Quality of comprehensive HIV care in underserved communities: does clinical training lead to improvement

Practice transformations to optimize the delivery of HIV primary care in community healthcare settings in the United States: A program implementation study

BACKGROUND

The United States HIV care workforce is shrinking, which could complicate service delivery to people living with HIV (PLWH). In this study, we examined the impact of practice transformations, defined as efficiencies in structures and delivery of care, on demonstration project sites within the Workforce Capacity Building Initiative, a Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS).

METHODS AND FINDINGS

Data were collected at 14 demonstration project sites in 7 states and the District of Columbia. Organizational assessments were completed at sites once before and 4 times after implementation. They captured 3 transformation approaches: maximizing the HIV care workforce (efforts to increase the number of existing healthcare workforce members involved in the care of PLWH), share-the-care (team-based care giving more responsibility to midlevel providers and staff), and enhancing client engagement in primary HIV care to reduce emergency and inpatient care (e.g., care coordination). We also obtained Ryan White HIV/AIDS Program Services Reports (RSRs) from sites for calendar years (CYs) 2014-2016, corresponding to before, during, and after transformation. The RSR include data on client retention in HIV care, prescription of antiretroviral therapy (ART), and viral suppression. We used generalized estimating equation (GEE) models to analyze changes among sites implementing each practice transformation approach. The demonstration projects had a mean of 18.5 prescribing providers (SD = 23.5). They reported data on more than 13,500 clients per year (mean = 969/site, SD = 1,351). Demographic characteristics remained similar over time. In 2014, a majority of clients were male (71% versus 28% female and 0.2% transgender), with a mean age of 47 (interquartile range [IQR] 37-54). Racial/ethnic characteristics (48% African American, 31% Hispanic/Latino, 14% white) and HIV risk varied (31% men who have sex with men; 31% heterosexual men and women; 7% injection drug use). A substantial minority was on Medicaid (41%). Across sites, there was significant uptake in practices consistent with maximizing the HIV care workforce (18% increase, p < 0.001), share-the-care (25% increase, p < 0.001), and facilitating patient engagement in HIV primary care (13% increase, p < 0.001). There were also significant improvements over time in retention in HIV care (adjusted odds ratio [aOR] = 1.03; 95% confidence interval [CI] 1.02-1.04; p < 0.001), ART prescription levels (aOR = 1.01; 95% CI 1.00-1.01; p < 0.001), and viral suppression (aOR = 1.03; 95% CI 1.02-1.04; p < 0.001). All outcomes improved at sites that implemented transformations to maximize the HIV care workforce or improve client engagement. At sites that implemented share-the-care practices, only retention in care and viral suppression outcomes improved. Study limitations included use of demonstration project sites funded by the Ryan White HIV/AIDS Program (RWHAP), which tend to have better HIV outcomes than other US clinics; varying practice transformation designs; lack of a true control condition; and a potential Hawthorne effect because site teams were aware of the evaluation.

CONCLUSIONS

In this study, we found that practice transformations are a potential strategy for addressing anticipated workforce challenges among those providing care to PLWH. They hold the promise of optimizing the use of personnel and ensuring the delivery of care to all in need while potentially enhancing HIV care continuum outcomes.

Impact of AIDS Education and Training Centers on the US HIV Medical Workforce

OBJECTIVES

To examine the extent to which the AIDS Education and Training Centers (AETCs) are increasing the number and racial/ethnic diversity of HIV medical providers, in accordance with the US National HIV/AIDS Strategy (NHAS).

METHODS

We used administrative data from funding year 2012-2013 to describe AETC trainee characteristics, including the types of medical providers trained, compared with national estimates of available US medical providers to estimate the proportion of providers trained for every 1000 available providers by professional group and race/ethnicity.

RESULTS

AETCs trained 56 127 unique trainees, of whom 64.1% were medical providers and 45.5% were racial/ethnic minorities. Compared to national proportions, participation in AETC training was higher among racial/ethnic minorities. The proportions of racial/ethnic minority groups trained differed across regional AETCs.

CONCLUSIONS

AETCs support NHAS goals by expanding the HIV medical workforce and strengthening the skills of minority medical providers to deliver high quality HIV care. Public Health Implications. Some AETCs made greater contributions to training different types of racial/ethnic minorities, which indicates varied approaches are needed to best target these efforts in communities heavily impacted by HIV.

A review of how the quality of HIV clinical services has been evaluated or improved

To examine approaches being used to evaluate and improve quality of HIV clinical services we searched the MEDLINE, Cochrane Library collection, EMBASE, Global Health, and Web of Science databases for articles and abstracts focused on evaluating or improving quality of HIV clinical services. We extracted country income level, targeted clinical services, and quality evaluation approaches, data sources, and criteria. Fifty journal articles and 46 meeting abstracts were included. Of the 96 studies reviewed, 65% were programme evaluations, 71% focused on low- and middle-income countries, and 65% focused on antiretroviral therapy services. With regard to quality, 45% used a quality improvement model or programme, 13% set a quality threshold, and 51% examined patient records to evaluate quality. No studies provided a definition for quality HIV care. Quality assurance and improvement of HIV clinical services is increasingly important. This review highlights gaps in knowledge for future research, and may also help countries and programmes develop their HIV care quality improvement frameworks.

Prevention counseling practices of HIV care providers with patients new to HIV medical care: medical monitoring project provider survey, 2009

OBJECTIVES

To determine the prevalence of prevention counseling discussions between HIV care providers and their patients who are newly linked to care and to assess factors that facilitate such discussions.

METHODS

In 2009, a probability sample of HIV care providers in 582 outpatient settings in the United States and Puerto Rico was surveyed regarding provider's HIV prevention discussions with HIV-infected patients newly linked to HIV medical care.

RESULTS

A majority of providers reported consistently discussing HIV transmission risk reduction (76%), sexually transmitted disease risk (66%), and adherence to antiretroviral regimens (87%). Only 35% of providers reported consistently discussing partner counseling services.

CONCLUSION

The proportion of providers engaged in HIV prevention counseling with patients newly linked to HIV care is generally high, but more work is needed to encourage providers to fully participate as partners in prevention, which is central to preventing onward transmission of HIV.