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Sweitzer S, Giegold M, Chen Y, Farber EW, Sumitani J, Henderson A, Easley K, Armstrong WS, Colasanti JA, Ammirati RJ, Marconi VC. The CARES Program: Improving Viral Suppression and Retention in Care Through a Comprehensive Team-Based Approach to Care for People with HIV and Complex Psychosocial Needs. AIDS Patient Care STDS 2023; 37:416-424. [PMID: 37566532 PMCID: PMC10623061 DOI: 10.1089/apc.2023.0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023] Open
Abstract
Retention in HIV care and viral suppression rates remain suboptimal, especially among people with HIV (PWH) facing complex barriers to care such as mental health conditions, substance use disorders, and housing insecurity. The Center for Adherence, Retention, and Engagement Support (CARES) program utilizes an interdisciplinary team that delivers integrated services in a drop-in setting to provide individualized care to PWH with complex psychosocial needs. We describe the CARES program and evaluate its effectiveness in retaining patients in care to achieve virological suppression. We characterized 119 referrals of PWH experiencing homelessness, mental health conditions, and substance use disorders to CARES between 2011 and 2017, and collected data for a 24-month observation period through 2019. Outcomes of patients who participated in CARES were compared with those who were referred but did not participate. The primary outcome was viral suppression (<200 copies/mL) at least once during 2-year follow-up. Retention in care (≥2 completed medical visits ≥90 days apart in each year post-referral) was a secondary outcome. Of 119 PWH referred to CARES, 59 participated with ≥2 visits. Those who participated in CARES were more likely to achieve viral suppression [adjusted odds ratio (aOR) 3.50, 95% confidence interval (CI) 1.19-10.32] and to be retained in care (aOR 3.73, 95% CI 1.52-9.14) compared with those who were referred but did not participate. This analysis found that the CARES program improved retention in care and viral suppression among PWH with complex psychosocial needs and suggests that it may represent a useful model for future programming.
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Affiliation(s)
- Stephanie Sweitzer
- J. Willis Hurst Internal Medicine Residency Program, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maddie Giegold
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Yunyun Chen
- Biostatistics and Informatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Eugene W. Farber
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
| | - Jeri Sumitani
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
| | | | - Kirk Easley
- Biostatistics and Informatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Wendy S. Armstrong
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jonathan A. Colasanti
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Rachel J. Ammirati
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
| | - Vincent C. Marconi
- Ponce de Leon Center, Grady Health System, Atlanta, Georgia, USA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Emory Vaccine Center, Atlanta, Georgia, USA
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Chen W, Gandhi M, Sax PE, Neilan AM, Garland WH, Wilkin T, Cohen R, Ciaranello AL, Kulkarni SP, Eron J, Freedberg KA, Hyle EP. Projected Benefits of Long-Acting Antiretroviral Therapy in Nonsuppressed People With Human Immunodeficiency Virus Experiencing Adherence Barriers. Open Forum Infect Dis 2023; 10:ofad390. [PMID: 37601728 PMCID: PMC10439527 DOI: 10.1093/ofid/ofad390] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/19/2023] [Indexed: 08/22/2023] Open
Abstract
Background In a demonstration project, long-acting, injectable cabotegravir-rilpivirine (CAB-RPV) achieved viral suppression in a high proportion of people with HIV (PWH) who were virologically nonsuppressed with adherence barriers. We projected the long-term impact of CAB-RPV for nonsuppressed PWH experiencing adherence barriers. Methods Using the Cost-Effectiveness of Preventing AIDS Complications (CEPAC) model, we compared 3 strategies: (1) standard of care oral integrase inhibitor-based ART (INSTI); (2) INSTI-based ART with supportive social services ("wraparound services" [WS]) (INSTI/WS); and (3) CAB-RPV with WS (CAB-RPV/WS). Model outcomes included viral suppression (%) and engagement in care (%) at 3 years, and life expectancy (life-years [LYs]). Base case cohort characteristics included mean age of 47y (standard deviation [SD], 10y), 90% male at birth, and baseline mean CD4 count 150/µL (SD, 75/µL). Viral suppression at 3 months was 13% (INSTI), 28% (INSTI/WS), and 60% (CAB-RPV/WS). Mean loss to follow-up was 28/100 person-years (PY) (SD, 2/100 PY) without WS and 16/100 PY (SD, 1/100 PY) with WS. Results Projected viral suppression at 3 years would vary widely: 16% (INSTI), 38% (INSTI/WS), and 44% (CAB-RPV/WS). Life expectancy would be 7.4 LY (INSTI), 9.0 LY (INSTI/WS), and 9.4 LY (CAB-RPV/WS). Projected benefits over oral ART would be greater for PWH initiating CAB-RPV/WS at lower CD4 counts. Across plausible key parameter ranges, CAB-RPV/WS would improve viral suppression and life expectancy compared with oral INSTI strategies. Conclusions These model-based results support that long-acting injectable CAB-RPV with extensive support services for nonsuppressed PWH experiencing adherence barriers is likely to increase viral suppression and improve survival. A prospective study to provide further evidence is needed.
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Affiliation(s)
- Wanyi Chen
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Monica Gandhi
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Paul E Sax
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anne M Neilan
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wendy H Garland
- Division of HIV and STD Programs, Los Angeles County Department of Public Health, Los Angeles, California, USA
| | - Timothy Wilkin
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA
| | - Rebecca Cohen
- Division of HIV and STD Programs, Los Angeles County Department of Public Health, Los Angeles, California, USA
| | - Andrea L Ciaranello
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for AIDS Research, Harvard University, Cambridge, Massachusetts, USA
| | - Sonali P Kulkarni
- Division of HIV and STD Programs, Los Angeles County Department of Public Health, Los Angeles, California, USA
| | - Joseph Eron
- Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kenneth A Freedberg
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for AIDS Research, Harvard University, Cambridge, Massachusetts, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Emily P Hyle
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Center for AIDS Research, Harvard University, Cambridge, Massachusetts, USA
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Higashi RT, Rodriguez SA, Betts AC, Tiro JA, Luque AE, Rivera R, Barnes A. Anal cancer screening among women with HIV: provider experiences and system-level challenges. AIDS Care 2022; 34:220-226. [PMID: 33594934 PMCID: PMC8368076 DOI: 10.1080/09540121.2021.1883512] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Women living with HIV (WLWH) are at increased risk of anal cancer compared to women without HIV, often due to persistent human papillomavirus (HPV) infections. This paper describes current practices and challenges conducting anal cancer screening for WLWH at an urban integrated safety-net system and a non-profit community-based HIV clinic. We conducted 25 semi-structured interviews with clinical and administrative stakeholders to assess knowledge, clinic practices and procedures, and experiences with anal cancer screening. Interview transcripts and fieldnotes were thematically analyzed using an iterative deductive and inductive coding scheme. Findings were organized by the Consolidated Framework for Implementation Research (CFIR) domains and constructs. Provider-level barriers to conducting anal cancer screening included limited knowledge of guidelines. System-level barriers included: structural characteristics such as lack of coordination between clinics to discern provider roles and responsibilities; and limitations in available resources such as configuration of electronic health records and infrastructure to manage referrals of abnormal anal Pap results. We conclude that anal cancer screening and follow-up for WLWH requires organization and coordination between multiple care teams, updated clinical information systems to facilitate communication and support anal Pap ordering and result documentation, and infrastructure that includes policies and protocols for management of abnormal results.Trial registration: ClinicalTrials.gov identifier: NCT02135419.
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Affiliation(s)
- Robin T. Higashi
- University of Texas Southwestern Medical Center,Harold C. Simmons Comprehensive Cancer Center
| | | | - Andrea C. Betts
- University of Texas Health Science Center at Houston, School of Public Health, Dallas
| | - Jasmin A. Tiro
- University of Texas Southwestern Medical Center,Harold C. Simmons Comprehensive Cancer Center
| | - Amneris E. Luque
- University of Texas Southwestern Medical Center,Parkland Health & Hospital System
| | | | - Arti Barnes
- University of Texas Southwestern Medical Center,Harold C. Simmons Comprehensive Cancer Center
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DelaCruz JJ, Brennan-Ing M, Kakolyris A, Martinez O. The Cost Effectiveness of Mental Health Treatment in the Lifetime of Older Adults with HIV in New York City: A Markov Approach. PHARMACOECONOMICS - OPEN 2021; 5:221-236. [PMID: 33165825 PMCID: PMC7649900 DOI: 10.1007/s41669-020-00238-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/22/2020] [Indexed: 05/05/2023]
Abstract
BACKGROUND There are noticeable gaps in knowledge regarding the cost and effectiveness of integrated medical and behavioral services for older adults with HIV. Their lifespan is close to the population's level but their quality of life has sharply declined due to depression and substance use. Mental health disorders are widespread among an aging population with HIV. OBJECTIVE The aim of this study was to build a decision analytic model to evaluate medical interventions with and without mental health treatment using primary data of 139 older adults with HIV and health outcomes from the literature. METHODS We tracked the progression of depression and cumulative deaths among older adults with HIV using a Markov model with 50 annual cycles through three health states. Deterministic and probabilistic sensitivity analyses addressed uncertainty in estimating the parameters and around the model's assumptions. RESULTS An integrated medical and behavioral care system is cost effective at a willingness to pay of $50,000 per QALY compared with medical care only. The incremental cost was $516,452 and the incremental effectiveness was 38.8 quality-adjusted life-years (QALY), with an incremental cost-effectiveness ratio of $13,316 per QALY. CONCLUSIONS Appropriate and efficacious referrals to integrated medical + behavioral services, either in the same facility or connected to their primary care doctor, are instrumental to reverse loses in quality of life and avoid premature death. If mental health is left unattended, HIV would progress, causing declines in quality of life and ultimately triggering premature death. Reliable data on the cost and effectiveness of different types of HIV integrated services are needed.
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Affiliation(s)
- Juan J. DelaCruz
- Department of Economics and Business, Lehman College, CUNY, 250 Bedford Park Blvd W, Bronx, NY USA
| | - Mark Brennan-Ing
- Brookdale Center for Healthy Aging, Hunter College, CUNY, 2180 Third Avenue, 8th Floor, New York, NY 10035 USA
| | - Andreas Kakolyris
- Department of Economics and Finance, Manhattan College, 4513 Manhattan College Parkway, Room DLS 505, Bronx, NY USA
| | - Omar Martinez
- College of Public Health, Temple University, 1301 Cecil B. Moore Ave, Ritter Annex 505, Philadelphia, PA USA
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Trajectories of Viral Suppression in People Living With HIV Receiving Coordinated Care: Differences by Comorbidities. J Acquir Immune Defic Syndr 2021; 84:387-395. [PMID: 32598118 DOI: 10.1097/qai.0000000000002351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND In March of 2013, the Los Angeles County (LAC) Division of HIV and STD Programs implemented a clinic-based Medical Care Coordination (MCC) Program to increase viral suppression (VS) (<200 c/mL) among people living with HIV (PLWH) at high risk for poor health outcomes. OBJECTIVE This study aimed to estimate trajectories of VS and to assess whether these trajectories differed by stimulant use, housing instability, and depressive symptom severity as reported by PLWH participating in MCC. METHODS Data represent 6408 PLWH in LAC receiving services from the MCC Program and were obtained from LAC HIV surveillance data matched to behavioral assessments obtained across 35 Ryan White Program clinics participating in MCC. Piecewise mixed-effects logistic regression with a random intercept estimated probabilities of VS from 12 months before MCC enrollment through 36 months after enrollment, accounting for time by covariate interactions for 3 comorbid conditions: housing instability, stimulant use, and depressive symptoms. RESULTS The overall probability of VS increased from 0.35 to 0.77 within the first 6 months in the MCC Program, and this probability was maintained up to 36 months after enrollment. Those who reported housing instability, stimulant use, or multiple comorbid conditions did not achieve the same probability of VS by 36 months as those with none of those comorbidities. CONCLUSIONS Findings suggest that MCC improved the probability of VS for all patient groups regardless of the presence of comorbidities. However, those with comorbid conditions will still require increased support from patient-centered programs to address disparities in VS.
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Goyal R, Luca D, Klein PW, Morris E, Mandsager P, Cohen SM, Hu C, Hotchkiss J, Gao J, Jones A, Addison W, O'Brien-Strain M, Cheever LW, Gilman B. Cost-Effectiveness of HRSA's Ryan White HIV/AIDS Program? J Acquir Immune Defic Syndr 2021; 86:174-181. [PMID: 33093330 DOI: 10.1097/qai.0000000000002547] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND With an annual budget of more than $2 billion, the Health Resources and Services Administration's Ryan White HIV/AIDS Program (RWHAP) is the third largest source of public funding for HIV care and treatment in the United States, yet little analysis has been done to quantify the long-term public health and economic impacts of the federal program. METHODS Using an agent-based, stochastic model, we estimated health care costs and outcomes over a 50-year period in the presence of the RWHAP relative to those expected to prevail if the comprehensive and integrated system of medical and support services funded by the RWHAP were not available. We made a conservative assumption that, in the absence of the RWHAP, only uninsured clients would lose access to these medical and support services. RESULTS The model predicts that the proportion of people with HIV who are virally suppressed would be 25.2 percentage points higher in the presence of the RWHAP (82.6 percent versus 57.4 percent without the RWHAP). The number of new HIV infections would be 18 percent (190,197) lower, the number of deaths among people with HIV would be 31 percent (267,886) lower, the number of quality-adjusted life years would be 2.7 percent (5.6 million) higher, and the cumulative health care costs would be 25 percent ($165 billion) higher in the presence of the RWHAP relative to the counterfactual. Based on these results, the RWHAP has an incremental cost-effectiveness ratio of $29,573 per quality-adjusted life year gained compared with the non-RWHAP scenario. Sensitivity analysis indicates that the probability of transmitting HIV via male-to-male sexual contact and the cost of antiretroviral medications have the largest effect on the cost-effectiveness of the program. CONCLUSIONS The RWHAP would be considered very cost-effective when using standard guidelines of less than the per capita gross domestic product of the United States. The results suggest that the RWHAP plays a critical and cost-effective role in the United States' public health response to the HIV epidemic.
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Affiliation(s)
| | | | - Pamela W Klein
- HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services; and
| | | | - Paul Mandsager
- HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services; and
| | - Stacy M Cohen
- HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services; and
| | | | | | | | | | | | | | - Laura W Cheever
- HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services; and
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