The Contribution of Missed Clinic Visits to Disparities in HIV Viral Load Outcomes.

OBJECTIVES: We explored the contribution of missed primary HIV care visits ("no-show") to observed disparities in virological failure (VF) among Black persons and persons with injection drug use (IDU) history. METHODS: We used patient-level data from 6 academic clinics, before the Centers for Disease Control and Prevention and Health Resources and Services Administration Retention in Care intervention. We employed staged multivariable logistic regression and multivariable models stratified by no-show visit frequency to evaluate the association of sociodemographic factors with VF. We used multiple imputations to assign missing viral load values. RESULTS: Among 10 053 patients (mean age = 46 years; 35% female; 64% Black; 15% with IDU history), 31% experienced VF. Although Black patients and patients with IDU history were significantly more likely to experience VF in initial analyses, race and IDU parameter estimates were attenuated after sequential addition of no-show frequency. In stratified models, race and IDU were not statistically significantly associated with VF at any no-show level. CONCLUSIONS: Because missed clinic visits contributed to observed differences in viral load outcomes among Black and IDU patients, achieving an improved understanding of differential visit attendance is imperative to reducing disparities in HIV.

Clinic-wide intervention lowers financial risk and improves revenue to HIV clinics through fewer missed primary care visits.

: We calculated the financial impact in 6 HIV clinics of a low-effort retention in care intervention involving brief motivational messages from providers, patient brochures, and posters. We used a linear regression model to calculate absolute changes in kept primary care visits from the preintervention year (2008-2009) to the intervention year (2009-2010). Revenue from patients' insurance was also assessed by clinic. Kept visits improved significantly in the intervention year versus the preintervention year (P < 0.0001). We found a net-positive effect on clinic revenue of +$24,000/year for an average-size clinic (7400 scheduled visits/year). We encourage HIV clinic administrators to consider implementing this low-effort intervention.

Estimating the cost of increasing retention in care for HIV-infected patients: results of the CDC/HRSA retention in care trial.

BACKGROUND: Retaining HIV patients in medical care promotes access to antiretroviral therapy, viral load suppression, and reduced HIV transmission to partners. We estimate the programmatic costs of a US multisite randomized controlled trial of an intervention to retain HIV patients in care. METHODS: Six academically affiliated HIV clinics randomized patients to intervention (enhanced personal contact with patients across time coupled with basic HIV education) and control [standard of care (SOC)] arms. Retention in care was defined as 4-month visit constancy, that is, at least 1 primary care visit in each 4-month interval over a 12-month period. We used microcosting methods to collect unit costs and measure the quantity of resources used to implement the intervention in each clinic. All fixed and variable labor and nonlabor costs of the intervention were included. RESULTS: Visit constancy was achieved by 45.7% (280/613) of patients in the SOC arm and by 55.8% (343/615) of patients in the intervention arm, representing an increase of 63 patients (relative improvement 22.1%; 95% confidence interval: 9% to 36%; P < 0.01). The total annual cost of the intervention at the 6 clinics was $241,565, the average cost per patient was $393, and the estimated cost per additional patient retained in care beyond SOC was $3834. CONCLUSIONS: Our analyses showed that a retention in care intervention consisting of enhanced personal contact coupled with basic HIV education may be delivered at fairly low cost. These results provide useful information for guiding decisions about planning or scaling-up retention in care interventions for HIV-infected patients.

High rates of retention and viral suppression in the US HIV safety net system: HIV care continuum in the Ryan White HIV/AIDS Program, 2011.

BACKGROUND: In the human immunodeficiency virus (HIV) care continuum, retention in HIV medical care and viral suppression are key goals to improve individual health outcomes and reduce HIV transmission. National data from clinical providers are lacking. METHODS: HIV providers funded by the Ryan White HIV/AIDS Program (RWHAP) annually report demographic, service, and clinical data using encrypted unique client identifiers, and data are processed and de-duplicated to create a single record for each client. We calculated retention and viral suppression for clients who received RWHAP-funded HIV medical care in 2011. We conducted multivariate logistic regression to identify factors associated with these outcomes. RESULTS: In 2011, an estimated 512 911 HIV-infected clients received at least 1 RWHAP-funded non-AIDS Drug Assistance Program service. Of these, 317 458(61.8%) were seen for at least 1 HIV medical care visit. Of these, 82.2% were retained in HIV medical care, and 72.6% achieved viral suppression. Viral suppression was higher among retained clients (77.7%) vs clients who were not retained (58.3%). The lowest levels of retention and viral suppression were among individuals aged 13-34 years. CONCLUSIONS: The RWHAP provides HIV medical care and support services for more than half a million poor and underinsured individuals living with HIV in the United States. Rates of retention and viral suppression are relatively high compared with other national estimates but demonstrate room for improvement, especially among youth and racial minorities. Additional improvements in retention and viral suppression will contribute to achieving the goals of the National HIV/AIDS Strategy and improve individual and public health.

Enhanced personal contact with HIV patients improves retention in primary care: a randomized trial in 6 US HIV clinics.

BACKGROUND: The aim of the study was to determine whether enhanced personal contact with human immunodeficiency virus (HIV)-infected patients across time improves retention in care compared with existing standard of care (SOC) practices, and whether brief skills training improves retention beyond enhanced contact. METHODS: The study, conducted at 6 HIV clinics in the United States, included 1838 patients with a recent history of inconsistent clinic attendance, and new patients. Each clinic randomized participants to 1 of 3 arms and continued to provide SOC practices to all enrollees: enhanced contact with interventionist (EC) (brief face-to-face meeting upon returning for care visit, interim visit call, appointment reminder calls, missed visit call); EC + skills (organization, problem solving, and communication skills); or SOC only. The intervention was delivered by project staff for 12 months following randomization. The outcomes during that 12-month period were (1) percentage of participants attending at least 1 primary care visit in 3 consecutive 4-month intervals (visit constancy), and (2) proportion of kept/scheduled primary care visits (visit adherence). RESULTS: Log-binomial risk ratios comparing intervention arms against the SOC arm demonstrated better outcomes in both the EC and EC + skills arms (visit constancy: risk ratio [RR], 1.22 [95% confidence interval {CI}, 1.09-1.36] and 1.22 [95% CI, 1.09-1.36], respectively; visit adherence: RR, 1.08 [95% CI, 1.05-1.11] and 1.06 [95% CI, 1.02-1.09], respectively; all Ps < .01). Intervention effects were observed in numerous patient subgroups, although they were lower in patients reporting unmet needs or illicit drug use. CONCLUSIONS: Enhanced contact with patients improved retention in HIV primary care compared with existing SOC practices. A brief patient skill-building component did not improve retention further. Additional intervention elements may be needed for patients reporting illicit drug use or who have unmet needs. CLINICAL TRIALS REGISTRATION: CDCHRSA9272007.

The association of clinical follow-up intervals in HIV-infected persons with viral suppression on subsequent viral suppression.

The recommendation for the frequency for routine clinical monitoring of persons with well-controlled HIV infection is based on evidence that relies on observed rather than intended follow-up intervals. We sought to determine if the scheduled follow-up interval is associated with subsequent virologic failure. Participants in this 6-clinic retrospective cohort study had an index clinic visit in 2008 and HIV viral load (VL) ≤400 c/mL. Univariate and multivariate tests evaluated if scheduling the next follow-up appointment at 3, 4, or 6 months predicted VL >400 c/mL at 12 months (VF). Among 2171 participants, 66%, 26%, and 8% were scheduled next follow-up visits at 3, 4, and 6 months, respectively. With missing 12-month VL considered VF, 25%, 25%, and 24% of persons scheduled at 3, 4, and 6 months had VF, respectively (p=0.95). Excluding persons with missing 12-month VL, 7.1%, 5.7%, and 4.5% had VF, respectively (p=0.35). Multivariable models yielded nonsignificant odds of VF by scheduled follow-up interval both when missing 12-month VL were considered VF and when persons with missing 12-month VL were excluded. We conclude that clinicians are able to make safe decisions extending follow-up intervals in persons with viral suppression, at least in the short-term.

Measuring retention in HIV care: the elusive gold standard.

BACKGROUND: Measuring retention in HIV primary care is complex, as care includes multiple visits scheduled at varying intervals over time. We evaluated 6 commonly used retention measures in predicting viral load (VL) suppression and the correlation among measures. METHODS: Clinic-wide patient-level data from 6 academic HIV clinics were used for 12 months preceding implementation of the Centers for Disease Control and Prevention/Health Resources and Services Administration (CDC/HRSA) retention in care intervention. Six retention measures were calculated for each patient based on scheduled primary HIV provider visits: count and dichotomous missed visits, visit adherence, 6-month gap, 4-month visit constancy, and the HRSA HIV/AIDS Bureau (HRSA HAB) retention measure. Spearman correlation coefficients and separate unadjusted logistic regression models compared retention measures with one another and with 12-month VL suppression, respectively. The discriminatory capacity of each measure was assessed with the c-statistic. RESULTS: Among 10,053 patients, 8235 (82%) had 12-month VL measures, with 6304 (77%) achieving suppression (VL <400 copies/mL). All 6 retention measures were significantly associated (P < 0.0001) with VL suppression (odds ratio; 95% CI, c-statistic): missed visit count (0.73; 0.71 to 0.75, 0.67), missed visit dichotomous (3.2; 2.8 to 3.6, 0.62), visit adherence (3.9; 3.5 to 4.3,0.69), gap (3.0; 2.6 to 3.3, 0.61), visit constancy (2.8; 2.5 to 3.0, 0.63), and HRSA HAB (3.8; 3.3 to 4.4, 0.59). Measures incorporating "no-show" visits were highly correlated (Spearman coefficient = 0.83-0.85), as were measures based solely on kept visits (Spearman coefficient = 0.72-0.77). Correlation coefficients were lower across these 2 groups of measures (range = 0.16-0.57). CONCLUSIONS: Six retention measures displayed a wide range of correlation with one another, yet each measure had significant association and modest discrimination for VL suppression. These data suggest there is no clear gold standard and that selection of a retention measure may be tailored to context.

National performance measures within a changing environment: how a federal agency developed and improved the measurement for HIV care and treatment.

The United States Department of Health and Human Services (HHS) must ensure that access to high quality care is provided through the Ryan White HIV/AIDS Program (RWP). The RWP is committed to improving the quality of care and services to reduce mortality and improve quality of life for people living with HIV. This commitment is evidenced by the comprehensive range of efforts taken by the HHS, Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB) to address the quality of care, treatment and other services across all programs funded by the RWP. To assure high quality care, HRSA/HAB engages in many quality initiatives, with the development of performance measures as a central core of its overall activities. The HRSA/HAB defined a solid foundation for the measures development process, which has been refined over time, facilitating the timely release and use of performance measures by the HIV service provider community.

A low-effort, clinic-wide intervention improves attendance for HIV primary care.

BACKGROUND: Retention in care for human immunodeficiency virus (HIV)-infected patients is a National HIV/AIDS Strategy priority. We hypothesized that retention could be improved with coordinated messages to encourage patients' clinic attendance. We report here the results of the first phase of the Centers for Disease Control and Prevention/Health Resources and Services Administration Retention in Care project. METHODS: Six HIV-specialty clinics participated in a cross-sectionally sampled pretest-posttest evaluation of brochures, posters, and messages that conveyed the importance of regular clinic attendance. 10,018 patients in 2008-2009 (preintervention period) and 11,039 patients in 2009-2010 (intervention period) were followed up for clinic attendance. Outcome variables were the percentage of patients who kept 2 consecutive primary care visits and the mean proportion of all primary care visits kept. Stratification variables were: new, reengaging, and active patients, HIV RNA viral load, CD4 cell count, age, sex, race or ethnicity, risk group, number of scheduled visits, and clinic site. Data were analyzed by multivariable log-binomial and linear models using generalized estimation equation methods. RESULTS: Clinic attendance for primary care was significantly higher in the intervention versus preintervention year. Overall relative improvement was 7.0% for keeping 2 consecutive visits and 3.0% for the mean proportion of all visits kept (P < .0001). Larger relative improvement for both outcomes was observed for new or reengaging patients, young patients and patients with elevated viral loads. Improved attendance among the new or reengaging patients was consistent across the 6 clinics, and less consistent across clinics for active patients. CONCLUSION: Targeted messages on staying in care, which were delivered at minimal effort and cost, improved clinic attendance, especially for new or reengaging patients, young patients, and those with elevated viral loads.

Interventions delivered in clinical settings are effective in reducing risk of HIV transmission among people living with HIV: results from the Health Resources and Services Administration (HRSA)'s Special Projects of National Significance initiative.

To support expanded prevention services for people living with HIV, the US Health Resources and Services Administration (HRSA) sponsored a 5-year initiative to test whether interventions delivered in clinical settings were effective in reducing HIV transmission risk among HIV-infected patients. Across 13 demonstration sites, patients were randomized to one of four conditions. All interventions were associated with reduced unprotected vaginal and/or anal intercourse with persons of HIV-uninfected or unknown status among the 3,556 participating patients. Compared to the standard of care, patients assigned to receive interventions from medical care providers reported a significant decrease in risk after 12 months of participation. Patients receiving prevention services from health educators, social workers or paraprofessional HIV-infected peers reported significant reduction in risk at 6 months, but not at 12 months. While clinics have a choice of effective models for implementing prevention programs for their HIV-infected patients, medical provider-delivered methods are comparatively robust.

Reported care quality in federal Ryan White HIV/AIDS Program supported networks of HIV/AIDS care.

Since 1991, the US Government has funded medical and support services for people living with HIV and AIDS (PLWHA) through the Ryan White HIV/AIDS Program. The Ryan White Program supports networks of care which include medical care providers and support services for PLWHA in 51 Eligible Metropolitan Areas (EMAs). In the 2000 reauthorization of the Ryan White Program, quality management programs were required for all sites receiving funding. To facilitate quality management and improvement activities in EMAs, we developed a set of surveys to measure characteristics of care networks and the quality, accessibility, and coordination of services from the perspective of case management and medical providers, administrators and consumers. The surveys measured quality management and support activities of the entire network, as well as reported quality of services at individual care sites. They were administered in 42 EMAs from a total of 43 who had not participated in earlier pilot testing and were located in the continental US. The care networks were rated highly on access, quality, and coordination between case management and primary care providers. However, there were frequently differences in ratings of quality and barriers by type of respondent (consumer representatives, Grantees, and providers). There were also substantial variations across EMAs in network characteristics, perceived effectiveness, performance measurement, and quality improvement activities. The results indicate that the Ryan White Program has been successful in some areas of developing networks of care, but additional support is needed to strengthen the comprehensiveness and coordination of care. Additional work also is needed to better define and measure the essential characteristics of coordinated and integrated networks of care and assess whether those characteristics are related to access and quality of care and services.

Sex, risk and responsibility: provider attitudes and beliefs predict HIV transmission risk prevention counseling in clinical care settings.

We examined factors associated with the frequency of HIV "prevention with positives" (PwP) counseling delivered by providers participating in demonstration projects at 26 clinics. Three hundred and fifteen primary care and support service providers completed a survey assessing the frequency of PwP delivered at initial medical care visits and at regular care visits. Providers reported delivering PwP counseling to more patients at initial visits (67%) than to those returning for regular care (53%; t = 11.8, p < 0.001). During initial and regular care visits, providers reporting a sense of responsibility for conducting PwP and those regularly discussing the risk of reinfection with patients reported significantly more frequent PwP counseling. Providers expressing a belief that no matter how much counseling was delivered, some HIV-infected patients would still infect others (prevention fatalism) reported significantly less frequent counseling at all visits. To improve the quality and quantity of HIV PwP counseling, providers training should address attitudinal barriers and facilitators to counseling and the importance of addressing risk routinely.

The impact of a quality improvement program on systems, processes, and structures in medical clinics.

OBJECTIVE: We sought to assess whether participation in a quality-improvement collaborative changed care processes, systems, and organization of outpatient human immunodeficiency virus (HIV) clinics. METHODS: We surveyed clinicians, medical directors, and HIV program administrators before and after an 18-month quality improvement collaborative at 54 intervention and 37 control clinics providing HIV care. Surveys assessed clinic structures, processes, systems, and culture. During the collaborative, a clinician-administrator team from each intervention clinic attended 4 2-day sessions on quality improvement techniques. Conference calls, a website, and an e-mail list provided support and facilitated communication among collaborative participants. RESULTS: Survey response rates were 85% or greater. Six of 54 organizational measures differed significantly between baseline and follow-up. Intervention clinicians reported greater computer availability (82% vs. 67%, P = 0.03) and use (3.13 vs. 2.68, P = 0.02; 4-point scale), attended more local (14.2 vs. 8.6, P < 0.01) and national (4.1 vs. 2.9, P = 0.01) conferences, and rated leaders' ability to implement quality improvement higher (3.8 vs. 3.4, P = 0.01; 5-point scale). Intervention directors were more likely to compare quality data to other clinics (79% vs. 54%, P = 0.04). For the set of 54 measures, intervention clinics were more likely to have higher post-intervention scores than controls (sign test, mean = 14.5, P < 0.0001). CONCLUSIONS: A quality-improvement collaborative for HIV clinics resulted in modest organizational changes. Achieving greater change may require more focused and/or intensive interventions, greater resources for participating clinics, and better developed information technology.

Gender differences in quality of HIV care in Ryan White CARE Act-funded clinics.

BACKGROUND: Women with HIV infection have lagged behind men in receipt of critical health care, but it is not known if those disparities are due in part to where women receive care. We examined differences in care received by HIV-infected women and men in a national sample of Ryan White CARE Act-funded clinics and explored the influence of clinic characteristics on care quality. METHODS: Record review was done on a sample of 9,015 patients who received care at 69 CARE Act-funded HIV primary care clinics that participated in a quality improvement study. Outcome measures studied were highly active antiretroviral therapy (HAART) use, HIV viral suppression, Pneumocystis jiroveci pneumonia (PCP) prophylaxis, screening, and other disease prevention efforts. RESULTS: Women were less likely than men to receive HAART (78% versus 82%, p < .001), receive PCP prophylaxis (65% versus 75%, p < .0001), or have their hepatitis C virus status known (87% versus 88%, p = .02) despite being seen more regularly (69% versus 66%, p = .04). Sites serving high percentages of women delivered similar or better care for both men and women than other sites. Although sites serving a higher percent of women had more support services such as case management and onsite obstetrician-gynecologists and provided Pap smears at higher rates, women at such sites remained less likely than men to receive important HIV care including HAART and PCP prophylaxis. CONCLUSIONS: The gap in the quality of care provided to HIV-infected men and women in critical areas persists, and is not explained by the types of sites where men and women receive care.

A two-stage sampling method for clinical surveillance of individuals in care for HIV infection in the United States.

OBJECTIVES: The goals of this study were two-fold: (1) to describe methods for drawing a population-based sample of individuals in care for HIV infection and (2) to compare data from the sample with data from existing surveillance systems that describe care for HIV. METHODS: The authors implemented a two-stage sampling method, using local HIV/AIDS surveillance data as a sampling frame of HIV care providers in three states. At selected providers, medical records of a random sample of patients were abstracted. RESULTS: The medical records of a number of patients, ranging from 253 to 374 individuals per state, were abstracted. The demographics of sampled individuals and of individuals reported to the local HIV/AIDS surveillance program were similar; however, differences existed in the proportion of individuals receiving HIV care consistent with treatment guidelines between the sample and a contemporary facility-based supplemental surveillance project. The median design effect for outcomes collected in the sample was 1.8 (range=0.5-29.6). CONCLUSIONS: This survey method is feasible for collecting population-based data on patients in care for HIV. Sample size and some design elements should be changed in future studies to increase precision of estimates and usefulness of data for local planning and evaluation.