edward m. gardner, md denver public health december 10, 2014 · edward m. gardner, md denver public...
TRANSCRIPT
Edward M. Gardner, MD
Denver Public Health
December 10, 2014
No financial relationships to disclose
No off-label discussions in presentation
Describe the evolution of the HIV care continuum and its applications
Discuss how engagement in HIV care across the spectrum of engagement promotes prevention of HIV transmission
Discuss what implications the HIV care continuum has on the work of ASOs/CBOs
Adapted from
Eldred et al AIDS Patient Care STDs 2007;21(Suppl1):S1-S2
Cheever Clin Infect Dis 2007;44:1500-2
Not in HIV Care Engaged in HIV Care
Unaware of
HIV infection
Aware of
HIV infection
(not in care)
Receiving some
medical care but
not HIV care
Entered HIV
care but lost to
follow-up
Cyclical or
intermittent user
of HIV care
Fully engaged
in HIV care
Mugavero et al. Clin Infect Dis. 2011;52:S238-S246
19%
Gardner et al. Clin Infect Dis 2011;52(6):793–800
Slide Courtesy of Dr. Irene Hall, CDC IAC 2012 Abstract FRLBX05
CDC Vital Signs 11/25/2014
19% or 25% or 30%
Probably More!
Where are the problems?
• Accuracy and completeness of reported data
• Migration out of state and out of country
• Mortality data
76%70%
62% 61%55% 55% 54% 54%
58%54%
9%16% 17% 22% 23% 21% 21% 18% 21%
17% 12% 11% 9% 9% 8% 8% 8% 7% 6%
5% 7% 9% 11% 10% 11% 14% 13% 14% 14%
2% 2% 2% 2% 3% 3% 3% 3% 2% 4%
21%29% 32%
37% 35% 33% 35% 37% 37% 36%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
6 12 18 24 30 36 42 48 54 60
Months After HIV Diagnosis
% in care %not retained %not linked
%out of state %expired % VL<200cps/ml
Rowan et al. IAC 2012 Poster MOPDC0305
Rowan et al. IAC 2012 Poster MOPDC0305
Dombrowski et al. JAIDS 2014;67(3):323-330.
Slide Courtesy of Dr. Irene Hall, CDC IAC 2012 Abstract FRLBX05
Nosyk et al. Lancet Infect Dis 2014;14:40-9.
Rowan et al. CROI 2012; Poster 1118.
81% 92% 81% 86%
Supervie V. & Costagliola D. The spectrum of engagement in HIV care in France: strengths and gaps. 20th Conference on
Retroviruses and Opportunistic Infections. Atlanta, USA: March 2013. Abstract #: 1030.
IAS 2013 Abstract:MOPE143
20%
Cascades provide a snapshot of HIV prevention and care services in a geographic area
May facilitate comparison of services in different locations, populations, and under different health care financing systems • Make sure definitions are the same for cascade
steps
Can facilitate tracking services over time
May facilitate health policy decisions regarding types and locations of services needed
Engagement with Prevention (HIV negative) • Pre-Exposure Prophylaxis (PrEP) • Non-occupational Post-Exposure Prophylaxis (NPEP) • Circumcision • Microbicides
Decreased risk behaviors (HIV positive or negative) • Sexual • Injection • Sero-adaptive behavior
Decreased HIV-RNA level (HIV positive) • Access to antiretroviral therapy • Adherence to antiretroviral therapy
Youth Risk Behavior Survey (YRBS) MMWR 2012;61(29):556-60.
Liu et al. PLoS Med 2014;11(3):e1001613
Marks et al. JAIDS 2005;39:446-53.
UAV = Unprotected Anal or Vaginal Intercourse
Metsch et al. Clin Infect Dis 2008;47:577-84.
Dombrowski et al. JAIDS 2013;63:299-306.
Quarters with an HIV Clinic Visit
Adherence by Pharmacy Refill
P-value (overall)
4 79% P<0.001
3 74%
2 68%
1 59%
Adherence was higher in newly engaging patients with better
engagement in care over one year (number of quarters with
an HIV Clinic Visit
Giordano et al. Clin Infect Dis. 2007;44:1493-9.
Fu et al. AIDS 2012;26:2383-91.
Ch
an
ge
in
HIV
-1 R
NA
(lo
g 1
0 c
op
ies/m
l)
Hammer et al. NEJM 1997;337:725-33.
Dual Nucleosides
Indinavir + Dual Nucleosides
Patterson et al. Ann Intern Med. 2000;133:21-30.
Connor et al. NEJM. 1994;331:1173-80.
NEJM 2011;365: 493-505.
HPTN-052
96% reduction
In HIV incidence
It is more readily apparent that prevention and treatment are part of the same continuum
Funding is becoming streamlined
• CDC – HIV testing and prevention
• HRSA – HIV treatment and care
Gives structure to our conversations
• With funders, HCWs, patients, clients
Allows us to measure and track our efforts
Patients/Clients
Activists
Providers and Health Care Workers
Community Based Organizations
Community members
Health departments
Funders
Social support Outreach and navigation (Next Slides) Improve messaging on the importance of
engagement (Next Slides) Substance abuse counseling and treatment Mental Health diagnosis and care Universal Health Care? (Next Slides) Improve housing and decrease homelessness Decrease competing needs (food, clothing, etc.) Improve the system of health care delivery
Observational demonstration project (Special Projects of National Significance, SPNS)
Underserved recently diagnosed individuals • women, youth, substance abuse, mental illness
Intensive outreach defined as • HIV education and support
• Addressing stigma
• Helping individuals access resources
• Addressing structural barriers to care
Naar-King et al. AIDS Pat Care STDs 2007;21 (Suppl1): S40-8
104 participants had an average of 19 contacts over 12 months, 15 minutes per contact
Results:
• 81% had two visits over the first year
• 45% undetectable viral load at 12 months
• 50% of uninsured gained insurance at 12 months
• 50% reduction in self-reported stigma as barrier
• 50% reduction in unmet support service need
Naar-King et al. AIDS Pat Care STDs 2007;21 (Suppl1): S40-8
Another SPNS publication
Peer patient Navigation supported: • Coaching patients
• Health system navigation
• Community linkages
437 individuals followed • Engagement at 6 months improved 64% to 87%
• 79% were still engaged at 12 months
• 50% increase in rates of viral suppression
Bradford et al. AIDS Pat Care STDs 2007;21 (Suppl1): S49-58
The messaging intervention included: • Print reminder material including brochures and
posters that encouraged staying in care and contained information on: • The importance of staying in care
• Clinic contact numbers
• Research showing better health with regular care
• Brief verbal messages used by all clinic staff • “Thank you for doing such a good job of keeping your
appointments. It makes it easier for all of us to work together to keep you healthy.”
Gardner L et al. Clin Infect Dis 2012;55:1124-34
Gardner L et al. Clin Infect Dis 2012;55:1124-34
Table 2. Adjusted Percentage of Patients Keeping Next 2 Primary Care Visits During
Preintervention and Intervention Periods, 2008 - 2010
Table 3. Adjusted Mean Proportion of All Primary Care Visits Among Patients During
Preintervention and Intervention Periods, 2008 - 2010
Colorado expanded Medicaid and started a State-Wide Exchange in 2014
In 2014 we witnessed the following at our clinic:
• Uninsured dropped from 60% to 15%
• Medicaid increased from 15% to 50%
• Private insurance (exchange) increased from 5% to 15%
No data yet on the impact on engagement in HIV care
Slide Courtesy of Karen Robinson and David Heal, Washington State DOH
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