Care programme improves clinic attendance and rates of virologic suppression among vulnerable HIV-positive patients in New York

Enrolment in a comprehensive care co-ordination programme significantly improves levels of engagement with HIV care and virologic suppression in vulnerable HIV-positive adults, according to research published in the online edition of Clinical Infectious Diseases. The research was conducted in New York City and involved over 3600 people who either had previous poor engagement with care or were newly diagnosed. Their package of support included case-finding after missed appointments; individual case management; a multi-disciplinary care team; accompanied clinic visits; adherence support and structured health promotion information.

Patients were followed for one year and the intervention was shown to have a “substantial and robust impact.”

Improvements in antiretroviral therapy mean that many HIV-positive patients now have an excellent life expectancy. HIV treatment also has public health benefits as an undetectable viral load is associated with a zero or extremely low risk of passing on the infection to sexual partners.

Glossary

virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

treatment cascade

A model that outlines the steps of medical care that people living with HIV go through from initial diagnosis to achieving viral suppression, and shows the proportion of individuals living with HIV who are engaged at each stage. 

linkage to care

Refers to an individual’s entry into specialist HIV care after being diagnosed with HIV. 

continuum of care

A model that outlines the steps of medical care that people living with HIV go through from initial diagnosis to achieving viral suppression, and shows the proportion of individuals living with HIV who are engaged at each stage. 

Ryan White HIV/AIDS Program

In the United States, the largest federally funded programme providing HIV-related services to low-income, uninsured, and underinsured people with HIV/AIDS.

However, people can only benefit from HIV therapy if they engage with the care continuum or treatment cascade. This involves diagnosis; linkage to care; ongoing engagement with care; appropriate use of HIV therapy; adherence to therapy; and achievement of an undetectable viral load.

In the US, between 72 and 80% of those diagnosed with HIV are linked to care and further attrition occurs at each stage of the treatment cascade with only 24 to 42% of patients achieving virologic suppression.

Strategies and interventions are therefore urgently needed to improve outcomes.

In 2009, New York City’s Ryan White part A HIV Care Coordination Program was launched at 29 agencies. Investigators wanted to determine the short-term impact of participation in this project, which provides support to people at high risk of poor HIV-related outcomes.

The study outcomes were engagement in (at least two CD4 and/or viral load evaluations 90 days apart, with at least one assessment in each six-month period of the study) and virological suppression (a viral load below 200 copies/ml in the second six-month period).

People were categorised as newly diagnosed if they were diagnosed with HIV in the twelve months before enrolment in the study, and as previously diagnosed if they had been diagnosed for more than twelve months. Previously diagnosed patients were defined as out of care if they had not had a CD4/viral load evaluation in the six months prior to enrolment.

Most of the participants were black or Hispanic (92%), male (63%) and US born (66%). The median age at enrolment was 45 years, and 46% of patients had a CD4 count below 350 cells/mm3. At the start of the study, 74% were currently in care, 14% were out of care and 13% were newly diagnosed.

Among the previously diagnosed patients, engagement with care increased from 74 to 91% and the proportion of patients with virological suppression increased from 32 to 51%. The best improvements were seen in patients who had previously been out of care for at least six months.

Analysis of the newly diagnosed patients showed that 91% were engaged with care and 66% achieved a viral load below 200 copies/ml.

The investigators were especially encouraged that the greatest relative improvements in engagement and/or virological suppression were seen in the most vulnerable people, for instance those without an antiretroviral prescription at enrolment, individuals on a low income, patients with no health insurance and the homeless.

“Among vulnerable populations with HIV, comprehensive care coordination may substantially improve short-term outcomes for previously diagnosed clients, especially those returning to care after a >6 month gap. Newly diagnosed clients in this study also fared well,” conclude the authors. “Our initial analyses of short-term care coordination program client outcomes suggest the promise of this comprehensive combination intervention model for optimizing the individual and community impact of HIV care among persons at risk for suboptimal outcomes.”

References

Irvine MK et al. Improvements in HIV care engagement and viral load suppression following enrollment in a comprehensive HIV care coordination program. Clin Infect Dis, online edition, 2014.