The Impact of Comprehensive Case Management on HIV Client Outcomes

Understanding effective post-test linkage strategies for HIV prevention and care: a scoping review

INTRODUCTION

Following HIV testing services (HTS), the World Health Organization recommends prompt linkage to prevention and treatment. Scale-up of effective linkage strategies is essential to achieving the global 95-95-95 goals for maintaining low HIV incidence by 2030 and reducing HIV-related morbidity and mortality. Whereas linkage to care including same-day antiretroviral therapy (ART) initiation for all people with HIV is now routinely implemented in testing programmes, linkage to HIV prevention interventions including behavioural or biomedical strategies, for HIV-negative individuals remains sub-optimal. This review aims to evaluate effective post-HTS linkage strategies for HIV overall, and highlight gaps specifically in linkage to prevention.

METHODS

Using the five-step Arksey and O'Malley framework, we conducted a scoping review searching existing published and grey literature. We searched PubMed, Cochrane Library, CINAHL, Web of Science and EMBASE databases for English-language studies published between 1 January 2010 and 30 November 2023. Linkage interventions included as streamlined interventions-involving same-day HIV testing, ART initiation and point-of-care CD4 cell count/viral load, case management-involving linkage coordinators developing personalized HIV care and risk reduction plans, incentives-financial and non-financial, partner services-including contact tracing, virtual-like social media, quality improvement-like use of score cards, and peer-based interventions. Outcomes of interest were linkage to any form of HIV prevention and/or care including ART initiation.

RESULTS

Of 2358 articles screened, 66 research studies met the inclusion criteria. Only nine linkage to prevention studies were identified (n = 9/66, 14%)-involving pre-exposure prophylaxis, voluntary medical male circumcision, sexually transmitted infection and cervical cancer screening. Linkage to care studies (n = 57/66, 86%) focused on streamlined interventions in the general population and on case management among key populations.

DISCUSSION

Despite a wide range of HIV prevention interventions available, there was a dearth of literature on HIV prevention programmes and on the use of messaging on treatment as prevention strategy. Linkage to care studies were comparatively numerous except those evaluating virtual interventions, incentives and quality improvement.

CONCLUSIONS

The findings give insights into linkage strategies but more understanding of how to provide these effectively for maximum prevention impact is needed.

Perceptions and Current Practices in Patient-Centered Care: A Qualitative Study of Ryan White HIV Providers in South Florida

Background: Patient-centered care (PCC) improves HIV adherence and retention, though lack of consensus on its conceptualization and understanding how it is interpreted has hindered implementation. Methods: We recruited 20 HIV providers at Ryan White Programs in FL for in-depth interviews. Thematic analysis identified core consistencies pertaining to: 1) provider perceptions, 2) current practices promoting PCC. Results: Provider perceptions of PCC emerged under four domains: 1) holistic, 2) individualized care, 3) respect for comfort and security, and 4) patient engagement and partnership. PCC practices occurred at multiple levels: 1) individual psychosocial and logistical support, 2) interpersonal support within patient-provider relationships through respectful communication and active engagement, and 3) institutional practices including feedback mechanisms, service integration, patient convenience, and diverse staffing. Conclusions: Our findings highlight the central tenets of PCC as respectful, holistic, individualized, and engaging care. We offer an HIV-adapted framework of PCC as a multilevel construct to guide future intervention.

Longitudinal Associations of Psychiatric Risk Factors with Non-psychiatric Hospitalization in a Large Cohort of People Living with HIV in New York City

Hospitalizations among people living with HIV (PLWH) are frequent and costly. This study examined the association between psychiatric, HIV-related, and demographic factors and hospitalization rates among PLWH using data from the Einstein-Rockefeller-City University of New York Center for AIDS Research Clinical Cohort Database. Of the 10,215 PLWH included in the sample, 45% had at least one non-psychiatric hospitalization between 2009 and 2018, with significant risk factors including prior psychiatric outpatient visits, depression, or alcohol-related disorder diagnoses, female sex, older age, CD4 count < 500 cells/uL, and detectable viral load. Additionally, 14% had an HIV-related hospitalization, with significant risk factors including prior psychiatric outpatient visits, alcohol- and substance-related disorder diagnoses, female sex, older age, CD4 count < 500 cells/uL, and detectable viral load. The study emphasizes the need for tailored interventions, including integrated treatment and comprehensive case management, for PLWH with comorbid psychiatric disorders, women, and older adults.

Intersectionality-informed analysis of durable viral suppression disparities in people with HIV

OBJECTIVE

The aim of this study was to examine drivers of durable viral suppression (DVS) disparities among people with HIV (PWH) using quantitative intersectional approaches.

DESIGN

A retrospective cohort analysis from electronic health records informed by intersectionality to better capture the concept of interlocking and interacting systems of oppression.

METHODS

We analyzed data of PWH seen at a LGBTQ federally qualified health center in Chicago (2012-2019) with at least three viral loads. We identified PWH who achieved DVS using latent trajectory analysis and examined disparities using three intersectional approaches: Adding interactions, latent class analysis (LCA), and qualitative comparative analysis (QCA). Findings were compared with main effects only regression.

RESULTS

Among 5967 PWH, 90% showed viral trajectories consistent with DVS. Main effects regression showed that substance use [odds ratio (OR) 0.56, 0.46-0.68] and socioeconomic status like being unhoused (OR: 0.39, 0.29-0.53), but not sexual orientation or gender identity (SOGI) were associated with DVS. Adding interactions, we found that race and ethnicity modified the association between insurance and DVS ( P for interaction <0.05). With LCA, we uncovered four social position categories influenced by SOGI with varying rates of DVS. For example, the transgender women-majority class had worse DVS rates versus the class of mostly nonpoor white cisgender gay men (82 vs. 95%). QCA showed that combinations, rather than single factors alone, were important for achieving DVS. Combinations vary with marginalized populations (e.g. black gay/lesbian transgender women) having distinct sufficient combinations compared with historically privileged groups (e.g. white cisgender gay men).

CONCLUSION

Social factors likely interact to produce DVS disparities. Intersectionality-informed analysis uncover nuance that can inform solutions.

Clients' Perspectives on Patient-Centeredness: a Qualitative Study with Low-Income Minority Women Receiving HIV Care in South Florida

Low-income, minority women living with HIV often experience multiple barriers in care that contribute to suboptimal care outcomes. Medical case managers (MCM) and medical providers are key players involved in care coordination and aid women along the HIV care continuum. The objective of this study was to identify current and potential patient-centered practices that facilitate adherence to medication and retention in care, from the perspective of racially and ethnically diverse women living with HIV. We implemented a qualitative study using semi-structured interviews with 75 African American, Hispanic/Latina, and Haitian women who were enrolled in the Ryan White HIV/AIDS Program in South Florida in 2019. We organized domains of exploration using a patient-centered care framework to identify practices in which providers acknowledged, respected, and responded to clients' preferences, needs, and values. Interviews were analyzed using consensual thematic analysis approach. Findings reflect women valued MCMs who were proactive and directive in care, provided motivation, and aided with navigation of shame, fear, and stigma. Women valued medical providers who upheld simple educational communication. Moreover, women reported that providers who reviewed medical results with clients, incorporated questions about families, and inquired about multiple physical and clinical needs beyond HIV created opportunities for women to feel respected, valued, and in turn, enhanced their involvement in their care. Findings identify specific interpersonal practices that can enhance the ability to better meet the needs of diverse groups of women, specifically those from racial/ethnic minority groups who face multiple sociocultural barriers while in care.

HTPN 078: an enhanced case management study to achieve viral suppression among viremic HIV-positive men who have sex with men in the United States

OBJECTIVES

After identifying and recruiting men who have sex with men living with HIV and virally unsuppressed, this study attempted to enhance treatment and care via case management to increase the proportion who achieved viral suppression.

DESIGN

Participants were randomized into one of two study arms: standard of care (SOC) or enhanced case management (CM) intervention. Participants were followed for 12 months with quarterly study assessments, with blood collected for CD4+ cell count testing, HIV viral load testing (primary prespecified outcome), and plasma storage.

METHODS

Participants identified via respondent-driven sampling and direct recruitment and were invited to participate in the randomized controlled trial. The CM intervention provided a wide range of support services including, health education, clinical care coordination, medication adherence support, and social service assistance. The month-12 assessment included questions about healthcare utilization, stigma, substance use, and mental health.

RESULTS

Among the 144 participants virally unsuppressed at baseline, most had had a previous positive HIV test result; were Black, non-Hispanic, gay and bisexual men, aged 22-50. Among the 128 participants at the last study visit, 68 were virally suppressed, with no statistically significant difference between the CM and SOC arms (viral suppression 42% and 53%, respectively; adjusted odds ratio = 0.62 [P = 0.15; 95% confidence interval: 0.32, 1.2]).

CONCLUSIONS

Reaching targets of at least 90% sustained viral suppression among all people with HIV will likely require more than an individual-level CM approach that addresses barriers to optimal care and treatment at multiple levels.

The Impact of the COVID-19 Pandemic on HIV-Positive Men Who Have Sex With Men: (Dis)connection to Social, Sexual, and Health Networks

The COVID-19 pandemic has disproportionately affected HIV-positive cisgender men who have sex with men (MSM). Between May and June in 2020, we conducted one-on-one semi-structured qualitative interviews with 20 HIV-positive MSM aiming to describe their (dis)connection to social, sexual, and health networks during the COVID-19 pandemic. All participants relied on social support networks to manage pandemic-based distress, using computer-mediated communication as well as physical proximity. To connect to sexual networks, this sample described adaptations to their partner selection strategies, such as enumerating harm reduction approaches. To connect to health networks, participants depended on reassuring providers, resourceful case managers, telehealth, and streamlined access to their antiretroviral therapy (ART) medications. Nonetheless, stay-at-home recommendations reduced community connection, sexual activity, and healthcare access for many participants, and perceptions of these losses were shaped by psychosocial burdens (e.g., loneliness), structural burdens (e.g., environmental barriers, financial difficulties), and health-protective factors (e.g., hopeful outlook, adherence to a regular routine). The COVID-19 pandemic appears to have exacerbated health-related issues for HIV-positive MSM. Given the ongoing COVID-19 mutations, community-based organizations, clinicians, and researchers might use these findings to modify HIV prevention and intervention efforts.

Characterizing Ryan White Part A-funded support service utilization patterns and their association with viral suppression among people with HIV in New York City

Use of HIV-related support services has been demonstrated to improve outcomes for people living with HIV. Further exploring patterns of use could help identify how and in what settings additional HIV care and treatment adherence support could be provided. We aimed to identify support service utilization patterns and examine their association with viral load suppression (VLS). Our sample comprised 6,581 people with HIV who received Ryan White Part A support services for basic needs (food and nutrition, legal, harm reduction, housing services) in New York City from 1/2013 to 12/2016, but had not received services specifically targeting HIV care and treatment adherence. Five support service utilization classes were identified using latent class analysis, the majority of which were characterized by the predominant use of concrete services (e.g., food assistance). Compared with the low-intensity, sporadic concrete service use class, clients in all other classes had lower odds of VLS in a 365-day follow-up period, but this disadvantage disappeared with adjustment for confounding variables indicative of need. Our findings underscore the impact of need-related barriers on VLS and suggest that long-term service utilization beyond the one year period of this study may be required to diminish their negative effect on HIV outcomes.

A 10-year economic analysis of HIV management in Greece: evidence of efficient resource allocation

OBJECTIVE

Human Immunodeficiency Virus (HIV) prevalence has substantially increased over the years, leading to increased direct medical costs. The aim of the present study was to assess the long-term cost of HIV care in Greece incurred over the last decade.

METHODS

In order to assess the long-term cost of HIV care, a cost analysis was undertaken for three discrete time points (which reflect major changes in the HIV treatment paradigm), incorporating the evolution of the cost of pharmaceuticals, hospitalization, primary care visits and diagnostic tests. The cost per life year gained (LYG) was also estimated.

RESULTS

Total cost of HIV care increased by 57% over the last decade (€53.7 million in 2010 vs €84.5 million in 2019), which can be mainly attributed to a 107% (5084 in 2010 vs. 10,523 in 2019) increase observed in the number of people living with HIV (PLWH) under care. As a result, the cost per person on treatment has decreased by 24.0% (€10,567 in 2010 vs €8032 in 2019). Lifetime cost was lower and life expectancy higher in 2019 compared to 2010, leading to a - €711 cost per LYG, suggesting that the current treatment paradigm produces better health outcomes at a lower cost compared to a decade ago, implying that resources are used in a more efficient way.

CONCLUSION

The paper presents some evidence towards the direction that HIV management in Greece can be considered efficient in both clinical and financial terms, as it offers measurable clinical outcomes at well-controlled, almost inelastic spending.

Supporting retention in HIV care through a holistic, patient-centred approach: a qualitative evaluation

BACKGROUND

HIV is a complex disease which affects different facets (social, economic, physical, emotional and spiral) of an individual's life, making the goals of retention in care and adherence to treatment difficult to achieve. Holistic patient-centred approaches to providing care for people living with HIV bind together economic, social, emotional and physiological aspects and have the potential to improve retention in care and ART adherence. Case management is a holistic, patient-centred approach which is increasingly being implemented in the management of chronic illnesses.

METHODS

We conducted a qualitative study based on semi-structured interviews with key informants (retention officers and social auxiliary workers) and patients. A total of 60 patients and 17 KIs (11 retention officers and 6 social auxiliary workers) participated in the study. The study was conducted in Johannesburg District, Gauteng province, South Africa. Key informants (KIs) and patients were drawn from 8 health facilities located in four management clusters of the district.

RESULTS

The findings identified facilitators and barriers to adherence and retention in care, and demonstrated that case management offered holistic, patient-centred services which patients considered to be beneficial to their well-being and helped them overcome some of these barriers. The success of case management was driven by its holistic and patient-centred approach, which extended the focus to patients' non-clinical needs which impact on their quality of life. Complex interacting barriers and facilitators at different levels influenced implementation of the model and its outcomes.

CONCLUSION

Holistic approaches such as case management have a strong potential to improve retention in care and adherence to ART. HIV is a complex disease which impacts different facets of an individual's life, hence requires holistic care to address all facets. Health systems need to transition towards holistic care to ensure that some patients do not slip through the cracks, improve patient outcomes and efficiency.

Determinants of loss to follow-up among people living with HIV on antiretroviral therapy in Nigeria

Background: Considerable success has been recorded in the global fight against the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS). Retention in care is the key to the attainment of set goals in the fight against the disease. We aim to determine the factors associated with loss to follow-up (LTFU) among people living with HIV on antiretroviral therapy (ART) in a limited resource setting.Method: This was a retrospective cohort study that included adult patients who accessed ART at the study site between January 2005 and October 2018. A multivariate logistic regression model was used to obtain adjusted odds ratios and 95% confidence intervals of independent determinants of LTFU.Results: Of the 8 679 patients included in the study, 3 716 (43%) were males, 4 009 (46%) were enrolled during the years 2005 to 2008, 8 421 (97%) spent less than two hours travelling from their residence to the treatment centre, and 3 523 (41%) had their first-line ART regimen changed. Among the characteristics that determine LTFU were male patients (OR = 1.167, 95% CI: 1.071-1.272), and World Health Organization clinical stage 3 (OR = 2.091, 95% CI: 1.485-2.944).Conclusion: In our study, male gender, enrolment year 2005 to 2008, no change in first-line ART and nevirapine-based therapy were more likely to be associated with LTFU.

Examining Interprofessional Collaboration across case managers, peer educators, and counselors in New York City

Many individuals who are vulnerable to HIV infection and People Living with HIV (PLWH) experience fragmented prevention and care. Prevention and care service integration, pivotal for the HIV care continuum, depends on relationships among service providers and agencies offering HIV services. Case managers, counselors, and peer educators often work together to provide integrated services through interprofessional collaboration (IPC) in HIV prevention and care. Although these providers have distinct job titles, they typically offer complementary services on the HIV care continuum. To better train and allocate professional development resources for these providers, research is needed to assess the overall differences between provider-type and their demographics, intrapersonal factors, and job characteristics most likely to predict IPC engagement. We administered a cross-sectional survey to 75 counselors, 80 peer educators, and 112 case managers in 36 agencies in New York City. We performed a series of linear mixed effects models. Most of the HIV-service providers identified as Black and female and had been working for their agencies for less than a year. Knowledge and skills, self-efficacy, understanding of the community, and greater work hours (> 35 hours) were significant predictors of endorsement of IPC. Peer educators compared to case managers were more likely to reflect on the process as they provide myriad services. Eliciting perspectives from providers allows us to explore interventions, both intra-agency (trainings, greater exposure to collaborative initiatives, and supervision) and interagency (retention programs and websites promoting provider collaboration), that could facilitate IPC engagement and integrated services across the HIV care continuum.

Establishing an Epidemiologic Profile of Hepatitis C Virus Infection at the Los Angeles County Jail

OBJECTIVE

The hepatitis C virus (HCV) is the most common blood-borne infection in the United States. Although 2% to 3% of the global population is estimated to be infected with HCV, an estimated 18% of the US prison population may be infected. The objective of this study was to establish an epidemiologic profile of HCV infection in the largest urban jail system in the United States.

METHODS

We retrospectively analyzed 20 years of data on demographic characteristics, risk factors, and HCV positivity among 80 681 individuals incarcerated at the Los Angeles County Jail who were tested for HCV infection from January 1, 2000, through December 31, 2019. We used multivariate logistic regression analysis to determine predictors of HCV positivity.

RESULTS

Of the 80 681 individuals tested, 27 881 (34.6%) had positive test results for HCV infection. In the multivariate analysis, HCV positivity was most strongly associated with injection drug use (adjusted odds ratio [aOR] = 34.9; 95% CI, 24.6-49.5) and being born during 1946-1955 (aOR = 13.0; 95% CI, 11.9-14.2). Men were more likely than women to have HCV infection (aOR = 1.4; 95% CI, 1.3-1.5), and Hispanic (aOR = 4.2; 95% CI, 3.9-4.4) and non-Hispanic White (aOR = 3.8; 95% CI, 3.5-4.0) individuals were more likely than non-Hispanic African American individuals to have HCV infection. Noninjection drug use, homelessness, and mental health issues were also significantly associated with HCV positivity.

CONCLUSION

Even in the absence of resources for universal screening for HCV infection, the creation of a risk profile and its implementation into a screening program may be a beneficial first step toward improving HCV surveillance and establishing an accurate estimate of HCV infection in the incarcerated population.

Healthcare Utilization, Unmet Service Needs, and Medication Adherence Among People Living with HIV/AIDS

BACKGROUND

Comorbidity rates and service needs are high among people living with HIV/AIDS (PLWHA). The effects of service utilization and unmet service needs on antiretroviral therapy (ART) adherence are not well understood. The purpose of this study was to investigate associations among PLWHA's service utilization, unmet service needs, and ART adherence.

METHODS

PLWHA (N=162) 18 years or older were recruited from a Nevada statewide needs assessment project in 2016. Participants completed a self-administered questionnaire on paper or online. The independent variables were service utilization and unmet service needs. The outcome variable was ART adherence. Multivariable logistic regression analyses were conducted to examine associations between the amount of utilized services and unmet service needs with ART adherence.

RESULTS

Only 12 (7.5%) participants reported they received all the needed services. The ART nonadherence group showed significantly higher unmet medical service needs compared to the ART adherence group (p=0.007). Unmet medical service needs (Adjusted Odds Ratio (AOR) 0.69, CI 0.53-0.90) and unmet support service needs (AOR 0.68, CI 0.48-0.97) were negatively associated with ART adherence. However, utilizing medical services (AOR 1.06, CI 0.87-1.30) and support services (AOR 0.88, CI 0.74-1.04) in the current year were not significantly associated with ART adherence.

CONCLUSION

The results of this study indicate that health promotion programming should focus not only on introducing new services at the community level, but also work to optimize the availability and awareness of current services. Furthermore, health promotion programs should focus on filling service coverage gaps and improving the facilitation of services.

A Cost Reimbursement Model for Hepatitis C Treatment Care Coordination

OBJECTIVE

To estimate the cost of delivering a hepatitis C virus care coordination program at 2 New York City health care provider organizations and describe a potential payment model for these currently nonreimbursed services.

DESIGN

An economic evaluation of a hepatitis C care coordination program was conducted using micro-costing methods compared with macro-costing methods. A potential payment model was calculated for 3 phases: enrollment to treatment initiation, treatment initiation to treatment completion, and a bonus payment for laboratory evidence of successful treatment outcome (sustained viral response).

SETTING

Two New York City health care provider organizations.

PARTICIPANTS

Care coordinators and peer educators delivering care coordination services were interviewed about time spent on service provision. De-identified individual-level data on study participant utilization of services were also used.

INTERVENTION

Project INSPIRE is an innovative hepatitis C care coordination program developed by the New York City Department of Health and Mental Hygiene.

MAIN OUTCOME MEASURES

Average cost per participant per episode of care for 2 provider organizations and a proposed payment model.

RESULTS

The average cost per participant at 1 provider organization was $787 ($522 nonoverhead cost, $264 overhead) per episode of care (5.6 months) and $656 ($429 nonoverhead cost, $227 overhead, 5.7 months) at the other one. The first organization had a lower macro-costing estimate ($561 vs $787) whereas the other one had a higher macro-costing estimate ($775 vs $656). In the 3-phased payment model, phase 1 reimbursement would vary between the provider organizations from approximately $280 to $400, but reimbursement for both organizations would be approximately $220 for phase 2 and approximately $185 for phase 3.

CONCLUSIONS

The cost of this 5.6-month care coordination intervention was less than $800 including overhead or less than $95 per month. A 3-phase payment model is proposed and requires further evaluation for implementation feasibility. Project INSPIRE's HCV care coordination program provides good value for a cost of less than $95 per participant per month. The payment model provides an incentive for successful cure of hepatitis C with a bonus payment; using the bonus payment to support HCV tele-mentoring expands HCV treatment capacity and empowers more primary care providers to treat their own patients with HCV.

The Impact of Clinic Policy Attendance and the Ryan White HIV/AIDS Medical Case Management Program on HIV Clinical Outcomes: A Retrospective Longitudinal Study

Clinic appointment attendance is a significant determinant of improved HIV health outcomes. A retrospective longitudinal analysis from 2009 to 2015 examined the relationship of clinic policy attendance with and without medical case management (MCM) on HIV clinical outcomes. Clinical parameters were abstracted across the study years and latent growth models measured HIV clinical outcomes as a function of time. A total of 2773 patients were included in this study. More than the majority of individuals had 75% clinic policy attendance during each of the study years and the median number of MCM contact visits with the case manager was 4.0 visits per year (p < 0.01). While the overall trend identified improved HIV clinical outcomes across the clinic population over the study period, it also revealed individuals receiving MCM and with 75% clinic policy attendance had significantly faster improvement in HIV clinical outcomes compared to the individuals who did not receive MCM nor had 75% clinic policy attendance. This study identified how MCM, in combination with clinic policy attendance efforts, are useful in quickly improving HIV viral load and CD4 T-cell count. These findings support the continued need for funding of the Ryan White Care Act as it assists with the support of MCM and appointment attendance through the guidance of wrap-around services.

Evaluation of smartphone APP-based case-management services among antiretroviral treatment-naïve HIV-positive men who have sex with men: a randomized controlled trial protocol

Background

Men who have sex with men (MSM) are disproportionally affected by HIV in China. ‘Treatment as Prevention’ is a promising strategy for HIV prevention but requires adequate adherence. Mobile health (mHealth) may be an acceptable and feasible approach for service delivery, but there is little evidence supporting mHealth intervention for improving antiretroviral treatment adherence among HIV-infected MSM in low- and middle-income countries, including China. This study will aim to develop a smartphone application-based case-management service and compare its efficacy to standard care with regards to adherence, CD4, HIV viral load and psychosocial outcomes among MSM patients in Guangzhou, China.

Methods

A non-blinded 1:1 parallel-group randomised controlled trial will be conducted in Guangzhou Eighth People’s Hospital, with 300 MSM enrolled in each arm. Eligible MSM who are newly initiating ART will be randomly assigned to an intervention group (standard-of-care case management plus mHealth intervention) or a control group (standard-of-care case management). The development of the mHealth intervention will be based on the information–motivation–behavioural skills theory of ART adherence, and comprise four components: educational articles, one-to-one online communication with case managers, support-service information and hospital-visit reminders. Outcome measures will be collected at baseline and at months 1, 3, 6, and 12. The primary outcomes will be ART adherence and CD4 count at month 6. Secondary outcomes include HIV RNA, sexual behaviours, mental health status, illness perceptions, and quality of life. χ² test and t-test will be used for between-group comparisons. Intervention effects will be evaluated using General estimating equation performed by SAS 9.0, on the principle of intention-to-treat. Structural equation modelling will be used to test potential mechanisms of intervention effect.

Discussion

This study is the first to explore the efficacy of mHealth intervention in the case management services targeted at HIV-infected MSM in low-and middle-income countries. Once proven effective, the innovative mHealth service could be integrated into the routine case management of PLWH. as well as be tailored to the patient management service for other chronic conditions.

Trial registration

ClinicalTrial.gov: NCT03860116; Registered on 1 March 2019.

Effectiveness of a Viral Load Suppression Intervention for Highly Vulnerable People Living with HIV

We examine the effect of the Undetectables Intervention (UI) on viral loads among socially vulnerable HIV-positive clients. The UI utilized a toolkit that included financial incentives, graphic novels, and community-based case management services. A pre-post repeated measures analysis (n = 502) through 4 years examined longitudinal effects of the intervention. Logistic models regressed social determinants on viral loads. Finally, in-depth qualitative interviews (n = 30) examined how UI shaped adherence. The proportion of virally suppressed time-points increased 15% (from 67 to 82% pre to post-enrollment, p < 0.0001). The proportion of the sample virally suppressed at all time-points increased by 23% (from 39 to 62% pre to post-enrollment, p < 0.0001). African Americans and the homeless were the most likely to be unsuppressed at baseline, but, along with substance users, benefitted the most from UI. The intervention shaped adherence through two pathways, by: (1) establishing worth around adherence, and (2) increasing motivation to become suppressed, and maintain adherence.

Trends in provider-advised HIV antiretroviral therapy deferral in the United States, 2009-2014

Since 2012, U.S. clinical guidelines for antiretroviral therapy (ART) initiation have recommended universal ART prescription barring patient contraindications. Although ART prescription has significantly increased among U.S. HIV patients in recent years, the reasons for this increase, and why some patients are still not taking ART, are not well characterized. To fill these gaps, we analyzed data from the Medical Monitoring Project (MMP), to assess the proportion of persons who reported provider-advised ART deferral during 2009-2014, and used bivariate linear regression to estimate linear trends in provider-advised ART deferral over time by patient characteristics and clinical setting. During this period, the proportion of patients reporting provider-advised ART deferral decreased from 67% to 40%. Significant decreases were observed in all patient subgroups and clinical settings. Patients recently reporting non-provider-advised reasons for ART deferral were significantly less likely to be virally suppressed and more likely to have inconsistent care, be depressed, binge drink, and use illicit drugs. This work suggests that U.S. providers are recommending ART deferral for fewer patients, consistent with increasing adoption of 2012 universal prescribing guidelines. Addressing patients' financial, mental health, and substance use barriers may be needed to achieve universal ART prescription in the United States.

Is HIV patient navigation associated with HIV care continuum outcomes?

OBJECTIVE

To provide the first systematic review on the associations between HIV patient navigation and HIV care continuum outcomes (i.e. linkage to care, retention in care, antiretroviral therapy (ART) uptake, medication adherence, and viral suppression) in the United States. We identified primary research studies that addressed these associations and qualitatively assessed whether provision of patient navigation was positively associated with these outcomes, including strength of the evidence.

METHODS

A systematic review, including both electronic [MEDLINE (OVID), EMBASE (OVID), PsycINFO (OVID), and CINAHL (EBSCOhost)] online databases and manual searches, was conducted to locate studies published from 1 January 1996 through 23 April 2018.

RESULTS

Twenty studies met our inclusion criteria. Of these, 17 found positive associations. Patient navigation was more likely to be positively associated with linkage to care (five of six studies that assessed this association), retention in care (10 of 11), and viral suppression (11 of 15) than with ART uptake (one of four) or ART adherence (two of four). However, almost two-thirds of the 17 studies were of weak study quality, and only three used a randomized controlled trial design.

CONCLUSION

Available evidence suggests that patient navigation is a potentially effective strategy to enhance engagement in care among persons with HIV. However encouraging, the evidence is still weak. Studies with more rigorous methodological designs, and research examining characteristics of navigators or navigational programs associated with better outcomes, are warranted given the current interest and use of this strategy.

Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department

Because of a soaring number of opioid-related deaths during the past decade, opioid use disorder has become a prominent issue in both the scientific literature and lay press. Although most of the focus within the emergency medicine community has been on opioid prescribing-specifically, on reducing the incidence of opioid prescribing and examining alternative pain treatment-interest is heightening in identifying and managing patients with opioid use disorder in an effective and evidence-based manner. In this clinical review article, we examine current strategies for identifying patients with opioid use disorder, the treatment of patients with acute opioid withdrawal syndrome, approaches to medication-assisted therapy, and the transition of patients with opioid use disorder from the emergency department to outpatient services.

The Impact of the Ryan White HIV/AIDS Medical Case Management Program on HIV Clinical Outcomes: A Longitudinal Study

Medical case management (MCM) is a core medical service in The Ryan White HIV/AIDS Program and aims to provide treatment and care for people living with HIV/AIDS by engaging, identifying and eliminating barriers to HIV care. Little research has examined the impact of this intervention; therefore, the purpose of this study was to examine the how MCM affects HIV clinical outcomes. The study took place at a midwestern, outpatient infectious diseases clinic. This study utilized a longitudinal, retrospective study design to analyze to the impact of MCM engagement on HIV clinical outcomes (viral loads, CD4 counts) from 2009 to 2015 as a time-varying predictor. A total of 2773 patients were included in this study, of which 975 patients (35.2%) engaged in MCM. Among those in MCM, approximately 90% of the population were between 25 and 64 years of age, more than three-quarters were African American men, mean time of HIV care engagement in at this clinic care was 3.2 (± 4.1), while mean years living with HIV was 10.5 (± 7.1). Throughout the study period, those engaged in MCM had a significantly faster improvement in their HIV clinical outcomes compared to the non-MCM group (p < 0.001). The study highlights the significant impact MCM services have on improving CD4 T cell counts and HIV viral loads. The successful care coordination that MCM offers clearly improves health outcomes while creating a network of patient 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.

Improving postpartum retention in care for women living with HIV in the United States

: Research findings have consistently demonstrated that women living with HIV in the United States and globally experience declines in medication adherence and retention in care after giving birth. A number of studies have identified factors associated with postpartum retention in care, but the evidence base for interventions to address the problem and close this gap in the HIV care continuum is limited. Furthermore, the majority of studies have been conducted in low-resource or moderate-resource countries and may be less applicable or require adaptation for use in high resource countries. In the United States, up to two-thirds of women drop out of care after delivery and are unable to maintain or achieve viral suppression postpartum, at a time when maternal and pediatric health are closely linked. We conducted a critical review of the literature to identify existing gaps regarding maternal retention in the United States and conceptualize the problem through the lens of the integrated and ecological models of health behavior. This review describes existing barriers and facilitators to retention in HIV care postpartum from published studies and suggests steps that can be taken, using a multilevel approach, to improve maternal retention. We propose five core action steps related to increasing awareness of the problem of poor postpartum retention, addressing needs for improved care coordination and case management, and using novel approaches to adapt and implement peer support and technology-based interventions to improve postpartum retention and clinical outcomes of women living with HIV.

Scoping Review of Nursing Case Management in the United States

The purpose of this study is to identify issues of case management (CM) interventions in the United States in recent studies and to identify implications for future research into CM. This study was guided by the following framework for a scoping review. Multiple electronic databases were searched to identify studies published between 2007 and 2016 in the United States and related to nursing CM. Five weaknesses were identified: no clear and consistent definition of CM, lack of theoretical frameworks, lack of standard guidelines in CM practice, lack of precise CM dosage and of process measures, and limited reports of explicit role of nurse case managers and role confusion by nurses. Three strengths were also identified. More rigorous and continuous efforts to develop theoretical frameworks and evaluation tools, as well as clear definitions and precise role descriptions, are required for future research and practice into CM.

Postpartum Human Immunodeficiency Virus Care Among Women Diagnosed During Pregnancy

OBJECTIVE

To identify factors associated with continuity of care and human immunodeficiency virus (HIV) virologic suppression among postpartum women diagnosed with HIV during pregnancy in New York State.

METHODS

This retrospective cohort study was conducted among 228 HIV-infected women diagnosed during pregnancy between 2008 and 2010. Initial receipt of HIV-related medical care (first CD4 or viral load test after diagnosis) was evaluated at 30 days after diagnosis and before delivery. Retention in care (2 or more CD4 or viral load tests, 90 days or greater apart) and virologic suppression (viral load 200 copies/mL or less) were evaluated in the 12 months after hospital discharge.

RESULTS

Most women had their initial HIV-related care encounter within 30 days of diagnosis (74%) and before delivery (87%). Of these women, 70% were retained in the first year postpartum. Women waiting more than 30 days for their initial HIV-related care encounter were more likely diagnosed in the first (29%) compared with the third (11%) trimester and were of younger (younger than 25 years, 32%) compared with older (35 years or older, 13%) age. Loss to follow-up within the first year was significantly greater among women diagnosed in the third compared with the first trimester (adjusted relative risk 2.21, 95% confidence interval [CI] 1.41-3.45) and among women who had a cesarean compared with vaginal delivery (adjusted relative risk 1.76, 95% CI 1.07-2.91). Of the 178 women with one or more HIV viral load test in the first year postpartum, 58% had an unsuppressed viral load.

CONCLUSION

Despite the high proportion retained in care, many women had poor postpartum virologic control. Robust strategies are needed to increase virologic suppression among newly diagnosed postpartum HIV-infected women.