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

Randomized Controlled Trial of 60 minutes for Health With Rapid Antiretroviral Therapy to Reengage Persons With HIV Who Are Out of Care

BACKGROUND

Many persons with HIV remain out of care (PWH-OOC). We evaluated InstaCare, a complex intervention integrating the brief behavioral intervention 60 minutes for Health with the rapid restart of antiretroviral therapy (rapid ART).

SETTING

Prospective open-label randomized controlled trial among PWH-OOC in San Diego, USA.

METHODS

PWH-OOC were randomized 1:1 to InstaCare or a time-and-attention control integrating a diet-and-nutrition behavioral intervention also with rapid ART initiation (restart ≤7 days from enrollment). All participants had access to support services (free transport, HIV peer navigation, adherence counseling, and linkage to care) and primary care services (mental health, case management, social work, medication-assisted treatment, and specialist pharmacy). The primary outcomes were viral suppression (<50 copies/mL) and re-engagement with care (≥2 HIV care visits >90 days apart) by 24 weeks. Outcomes were reported on an intention-to-treat basis.

RESULTS

Between November 2020 and August 2022, 52 PWH-OOC were enrolled. Baseline substance use in the preceding month (49%), unstable housing (51%), moderate/severe depression (49%), and moderate/severe anxiety (41.7%) were prevalent. Rapid ART was provided for all participants. At week 24, the proportion with HIV viral load <50 copies/mL was 37.3% (19/51) (InstaCare 28.0%, control 46.2%, P = 0.25). Fourteen (27.5%) were engaged with care (InstaCare 7/25 [28.0%], control 7/26 [26.9%], P = 1.00). Most participants (94%) reported low or very low emotional distress associated with rapid ART. Study lost to follow-up by week 24 was high (23/51, 45%).

CONCLUSIONS

The InstaCare complex intervention did not improve viral suppression or reengagement with care among PWH-OOC. Investigation of high-intensity, individually adapted interventions is needed among PWH-OOC.

Using Data-To-Care Strategies to Optimize the HIV Care Continuum in Connecticut: Results From a Randomized Controlled Trial

BACKGROUND

Re-engaging people with HIV who are newly out-of-care remains challenging. Data-to-care (D2C) is a potential strategy to re-engage such individuals.

METHODS

A prospective randomized controlled trial compared a D2C strategy using a disease intervention specialist (DIS) vs standard of care where 23 HIV clinics in 3 counties in Connecticut could re-engage clients using existing methods. Using a data reconciliation process to confirm being newly out-of-care, 655 participants were randomized to DIS (N = 333) or standard of care (N = 322). HIV care continuum outcomes included re-engagement at 90 days, retention in care, and viral suppression by 12 months. Multivariable regression models were used to assess factors predictive of attaining HIV care continuum outcomes.

RESULTS

Participants randomized to DIS were more likely to be re-engaged at 90 days (adjusted odds ratios [aOR] = 1.42, P = 0.045). Independent predictors of re-engagement at 90 days were age older than 40 years (aOR = 1.84, P = 0.012) and perinatal HIV risk category (aOR = 3.19, P = 0.030). Predictors of retention at 12 months included re-engagement at 90 days (aOR = 10.31, P < 0.001), drug injection HIV risk category (aOR = 1.83, P = 0.032), detectable HIV-1 RNA before randomization (aOR = 0.40, P = 0.003), and county (Hartford aOR = 1.74, P = 0.049; New Haven aOR = 1.80, P = 0.030). Predictors of viral suppression included re-engagement at 90 days (aOR = 2.85, P < 0.001), retention in HIV care (aOR = 7.07, P < 0.001), and detectable HIV-1 RNA prerandomization (aOR = 0.23, P < 0.001).

CONCLUSIONS

A D2C strategy significantly improved re-engagement at 90 days. Early re-engagement improved downstream benefits along the HIV care continuum like retention in care and viral suppression at 12 months. Moreover, other factors predictive of care continuum outcomes can be used to improve D2C strategies.

Adopting Data to Care to Identify and Address Gaps in Services for Children and Adolescents Living With HIV in Mozambique

BACKGROUND

The Data to Care (D2C) strategy uses multiple sources of complementary data on HIV clients and related services to identify individuals with gaps in HIV treatment. Although D2C has been widely used in the United States, there is no evidence on its use in other settings, such as countries most affected by the epidemic.

STRATEGY IMPLEMENTATION

The D2C strategy was implemented within the context of a project that provided community-based support to children and adolescents living with HIV (C/ALHIV) in Mozambique. A data tracking tool and a standard operating procedure manual for local partner community organizations and health care facilities were developed to support the effort. Project staff met with local project implementing partners to discuss and coordinate the intervention in pilot health facilities.

STRATEGY PILOTING

The project initiated a pilot D2C intervention in 2019, working with 14 health facilities across 5 additional districts within 1 province. COVida project data were compared with clinical data from facilities serving C/ALHIV. The D2C intervention identified gaps in HIV treatment for a substantial number of C/ALHIV, and targeted support services were provided to address those gaps. Viral load (VL) monitoring was added in March 2020. Before the intervention, 71% of C/ALHIV reported to be on HIV treatment by their caregivers were documented as on treatment in health facilities. Support interventions targeted those not on treatment, and this proportion increased to 96% within 1 year of implementation. Additionally, 12 months later, the proportion of C/ALHIV with a documented VL test increased from 52% to 72%.

CONCLUSION

Introducing the D2C pilot intervention was associated with substantial improvements in HIV treatment for C/ALHIV, including increased linkage to and continuity in treatment and increased VL testing. D2C may be a useful approach to improve health outcomes for C/ALHIV in settings outside of the United States.

Optimal strategies to improve uptake of and adherence to HIV prevention among young people at risk for HIV acquisition in the USA (ATN 149): a randomised, controlled, factorial trial

BACKGROUND

Pre-exposure prophylaxis (PrEP), condom use, post-exposure prophylaxis (PEP), and sexual partner reduction help to prevent HIV acquisition but have low uptake among young people. We aimed to assess the efficacy of automated text messaging and monitoring, online peer support, and strengths-based telehealth coaching to improve uptake of and adherence to PrEP, condom use, and PEP among adolescents aged 12-24 years at risk of HIV acquisition in Los Angeles, CA, USA, and New Orleans, LA, USA.

METHODS

We conducted a four-arm randomised controlled factorial trial, assessing interventions designed to support uptake and adherence of HIV prevention options (ie, PrEP, PEP, condom use, and sexual partner reduction). We recruited young people aged 12-24 years who were at risk of HIV acquisition from 13 community-based organisations, adolescent medicine clinics, and organisations serving people who are unstably housed, people who were previously incarcerated, and other vulnerable young people, and through dating apps, peer referrals, and social venues and events in Los Angeles, CA, USA, and New Orleans, LA, USA. Young people who tested seronegative and reported being gay, bisexual, or other men who have sex with men, transgender men or women, or gender diverse (eg. non-binary or genderqueer) were eligible for inclusion. Participants were randomly assigned to one of four intervention groups in a factorial design: automated text messaging and monitoring (AMMI) only, AMMI plus peer support via private social media, AMMI plus strengths-based telehealth coaching by near-peer paraprofessionals, or AMMI plus peer support and coaching. Assignment was further stratified by race or ethnicity and sexual orientation within each interviewer's group of participants. Participants were masked to intervention assignment until after baseline interviews when offered their randomly assigned intervention, and interviewers were masked throughout the study. Interventions were available throughout the 24-month follow-up period, and participants completed baseline and follow-up assessments, including rapid diagnostic tests for sexually transmitted infections, HIV, and substance use, at 4-month intervals over 24 months. The primary outcomes were uptake and adherence to HIV prevention options over 24 months, measured by self-reported PrEP use and adherence, consistent condom use with all partners, PEP prescription and adherence, and number of sexual partners in participants with at least one follow-up. We used Bayesian generalised linear modelling to assess changes in outcomes over time comparing the four study groups. This study is registered with ClinicalTrials.gov (NCT03134833) and is completed.

FINDINGS

We screened 2314 adolescents beginning May 1, 2017, to enrol 1037 participants (45%) aged 16-24 years between May 6, 2017, and Aug 30, 2019, of whom 895 (86%) had follow-up assessments and were included in the analytical sample (313 assigned to AMMI only, 205 assigned to AMMI plus peer support, 196 assigned to AMMI plus coaching, and 181 assigned to AMMI plus peer support and coaching). Follow-up was completed on Nov 8, 2021. Participants were diverse in race and ethnicity (362 [40%] Black or African American, 257 [29%] Latinx or Hispanic, 184 [21%] White, and 53 [6%] Asian or Pacific Islander) and other sociodemographic factors. At baseline, 591 (66%) participants reported anal sex without a condom in the past 12 months. PrEP use matched that in young people nationally, with 101 (11%) participants reporting current PrEP use at baseline, increasing at 4 months to 132 (15%) and continuing to increase in the AMMI plus peer support and coaching group (odds ratio 2·31, 95% CI 1·28-4·14 vs AMMI control). There was no evidence for intervention effect on condom use, PEP use (ie, prescription or adherence), PrEP adherence, or sexual partner numbers. No unanticipated or study-related adverse events occurred.

INTERPRETATION

Results are consistent with hypothesised synergistic intervention effects of evidence-based functions of informational, motivational, and reminder messaging; peer support for HIV prevention; and strengths-based, goal-focused, and problem-solving telehealth coaching delivered by near-peer paraprofessionals. These core functions could be flexibly scaled via combinations of technology platforms and front-line or telehealth HIV prevention workers.

FUNDING

Adolescent Medicine Trials Network for HIV/AIDS Interventions, US National Institutes of Health.

HIV epidemiology, prevention, treatment, and implementation strategies for public health

The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care.

Unmet Needs for Ancillary Services and Associations with Clinical Outcomes Among Transgender Women with Diagnosed HIV: Medical Monitoring Project, United States, 2015-2020

Purpose: Access to ancillary services-including HIV support services, non-HIV clinical services, and subsistence services-can support care engagement and viral suppression and reduce disparities among people with HIV (PWH). We used representative U.S. data to assess differences in unmet needs for ancillary services between transgender women with HIV and other PWH. In addition, we examined associations between unmet needs and clinical outcomes among transgender women. Methods: We analyzed 2015-2020 Medical Monitoring Project data among transgender women (N = 362), cisgender men (N = 17,319), and cisgender women (N = 6016) with HIV. We reported weighted percentages for characteristics, and reported adjusted prevalence ratios (aPRs) controlling for race/ethnicity and age, and 95% confidence intervals (CI) using logistic regression with predicted marginal means to assess differences between groups. Results: Among transgender women, unmet needs were highest for dental care (24.9%), shelter or housing (13.9%), and transportation assistance (12.6%). Transgender women were more likely than cisgender men to have unmet subsistence needs. Among transgender women, unmet needs for ancillary services were negatively associated with many clinical outcomes after adjusting for age and race/ethnicity. Unmet needs for subsistence services were associated with higher levels of antiretroviral therapy nonadherence (aPR: 1.39; 95% CI: 1.13-1.70) and detectable viral loads (aPR: 1.47; 1.09-1.98), emergency room visits (aPR: 1.42; 1.06-1.90), and depression (aPR: 2.74; 1.83-4.10) or anxiety (aPR: 3.20; 2.05-5.00) symptoms. Conclusions: Transgender women with HIV were more likely than cisgender men with HIV to experience unmet needs for subsistence services-likely a reflection of substantial socioeconomic disadvantage. Addressing unmet needs is an essential step for improving care outcomes among transgender women with HIV.

Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2022 Recommendations of the International Antiviral Society-USA Panel

Importance

Recent advances in treatment and prevention of HIV warrant updated recommendations to guide optimal practice.

Objective

Based on a critical evaluation of new data, to provide clinicians with recommendations on use of antiretroviral drugs for the treatment and prevention of HIV, laboratory monitoring, care of people aging with HIV, substance use disorder and HIV, and new challenges in people with HIV, including COVID-19 and monkeypox virus infection.

Evidence Review

A panel of volunteer expert physician scientists were appointed to update the 2020 consensus recommendations. Relevant evidence in the literature (PubMed and Embase searches, which initially yielded 7891 unique citations, of which 834 were considered relevant) and studies presented at peer-reviewed scientific conferences between January 2020 and October 2022 were considered.

Findings

Initiation of antiretroviral therapy (ART) is recommended as soon as possible after diagnosis of HIV. Barriers to care should be addressed, including ensuring access to ART and adherence support. Integrase strand transfer inhibitor-containing regimens remain the mainstay of initial therapy. For people who have achieved viral suppression with a daily oral regimen, long-acting injectable therapy with cabotegravir plus rilpivirine given as infrequently as every 2 months is now an option. Weight gain and metabolic complications have been linked to certain antiretroviral medications; novel strategies to ameliorate these complications are needed. Management of comorbidities throughout the life span is increasingly important, because people with HIV are living longer and confronting the health challenges of aging. In addition, management of substance use disorder in people with HIV requires an evidence-based, integrated approach. Options for preexposure prophylaxis include oral medications (tenofovir disoproxil fumarate or tenofovir alafenamide plus emtricitabine) and, for the first time, a long-acting injectable agent, cabotegravir. Recent global health emergencies, like the SARS-CoV-2 pandemic and monkeypox virus outbreak, continue to have a major effect on people with HIV and the delivery of services. To address these and other challenges, an equity-based approach is essential.

Conclusions and Relevance

Advances in treatment and prevention of HIV continue to improve outcomes, but challenges and opportunities remain.

The Impact of a Walk-in Human Immunodeficiency Virus Care Model for People Who Are Incompletely Engaged in Care: The Moderate Needs (MOD) Clinic

Background

The Moderate Needs (MOD) Clinic in Seattle, Washington provides walk-in primary care for people with human immunodeficiency virus (HIV) who are incompletely engaged in standard care.

Methods

We evaluated HIV outcomes among patients enrolled in the MOD Clinic (within group analysis) and, separately, among MOD patients versus patients who were MOD-eligible but did not enroll (comparison group analysis) during January 1, 2018-September 30, 2021. The primary outcome was viral suppression ([VS] viral load <200 copies/mL); secondary outcomes care engagement (≥2 visits ≥60 days apart) and sustained VS (≥2 consecutive suppressed viral loads ≥60 days apart). In the within group analysis, we examined outcomes at time of MOD enrollment versus 12 months postenrollment. In the comparison group analysis, we examined outcomes at the time of MOD eligibility versus 12 months posteligibility. Both analyses used modified Poisson regression.

Results

Most patients in MOD (N = 213) were unstably housed (52%) and had psychiatric comorbidities (86%) or hazardous substance use (81%). Among patients enrolled ≥12 months (N = 164), VS did not increase significantly from baseline to postenrollment (63% to 71%, P = .11), but care engagement and sustained VS both improved (37% to 86%, P < .001 and 20% to 53%, P < .001, respectively) from pre-enrollment to 12 months postenrollment. In the comparison group analysis, VS worsened in nonenrolled patients (N = 517) from baseline to 12 months posteligibility (82% to 75%, P < .001). Patients in the MOD Clinic who met criteria for the comparison group analysis (N = 68) were more likely than nonenrolled patients to be engaged in care at 12 months posteligibility (relative risk, 1.29; 95% confidence interval, 1.03-1.63).

Conclusions

The MOD Clinic enrollment was associated with improved engagement in care. This model adds to the spectrum of differentiated HIV care services.