: 0.3, 0.9), morality of homosexuality (OR = 1.7; 95% CI: 1.2, 2.5), and HIV-positive identity salience (OR = 1.5; 95% CI: 0.9, 2.4) were associated with significantly higher risk for missed appointments in the past 3 months. These findings highlight the importance of attending to developmental factors, such as the development of multiple identities, when attempting to increase engagement in care for gay/bisexual male adolescents living with HIV.

Developing PeerLink to engage out-of-care HIV+ substance users: training peers to deliver a peer-led motivational intervention with fidelity

Substance use among HIV+ individuals can be a barrier to HIV care, resulting in poor health outcomes. Motivational interviewing (MI) is an effective intervention to reduce substance abuse and increase HIV-related health. Healthcare workers from various backgrounds can be effectively trained in delivering MI interventions; however, there has been limited evidence that peers can effectively deliver MI interventions with fidelity. Peers have traditionally worked in HIV care settings and represent a valid context for a peer-delivered intervention focused on motivational issues. We trained four peers in MI. In this paper, we describe the intervention, explain the MI training methods, and investigate whether peers can be trained in MI with fidelity. The MI training included didactic instruction, group workshops, and individual feedback sessions. Two of four peers achieved MI treatment fidelity as measured by the Motivational Interviewing Treatment Integrity Code Version 3.0. Overall, peers had difficulty using open-ended questions and querying pros and cons, skills thought necessary to elicit change talk. They also tended to give too much direct advice where reflections would have been appropriate. A challenge was training peers to change familiar ways of communicating. Nonetheless, they did well at assessing and highlighting motivation to change. The total training hours (40 h) was long compared with other published MI studies. However, the intervention included several components with two targeted change behaviors. It is likely that peers can be trained in MI with fidelity in less time given a more streamlined intervention. When working with peers who have life stressors similar to the target group, it is important to be flexible in the training.

Recent trauma is associated with antiretroviral failure and HIV transmission risk behavior among HIV-positive women and female-identified transgenders

Trauma and posttraumatic stress disorder disproportionally affect HIV-positive women. Studies increasingly demonstrate that both conditions may predict poor HIV-related health outcomes and transmission-risk behaviors. This study analyzed data from a prevention-with-positives program to understand if socio-economic, behavioral, and health-related factors are associated with antiretroviral failure and HIV transmission-risk behaviors among 113 HIV-positive biological and transgender women. An affirmative answer to a simple screening question for recent trauma was significantly associated with both outcomes. Compared to participants without recent trauma, participants reporting recent trauma had over four-times the odds of antiretroviral failure (AOR 4.3; 95% CI 1.1-16.6; p = 0.04), and over three-times the odds of reporting sex with an HIV-negative or unknown serostatus partner (AOR 3.9; 95% CI 1.3-11.9; p = 0.02) and <100% condom use with these partners (AOR 4.5; 95% CI 1.5-13.3; p = 0.007). Screening for recent trauma in HIV-positive biological and transgender women identifies patients at high risk for poor health outcomes and HIV transmission-risk behavior.

Repeat Western blot testing after receiving an HIV diagnosis and its association with engagement in care

OBJECTIVES

To examine the prevalence of and factors associated with potentially unnecessary repeat confirmatory testing after initial HIV diagnosis and the relationship of repeat testing to medical care engagement.

DESIGN

South Carolina HIV/AIDS surveillance data for 12,504 individuals who were newly diagnosed with HIV infection between January 1997 and December 2008 were used for this analysis. State law requires that all positive Western blot [WB] results be reported regardless of frequency.

METHODS

HIV-infected persons, diagnosed from 1997-2008 and followed through 2009, with repeat positive WB results were compared to those who did not have repeat positive WB results. We defined repeat positive testing as documentation of one or more positive WB obtained ≥90 days following initial WB confirmatory result. HIV care engagement for the period from 2007-2009 was assessed by documentation of CD4+ T-cell/viral load reports to the South Carolina HIV/AIDS surveillance system during each six-month period of a calendar year for those individuals diagnosed prior to the assessment period and still alive at the end. Relative risk [RR] with 95% confidence intervals [CI] and multivariable general linear models were used to assess if any covariates of interest were independently associated with repeat positive confirmatory testing.

RESULTS

A total of 4,237 [34%] of 12,504 HIV-infected individuals had results of repeat positive WB testing reported to the surveillance system during 1997-2008. Persons who had repeat positive WB testing were more likely than persons who did not have repeat WB testing to have progressed to AIDS >1 year following diagnosis [RR: 1.70; 95% CI: 1.61, 1.80] and to be consistently in care [RR: 1.35; 95% CI: 1.24, 1.47] or have sporadic care [RR: 1.80; 95% CI: 1.68, 1.94].

DISCUSSION

Having repeat positive WB tests may be a marker of engaging HIV care. However, given the limited resources available for care, it is important that healthcare reform policy and clinical recommendations promote improvements in communications about previous test results.

Health information exchange interventions can enhance quality and continuity of HIV care

PURPOSE

The purpose of this article is to describe how comprehensive HIV care is delivered within Ryan White Program (RWP)-funded clinics and to characterize proposed health information exchange (HIE) interventions, which employ technology to exchange information among providers, designed to improve the quality and coordination of clinical and support services.

METHODS

We use HIV patient care quality and coordination indicators from electronic data systems to describe care delivery in six RWP demonstration sites and describe HIE interventions designed to enhance that care.

RESULTS

Among patients currently in care, 91% were retained in care in the previous six months (range across sites: 63-99%), 79% were appropriately prescribed antiretroviral therapy (54-91%) and 52% had achieved undetectable HIV viral load (16-85%). To facilitate coordination of care across clinical and support services, sites designed HIE interventions to access a variety of data systems (e.g. surveillance, electronic health records, laboratory and billing) and focused on improving linkage and retention, quality and efficiency of care and increased access to patient information.

DISCUSSION

Care quality in RWP settings can be improved with HIE tools facilitating linkage, retention and coordination of care. When fully leveraged, HIE interventions have the potential to improve coordination of care and thereby enhance patient health outcomes.

A low-effort, clinic-wide intervention improves attendance for HIV primary care

BACKGROUND

Retention in care for human immunodeficiency virus (HIV)-infected patients is a National HIV/AIDS Strategy priority. We hypothesized that retention could be improved with coordinated messages to encourage patients' clinic attendance. We report here the results of the first phase of the Centers for Disease Control and Prevention/Health Resources and Services Administration Retention in Care project.

METHODS

Six HIV-specialty clinics participated in a cross-sectionally sampled pretest-posttest evaluation of brochures, posters, and messages that conveyed the importance of regular clinic attendance. 10,018 patients in 2008-2009 (preintervention period) and 11,039 patients in 2009-2010 (intervention period) were followed up for clinic attendance. Outcome variables were the percentage of patients who kept 2 consecutive primary care visits and the mean proportion of all primary care visits kept. Stratification variables were: new, reengaging, and active patients, HIV RNA viral load, CD4 cell count, age, sex, race or ethnicity, risk group, number of scheduled visits, and clinic site. Data were analyzed by multivariable log-binomial and linear models using generalized estimation equation methods.

RESULTS

Clinic attendance for primary care was significantly higher in the intervention versus preintervention year. Overall relative improvement was 7.0% for keeping 2 consecutive visits and 3.0% for the mean proportion of all visits kept (P < .0001). Larger relative improvement for both outcomes was observed for new or reengaging patients, young patients and patients with elevated viral loads. Improved attendance among the new or reengaging patients was consistent across the 6 clinics, and less consistent across clinics for active patients.

CONCLUSION

Targeted messages on staying in care, which were delivered at minimal effort and cost, improved clinic attendance, especially for new or reengaging patients, young patients, and those with elevated viral loads.

Exploring the contribution of general self-efficacy to the use of self-care symptom management strategies by people living with HIV infection

General self-efficacy (GSE), the expectation that one is able to perform a behavior successfully, may differentiate those who are able to successfully utilize self-care symptom management strategies (SCSMS). This subanalysis (n=569) of an international 12 site longitudinal randomized controlled trial (RCT) (n=775), investigated GSE as an important factor determining symptom burden, SCSMS, engagement with the provider, and medication adherence over time, and identified differences in those with high and low GSE ratings concerning these variables. Parametric and nonparametric repeated-measures tests were employed to assess GSE and the perceived effectiveness of SCSMS for anxiety, depression, diarrhea, fatigue, nausea, and neuropathy. Symptom burden, engagement with the provider, and antiretroviral adherence were analyzed with regard to GSE. Our data indicated that there were differences in the perceived symptom burden over time of HIV infected individuals by GSE. Those individuals with higher GSE had fewer symptoms and these symptoms were perceived to be less intense than those experienced by the low GSE group. There were few meaningful differences in the SCSMS used by those with high versus low GSE other than the use of illicit substances in the low GSE group. The low GSE group was also significantly (p= < 0.001) less engaged with their healthcare providers. Given the difference in substance use by perceived GSE, and the importance of engagement with the healthcare provider, more attention to the resolution of the concerns of those with low GSE by healthcare providers is warranted.