The Cost and Threshold Analysis of Retention in Care (RiC): A Multi-Site National HIV Care Program.

Persons diagnosed with HIV but not retained in HIV medical care accounted for the majority of HIV transmissions in 2009 in the United States (US). There is an urgent need to implement and disseminate HIV retention in care programs; however little is known about the costs associated with implementing retention in care programs. We assessed the costs and cost-saving thresholds for seven Retention in Care (RiC) programs implemented in the US using standard methods recommended by the US Panel on Cost-effectiveness in Health and Medicine. Data were gathered from accounting and program implementation records, entered into a standardized RiC economic analysis spreadsheet, and standardized to a 12 month time frame. Total program costs for from the societal perspective ranged from $47,919 to $423,913 per year or $146 to $2,752 per participant. Cost-saving thresholds ranged from 0.13 HIV transmissions averted to 1.18 HIV transmission averted per year. We estimated that these cost-saving thresholds could be achieved through 1 to 16 additional person-years of viral suppression. Across a range of program models, retention in care interventions had highly achievable cost-saving thresholds, suggesting that retention in care programs are a judicious use of resources.

Exploring Changes in Interagency Collaboration Following AIDS United's Positive Charge: A Five-Site HIV Linkage and Retention in Care Program.

BACKGROUND: Many out-of-care people living with HIV have unmet basic needs and are served by loosely connected agencies. Prior research suggests that increasing agencies' coordination may lead to higher quality and better coordinated care. This study examines four U.S. interagency networks in AIDS United's HIV linkage and retention in care program. This study explores changes in the networks of implementing agencies. METHODS: Each network included a lead agency and collaborators. One administrator and service provider per agency completed an online survey about collaboration prior to and during Positive Charge. We measured how many organizations were connected to one another through density, or the proportion of reported connections out of all possible connections between organizations. Network centralization was measured to investigate whether this network connectivity was due to one or more highly connected organizations or not. To compare collaboration by type, density and centralization were calculated for any collaboration and specific collaboration types: technical assistance, shared resources, information exchange, and boosting access. To characterize the frequency of collaboration, we examined how often organizations interacted by "monthly or greater" versus "less than monthly." RESULTS: Density increased in all networks. Density was highest for information exchange and referring clients. When results were restricted to "monthly or greater," the densities of all networks were lower. CONCLUSIONS: This study suggests that a targeted linkage to care initiative may increase some collaboration types among organizations serving people living with HIV. It also provides insights to policy makers about how such networks may evolve.

Cost and cost threshold analyses for 12 innovative US HIV linkage and retention in care programs.

Out of >1,000,000 people living with HIV in the USA, an estimated 60% were not adequately engaged in medical care in 2011. In response, AIDS United spearheaded 12 HIV linkage and retention in care programs. These programs were supported by the Social Innovation Fund, a White House initiative. Each program reflected the needs of its local population living with HIV. Economic analyses of such programs, such as cost and cost threshold analyses, provide important information for policy-makers and others allocating resources or planning programs. Implementation costs were examined from societal and payer perspectives. This paper presents the results of cost threshold analyses, which provide an estimated number of HIV transmissions that would have to be averted for each program to be considered cost-saving and cost-effective. The methods were adapted from the US Panel on Cost-effectiveness in Health and Medicine. Per client program costs ranged from $1109.45 to $7602.54 from a societal perspective. The cost-saving thresholds ranged from 0.32 to 1.19 infections averted, and the cost-effectiveness thresholds ranged from 0.11 to 0.43 infections averted by the programs. These results suggest that such programs are a sound and efficient investment towards supporting goals set by US HIV policy-makers. Cost-utility data are pending.

Cost-Utility Analysis of Three U.S. HIV Linkage and Re-engagement in Care Programs from Positive Charge.

Linking and retaining people living with HIV in ongoing, HIV medical care is vital for ending the U.S. HIV epidemic. Yet, 41-44 % of HIV+ individuals are out of care. In response, AIDS United initiated Positive Charge, a series of five HIV linkage and re-engagement projects around the U.S. This paper investigates whether three Positive Charge programs were cost effective and calculates a return on investment for each program. It uses standard methods of cost utility analysis and WHO-CHOICE thresholds. All three projects were found to be cost effective, and two were highly cost effective. Cost utility ratios ranged from $4439 to $137,271. These results suggest that HIV linkage to care programs are a productive and efficient use of public health funds.

Unpacking Linkage and Reengagement in HIV Care: A Day in the Life of a Positive Charge Care Coordinator.

UNLABELLED: AIDS United's Positive Charge (PC) was a multiorganizational HIV linkage to care program implemented in five U.S. LOCATIONS: To better understand the process of linkage and reengagement in care, we conducted interviews with care coordinators and program supervisors at 20 PC implementing agencies. Though linkage to care is often considered a single column in the HIV continuum of care, we found that it contains several underlying and often complex steps. The steps described are: identifying individuals in need of services; contacting those individuals through a variety of means; assessing and addressing needs and barriers to care; initial engagement (or reengagement) in HIV primary care; and provision of ongoing support to promote retention. We highlight strategies used to complete these steps. These findings will be of utility to other HIV interventions that aim to improve linkage and engagement in HIV care.

Barriers and Facilitators to Implementing Access to HIV Care Interventions: A Qualitative Analysis of the Positive Charge Initiative.

Research indicates that less than half of people living with HIV (PLWH) have undetectable levels of virus, despite recent findings that viral load suppression dramatically reduces the transmissibility of HIV. Linkage to HIV care is a crucial initial step, yet we know relatively little about how to effectively implement linkage interventions to reach PLWH who are not in care. AIDS United's initiative, Positive Charge (PC), funded five U.S. sites to develop and implement comprehensive linkage interventions. Evaluation of the initiative included qualitative interviews with management and service staff from each intervention site. Sites experienced barriers and facilitators to implementation on multiple environmental, organization, and personnel levels. Successful strategies included developing early relationships with collaborating partners, finding ways to share key information among agencies, and using evaluation data to build support among leadership staff. Lessons learned will be useful for organizations that develop and implement future interventions targeting hard-to-reach, out-of-care PLWH.

Cost and threshold analysis of positive charge, a multi-site linkage to HIV care program in the United States.

Positive Charge (PC) is a linkage to HIV care initiative implemented by AIDS United with sites in New York, Chicago, Louisiana, North Carolina, and the San Francisco/Bay Area. This study employed standard methods of cost and threshold analyses, as recommended by the US Panel on Cost-effectiveness in Health and Medicine, to calculate cost-saving and cost effective thresholds of the initiative. The overall societal cost of the linkage to care programs ranged from $48,490 to $370,525. The study found that PC's five unique evidence-based linkage to care programs have relatively low costs per client served and highly achievable cost-saving and cost-effectiveness thresholds. The findings from this study suggest that HIV linkage to care programs have the potential to be a highly productive use of public health resources.

Positive Charge: Filling the Gaps in the U.S. HIV Continuum of Care.

Adequate engagement in HIV care is necessary for the achievement of optimal health outcomes and for the reduction of HIV transmission. Positive Charge (PC) was a national HIV linkage and re-engagement in care program implemented by AIDS United. This study describes three PC programs, the characteristics of their participants, and the continuum of engagement in care for their participants. Eighty-eight percent of participants were engaged in care post PC enrollment. Sixty-nine percent were retained in care, and 46 % were virally suppressed at follow-up. Older participants were more likely to be engaged, retained, and virally suppressed. Differences by race and gender in HIV care and treatment varied across PC programs, reflecting the diverse target populations, locations, and strategies employed by the PC grantees. There is an urgent need for programs that promote HIV care and treatment among vulnerable populations, including young people living with HIV. There is also an urgent need for additional research to test the effectiveness of promising linkage and retention in care strategies, such as peer navigation.

The development and implementation of the national evaluation strategy of Access to Care, a multi-site linkage to care initiative in the United States.

The Access to Care (A2C) is a multi-site initiative that seeks to increase the access to and retention in effective HIV healthcare and support services by people living with HIV across the United States. As the initiative implemented evidence-based programs in new settings with diverse populations, it was important to document these innovative efforts to contribute to the evidence base for best practices. In a partnership between Johns Hopkins University, AIDS United, and the A2C sites, a national evaluation strategy was developed and implemented to build knowledge about how linkage to care interventions could be most effectively implemented within the context of local, real-world settings. This article provides an overview of the efforts to develop and implement a national monitoring and evaluation strategy for a multi-site initiative. The findings may be of utility for other HIV interventions that are seeking to incorporate a monitoring and evaluation component into their efforts.