ABSTRACT
The Ryan White HIV/AIDS Program is a unique federal program to provide HIV care, treatment, and support services for people living with HIV in the United States. Through the distinctive structure of the program that allows for addressing both medical needs and some of the social determinants of health that can pose barriers to accessing care, the program has been instrumental in improving outcomes for people with HIV with documented improvement in HIV viral suppression and decreased disparities in that outcome over the past decade. To reach the goal of ending the HIV epidemic in the U.S., the program must expand services to people with HIV who are not regularly engaged in medical care.
Subject(s)
HIV Infections , Health Status Disparities , Healthcare Disparities , Humans , United States/epidemiology , HIV Infections/epidemiology , HIV Infections/therapy , Healthcare Disparities/ethnology , Health Services Accessibility/organization & administration , Social Determinants of Health , Government Programs , Acquired Immunodeficiency Syndrome/epidemiology , Acquired Immunodeficiency Syndrome/therapy , WhiteABSTRACT
Improvements in treatment have made HIV a manageable chronic condition, leading to increased life expectancy and a growing share of people with HIV who are older. Older people with HIV have higher rates of many chronic conditions, yet little is known about differences in health care utilization and spending. This study compared health care utilization and spending for Medicare beneficiaries with and without HIV, accounting for differential mortality. The data included demographic characteristics and claims-based information. Estimated cumulative spending for beneficiaries with HIV aged 67 to 77 years was 26% higher for Medicare Part A and 39% higher for Medicare Part B compared with beneficiaries without HIV; most of these differences would be larger if not for greater mortality risk among people with HIV (and therefore fewer years to receive care). Future research should disentangle underlying causes for this increased need and describe potential responses by policymakers and health care providers.
ABSTRACT
Increasing HIV testing, preexposure prophylaxis (PrEP), and antiretroviral therapy (ART) are pillars of the federal Ending the HIV Epidemic in the U.S. (EHE) initiative, with a goal of decreasing new HIV infections by 90% by 2030.* In response to the COVID-19 pandemic, a national emergency was declared in the United States on March 13, 2020, resulting in the closure of nonessential businesses and most nonemergency health care venues; stay-at-home orders also limited movement within communities (1). As unemployment increased during the pandemic (2), many persons lost employer-sponsored health insurance (3). HIV testing and PrEP prescriptions declined early in the COVID-19 pandemic (4-6); however, the full impact of the pandemic on use of HIV prevention and care services and HIV outcomes is not known. To assess changes in these measures during 2019-2021, quarterly data from two large U.S. commercial laboratories, the IQVIA Real World Data - Longitudinal Prescription Database (IQVIA), and the National HIV Surveillance System (NHSS)§ were analyzed. During quarter 1 (Q1)¶ 2020, a total of 2,471,614 HIV tests were performed, 190,955 persons were prescribed PrEP, and 8,438 persons received a diagnosis of HIV infection. Decreases were observed during quarter 2 (Q2), with 1,682,578 HIV tests performed (32% decrease), 179,280 persons prescribed PrEP (6% decrease), and 6,228 persons receiving an HIV diagnosis (26% decrease). Partial rebounds were observed during quarter 3 (Q3), with 2,325,554 HIV tests performed, 184,320 persons prescribed PrEP, and 7,905 persons receiving an HIV diagnosis. The proportion of persons linked to HIV care, the number who were prescribed ART, and proportion with a suppressed viral load test (<200 copies of HIV RNA per mL) among those tested were stable during the study period. During public health emergencies, delivery of HIV services outside of traditional clinical settings or that use nonclinical delivery models are needed to facilitate access to HIV testing, ART, and PrEP, as well as to support adherence to ART and PrEP medications.
Subject(s)
COVID-19 , HIV Infections , Pre-Exposure Prophylaxis , United States/epidemiology , Humans , COVID-19/epidemiology , Pandemics , HIV Infections/diagnosis , HIV Infections/drug therapy , HIV Infections/epidemiology , HIV TestingABSTRACT
BACKGROUND: The Health Resources and Services Administration's Ryan White HIV/AIDS Program provides services to more than half of all people diagnosed with HIV in the United States. We present and validate a mathematical model that can be used to estimate the long-term public health and cost impact of the federal program. METHODS: We developed a stochastic, agent-based model that reflects the current HIV epidemic in the United States. The model simulates everyone's progression along the HIV care continuum, using 2 network-based mechanisms for HIV transmission: injection drug use and sexual contact. To test the validity of the model, we calculated HIV incidence, mortality, life expectancy, and lifetime care costs and compared the results with external benchmarks. RESULTS: The estimated HIV incidence rate for men who have sex with men (502 per 100,000 person years), mortality rate of all people diagnosed with HIV (1663 per 100,000 person years), average life expectancy for individuals with low CD4 counts not on antiretroviral therapy (1.52-3.78 years), and lifetime costs ($362,385) all met our validity criterion of within 15% of external benchmarks. CONCLUSIONS: The model represents a complex HIV care delivery system rather than a single intervention, which required developing solutions to several challenges, such as calculating need for and receipt of multiple services and estimating their impact on care retention and viral suppression. Our strategies to address these methodological challenges produced a valid model for assessing the cost-effectiveness of the Ryan White HIV/AIDS Program.
Subject(s)
Cost-Benefit Analysis , HIV Infections/drug therapy , United States Health Resources and Services Administration , Anti-Retroviral Agents/economics , Anti-Retroviral Agents/therapeutic use , Continuity of Patient Care , HIV Infections/mortality , HIV Infections/transmission , Humans , Models, Theoretical , Mortality , United StatesABSTRACT
BACKGROUND: With an annual budget of more than $2 billion, the Health Resources and Services Administration's Ryan White HIV/AIDS Program (RWHAP) is the third largest source of public funding for HIV care and treatment in the United States, yet little analysis has been done to quantify the long-term public health and economic impacts of the federal program. METHODS: Using an agent-based, stochastic model, we estimated health care costs and outcomes over a 50-year period in the presence of the RWHAP relative to those expected to prevail if the comprehensive and integrated system of medical and support services funded by the RWHAP were not available. We made a conservative assumption that, in the absence of the RWHAP, only uninsured clients would lose access to these medical and support services. RESULTS: The model predicts that the proportion of people with HIV who are virally suppressed would be 25.2 percentage points higher in the presence of the RWHAP (82.6 percent versus 57.4 percent without the RWHAP). The number of new HIV infections would be 18 percent (190,197) lower, the number of deaths among people with HIV would be 31 percent (267,886) lower, the number of quality-adjusted life years would be 2.7 percent (5.6 million) higher, and the cumulative health care costs would be 25 percent ($165 billion) higher in the presence of the RWHAP relative to the counterfactual. Based on these results, the RWHAP has an incremental cost-effectiveness ratio of $29,573 per quality-adjusted life year gained compared with the non-RWHAP scenario. Sensitivity analysis indicates that the probability of transmitting HIV via male-to-male sexual contact and the cost of antiretroviral medications have the largest effect on the cost-effectiveness of the program. CONCLUSIONS: The RWHAP would be considered very cost-effective when using standard guidelines of less than the per capita gross domestic product of the United States. The results suggest that the RWHAP plays a critical and cost-effective role in the United States' public health response to the HIV epidemic.
Subject(s)
Cost-Benefit Analysis , Delivery of Health Care/economics , HIV Infections/drug therapy , Health Care Costs , United States Health Resources and Services Administration , Anti-Retroviral Agents/therapeutic use , HIV Infections/economics , Humans , Male , Patient Protection and Affordable Care Act/economics , United States , United States Health Resources and Services Administration/statistics & numerical dataABSTRACT
Demetrios Psihopaidas and co-authors discuss the implementation science framework of an HIV/AIDS program in the United States.
Subject(s)
Acquired Immunodeficiency Syndrome/epidemiology , HIV Infections/epidemiology , HIV/pathogenicity , Implementation Science , Epidemics , Health Services Accessibility , Humans , Patient Protection and Affordable Care Act , United States/epidemiology , United States Health Resources and Services AdministrationABSTRACT
BACKGROUND: Nearly half of people with HIV in the United States are 50 years or older, and this proportion is growing. Between 2012 and 2016, the largest percent increase in the prevalence rate of HIV was among people aged 65 and older, the eligibility age for Medicare coverage for individuals without a disability or other qualifying condition. Previous work suggests that older people with HIV may have higher rates of chronic conditions and develop them more rapidly than older people who do not have HIV. This study compared the health status of older people with HIV with the older US population not living with HIV by comparing: (1) mortality; (2) prevalence of certain conditions, and (3) incidence of these conditions with increasing age. METHODS AND FINDINGS: We used a sample of Medicare beneficiaries aged 65 and older from the Medicare Master Beneficiary Summary File for the years 2011 to 2016, including 100% of individuals with HIV (N = 43,708), as well as a random 1% sample of individuals without diagnosed HIV (N = 1,029,518). We conducted a survival analysis using a Cox proportional hazards model to assess mortality and to determine the need to adjust for differential mortality in our analyses of the incidence of certain chronic conditions. These results showed that Medicare beneficiaries living with HIV have a significantly higher hazard of mortality compared to older people without diagnosed HIV (3.6 times the hazard). We examined the prevalence of these conditions using logistic regression analysis and found that people with HIV have a statistically significant higher odds of depression, chronic kidney disease, chronic obstructive pulmonary disease (COPD), osteoporosis, hypertension, ischemic heart disease, diabetes, chronic hepatitis, end-stage liver disease, lung cancer, and colorectal cancer. To look at the rate at which older people are diagnosed with conditions as they age, we used a Fine-Gray competing risk model and showed that for individuals without diagnosis of a given condition at age 65, the future incidence of that condition over the remaining study period was higher for people with HIV even after adjusting for differential hazard of mortality and for other demographic characteristics. Many of these results also varied by personal characteristics including Medicaid dual enrollment, sex, and race and ethnicity, as well as by condition. CONCLUSIONS: Increasing access to care and improving health outcomes for people with HIV is a critical goal of the National HIV/AIDS Strategy 2020. It is important for clinicians and policymakers to be aware that despite significant advances in the treatment and care of people with HIV, older people with HIV have a higher odds of having multiple chronic conditions at any point in time, a higher incidence of new diagnoses of these conditions over time, and a higher hazard of mortality than Medicare beneficiaries without HIV.
Subject(s)
Chronic Disease/epidemiology , HIV Infections/epidemiology , Health Services Accessibility/statistics & numerical data , Aged , Aged, 80 and over , Case-Control Studies , Chronic Disease/mortality , Female , HIV Infections/mortality , Health Status , Humans , Incidence , Male , Medicare , Prevalence , Proportional Hazards Models , Retrospective Studies , Survival Analysis , United States/epidemiologyABSTRACT
BACKGROUND: The United States is in the midst of an unprecedented opioid crisis with increasing injection drug use (IDU)-related human immunodeficiency virus (HIV) outbreaks, particularly in rural areas. The Health Resources and Services Administration (HRSA)'s Ryan White HIV/AIDS Program (RWHAP) is well positioned to integrate treatment for IDU-associated HIV infections with treatment for drug use disorders. These activities will be crucial for the "Ending the HIV Epidemic: A Plan for America" (EHE) initiative, in which 7 southern states were identified with rural HIV epidemics. METHODS: The RWHAP Services Report data were used to assess the IDU population and substance use services utilization among RWHAP clients in 2017, nationally and in the 7 EHE-identified states. THe HRSA held a 1-day Technical Expert Panel (TEP) to explore how RWHAP can best respond to the growing opioid crisis. RESULTS: During the TEP, 8 key themes emerged and 11 best practices were identified to address opioid use disorder (OUD) among people with HIV. In 2017, among RWHAP clients with reported age and transmission category, 6.7% (31 683) had HIV attributed to IDU; among IDU clients, 6.3% (1988) accessed substance use services. CONCLUSIONS: The TEP results and RWHAP data were used to develop implementation science projects that focus on addressing OUD and integrating behavioral health in primary care. These activities are critical to ending the HIV epidemic.
Subject(s)
HIV Infections/prevention & control , Opioid Epidemic/prevention & control , Opioid-Related Disorders/epidemiology , Substance Abuse, Intravenous/epidemiology , United States Health Resources and Services Administration/organization & administration , Adolescent , Adult , Aged , Drug Users/statistics & numerical data , Female , HIV Infections/epidemiology , HIV Infections/transmission , Health Plan Implementation/organization & administration , Health Plan Implementation/statistics & numerical data , Humans , Implementation Science , Male , Middle Aged , Opioid-Related Disorders/complications , Self Report/statistics & numerical data , Substance Abuse, Intravenous/complications , United States/epidemiology , United States Health Resources and Services Administration/statistics & numerical data , Young AdultABSTRACT
BACKGROUND: The clinical management of low-level viremia (LLV) remains unclear. The objective of this study was to investigate the association of blips and LLV with virologic failure. METHODS: We enlisted patients who newly enrolled into the HIV Research Network between 2005 and 2015, had HIV-1 RNA more than 200 copies/ml, and were either antiretroviral therapy (ART)-naive or ART-experienced and not on ART. Patients were included who achieved virologic suppression (≤50 on two consecutive viral loads) and had at least two viral loads following suppression. Blips and LLV (≥2 consecutive >51 copies/ml) were categorized separately into three categories: no blips/LLV, 51-200, 201-500. Cox proportional hazards regression was used to assess association between rates of blips/LLV and virologic failure (two consecutive >500). RESULTS: The 2795 patients were mostly male (75.4%), black (50.3%), and MSM (52.9%). Median age was 38 years old (interquartile range 29-48). Most patients (88.8%) were ART-naive at study entry. Overall, 283 (10.1%) patients experienced virologic failure. A total of 152 (5.4%) patients experienced LLV to 51-200 and 110 (3.9%) patients experienced LLV to 201-500. Both LLV 51-200 [adjusted hazard ratio (aHR) 1.83 (1.10,3.04)] and LLV 201-500 [aHR 4.26 (2.65,6.86)] were associated with virologic failure. In sensitivity analysis excluding ART-experienced patients, the association between LLV 51 and 200 and virologic failure was not statistically significant. CONCLUSION: LLV between 201 and 500 was associated with virologic failure, as was LLV between 51 and 200, particularly among ART-experienced patients. Patients with LLV below the current Department of Health and Human Services threshold for virologic failure (persistent viremia ≥200) may require more intensive monitoring because of increased risk for virologic failure.
Subject(s)
Anti-HIV Agents/therapeutic use , HIV Infections/drug therapy , Viremia/drug therapy , Adult , Antiretroviral Therapy, Highly Active , Female , HIV-1 , Homosexuality, Male/statistics & numerical data , Humans , Kaplan-Meier Estimate , Longitudinal Studies , Male , Middle Aged , Proportional Hazards Models , Treatment Failure , United States , Viral LoadABSTRACT
In the United States, the all-cause mortality rate among persons living with diagnosed HIV infection (PLWH) is almost twice as high as among the general population. We aimed to identify amendable factors that state public health programs can influence to reduce mortality among PLWH. Using generalized estimating equations (GEE), we estimated age-group-specific models (24-34, 35-54, ≥ 55 years) to assess the association between state-level mortality rates among PLWH during 2010-2014 (National HIV Surveillance System) and amendable factors (percentage of Ryan White HIV/AIDS Program (RWHAP) clients with viral suppression, percentage of residents with healthcare coverage, state-enacted anti-discrimination laws index) while controlling for sociodemographic nonamendable factors. Controlling for nonamendable factors, states with 5% higher viral suppression among RWHAP clients had a 3-5% lower mortality rates across all age groups [adjusted Risk Ratio (aRR): 0.95, 95% Confidence Interval (CI): 0.92-0.99 for 24-34 years, aRR: 0.97, 95%CI: 0.94-0.99 for 35-54 years, aRR: 0.96, 95%CI: 0.94-0.99 for ≥ 55 years]; states with 5% higher health care coverage had 4-11% lower mortality rate among older age groups (aRR: 0.96, 95%CI: 0.93-0.99 for 34-54 years; aRR: 0.89, 95%CI: 0.81-0.97 for ≥ 55 years); and having laws that address one additional area of anti-discrimination was associated with a 2-3% lower mortality rate among older age groups (aRR: 0.98, 95%CI: 0.95-1.00 for 34-54 years; aRR: 0.97, 95%CI: 0.94-0.99 for ≥ 55 years). The mortality rate among PLWH was lower in states with higher levels of residents with healthcare coverage, anti-discrimination laws, and viral suppression among RWHAP clients. States can influence these factors through programs and policies.
Subject(s)
HIV Infections , Adult , HIV Infections/epidemiology , HIV Infections/mortality , Health Services Accessibility , Humans , Middle Aged , United States/epidemiology , Young AdultABSTRACT
Among 1942 persons with human immunodeficiency virus (HIV) without healthcare coverage in 2012-2015, transitioning to Medicaid (adjusted prevalence ratio, 0.95 [0.87, 1.04]) or to private health insurance (1.04 [0.95, 1.13]) was not associated with a change in consistent HIV viral suppression compared to continued reliance on the Ryan White HIV/AIDS Program.
Subject(s)
HIV Infections/drug therapy , Health Services Accessibility , Insurance Coverage/statistics & numerical data , Insurance, Health/statistics & numerical data , Medicaid/statistics & numerical data , Adolescent , Adult , Aged , Cohort Studies , Female , Humans , Male , Middle Aged , Patient Protection and Affordable Care Act , United States , Viral Load/drug effects , Young AdultABSTRACT
Faced with a critical shortage of physicians in Africa, which hampered the efforts of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Medical Education Partnership Initiative (MEPI) was established in 2010 to increase the number of medical graduates, the quality of their education, and their retention in Africa. To summarize the accomplishments of the initiative, lessons learned, and remaining challenges, the authors conducted a narrative review of MEPI-from the perspectives of the U.S. government funding agencies and implementing agencies-by reviewing reports from grantee institutions and conducting a search of scientific publications about MEPI. African institutions received 11 programmatic grants, totaling $100 million in PEPFAR funds, to implement MEPI from 2010 to 2015. The National Institutes of Health (NIH) provided an additional 8 linked and pilot grants, totaling $30 million, to strengthen medical research capacity. The 13 grant recipients (in 12 countries) partnered with dozens of additional government and academic institutions, including many in the United States, forming a robust community of practice in medical education and research. Interventions included increasing the number of medical school enrollees, revising curricula, recruiting new faculty, enhancing faculty development, expanding the use of clinical skills laboratories and community and rural training sites, strengthening computer and telecommunications capacity, and increasing e-learning. Research capacity and productivity increased through training and support. Additional support from NIH for faculty development, and from PEPFAR for health professions education and research, is sustaining and extending MEPI's transformative effect on medical education in select African sites.
Subject(s)
Acquired Immunodeficiency Syndrome/prevention & control , Curriculum/standards , Education, Medical/organization & administration , Partnership Practice/organization & administration , Program Development/standards , Schools, Medical/organization & administration , Workforce/organization & administration , Acquired Immunodeficiency Syndrome/epidemiology , Africa/epidemiology , Diffusion of Innovation , Humans , International Cooperation , Morbidity/trendsABSTRACT
The Health Resources and Services Administration's Ryan White HIV/AIDS Program (RWHAP) supports direct health care treatment and support services to more than 50% of all people living with diagnosed HIV in the United States. A critical goal of the RWHAP is to reduce HIV-related health disparities to help end the HIV epidemic. From 2010 through 2016, the RWHAP made significant progress reducing viral suppression disparities among client populations, particularly among women, transgender persons, youths, Blacks or African Americans, and unstably housed clients. To assist with the reduction of the remaining disparities in HIV-related health outcomes among clients, the RWHAP continues to support planning and resource allocation for RWHAP Parts A through D and AIDS Drug Assistance Program, as well as through implementing policy and program initiatives, Special Projects of National Significance, evaluation studies, and collaborations to disseminate effective interventions.
Subject(s)
HIV Infections , Healthcare Disparities/statistics & numerical data , Preventive Health Services , United States Health Resources and Services Administration , Black or African American , Female , HIV Infections/economics , HIV Infections/epidemiology , HIV Infections/prevention & control , HIV Infections/therapy , Humans , Male , Transgender Persons , United StatesABSTRACT
For twenty-five years, the Ryan White HIV/AIDS Program has supported a comprehensive system of health services for vulnerable and under- or uninsured people living with HIV. Using data from the Health Resources and Services Administration about people living with HIV and served by the Ryan White HIV/AIDS Program, we found reductions in disparities in viral suppression rates between 2010 and 2014-with rates for Blacks/African Americans, adolescents and young adults, and people living in the South becoming more similar to rates for Whites, older adults, and people in other regions of the United States, respectively. Although absolute viral suppression rates for people without stable housing and transgender people improved during the same time period, disparities were not reduced between these groups and those with stable housing and nontransgender people, respectively. Addressing persistent disparities through the effective use of this program will be one of the key ways to meet the goals of the National HIV/AIDS Strategy.
Subject(s)
Acquired Immunodeficiency Syndrome/drug therapy , Acquired Immunodeficiency Syndrome/virology , Health Status Disparities , Viral Load/trends , Acquired Immunodeficiency Syndrome/ethnology , Adolescent , Adult , Black or African American/statistics & numerical data , Aged , Female , Health Services Accessibility , Hispanic or Latino/statistics & numerical data , Humans , Male , Medically Uninsured , Middle Aged , United States , United States Health Resources and Services Administration , White People/statistics & numerical dataABSTRACT
BACKGROUND: Before implementation of the Patient Protection and Affordable Care Act (ACA) in 2014, 100 000 persons living with human immunodeficiency virus (HIV) (PLWH) lacked healthcare coverage and relied on a safety net of Ryan White HIV/AIDS Program support, local charities, or uncompensated care (RWHAP/Uncomp) to cover visits to HIV providers. We compared HIV provider coverage before (2011-2013) versus after (first half of 2014) ACA implementation among a total of 28 374 PLWH followed up in 4 sites in Medicaid expansion states (California, Oregon, and Maryland), 4 in a state (New York) that expanded Medicaid in 2001, and 2 in nonexpansion states (Texas and Florida). METHODS: Multivariate multinomial logistic models were used to assess changes in RWHAP/Uncomp, Medicaid, and private insurance coverage, using Medicare as a referent. RESULTS: In expansion state sites, RWHAP/Uncomp coverage decreased (unadjusted, 28% before and 13% after ACA; adjusted relative risk ratio [ARRR], 0.44; 95% confidence interval [CI], .40-.48). Medicaid coverage increased (23% and 38%; ARRR, 1.82; 95% CI, 1.70-1.94), and private coverage was unchanged (21% and 19%; 0.96; .89-1.03). In New York sites, both RWHAP/Uncomp (20% and 19%) and Medicaid (50% and 50%) coverage were unchanged, while private coverage decreased (13% and 12%; ARRR, 0.86; 95% CI, .80-.92). In nonexpansion state sites, RWHAP/Uncomp (57% and 52%) and Medicaid (18% and 18%) coverage were unchanged, while private coverage increased (4% and 7%; ARRR, 1.79; 95% CI, 1.62-1.99). CONCLUSIONS: In expansion state sites, half of PLWH relying on RWHAP/Uncomp coverage shifted to Medicaid, while in New York and nonexpansion state sites, reliance on RWHAP/Uncomp remained constant. In the first half of 2014, the ACA did not eliminate the need for RWHAP safety net provider visit coverage.
Subject(s)
HIV Infections/therapy , Insurance Coverage , Medicaid , Patient Protection and Affordable Care Act , Adolescent , Adult , Aged , California/epidemiology , Female , HIV Infections/epidemiology , Humans , Male , Maryland/epidemiology , Middle Aged , New York/epidemiology , Oregon/epidemiology , Sexual and Gender Minorities , United States/epidemiology , Young AdultABSTRACT
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.
Subject(s)
Continuity of Patient Care , HIV Infections/drug therapy , Medication Adherence , Adolescent , Adult , Aged , Aged, 80 and over , Child , Child, Preschool , Female , HIV Infections/virology , Humans , Infant , Infant, Newborn , Male , Middle Aged , United States , Viral Load , Young AdultSubject(s)
Academic Medical Centers/organization & administration , Delivery of Health Care/organization & administration , Education, Medical/organization & administration , Education, Nursing/organization & administration , International Cooperation , Schools, Medical/organization & administration , Schools, Nursing/organization & administration , Academic Medical Centers/economics , Africa South of the Sahara/epidemiology , Biomedical Research/education , Diffusion of Innovation , HIV Infections/epidemiology , HIV Infections/prevention & control , Humans , Nurses/supply & distribution , Physicians/supply & distribution , Program Evaluation , United StatesABSTRACT
This report updates US Public Health Service recommendations for the management of healthcare personnel (HCP) who experience occupational exposure to blood and/or other body fluids that might contain human immunodeficiency virus (HIV). Although the principles of exposure management remain unchanged, recommended HIV postexposure prophylaxis (PEP) regimens and the duration of HIV follow-up testing for exposed personnel have been updated. This report emphasizes the importance of primary prevention strategies, the prompt reporting and management of occupational exposures, adherence to recommended HIV PEP regimens when indicated for an exposure, expert consultation in management of exposures, follow-up of exposed HCP to improve adherence to PEP, and careful monitoring for adverse events related to treatment, as well as for virologic, immunologic, and serologic signs of infection. To ensure timely postexposure management and administration of HIV PEP, clinicians should consider occupational exposures as urgent medical concerns, and institutions should take steps to ensure that staff are aware of both the importance of and the institutional mechanisms available for reporting and seeking care for such exposures. The following is a summary of recommendations: (1) PEP is recommended when occupational exposures to HIV occur; (2) the HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP; (3) PEP medication regimens should be started as soon as possible after occupational exposure to HIV, and they should be continued for a 4-week duration; (4) new recommendation-PEP medication regimens should contain 3 (or more) antiretroviral drugs (listed in Appendix A ) for all occupational exposures to HIV; (5) expert consultation is recommended for any occupational exposures to HIV and at a minimum for situations described in Box 1 ; (6) close follow-up for exposed personnel ( Box 2 ) should be provided that includes counseling, baseline and follow-up HIV testing, and monitoring for drug toxicity; follow-up appointments should begin within 72 hours of an HIV exposure; and (7) new recommendation-if a newer fourth-generation combination HIV p24 antigen-HIV antibody test is utilized for follow-up HIV testing of exposed HCP, HIV testing may be concluded 4 months after exposure ( Box 2 ); if a newer testing platform is not available, follow-up HIV testing is typically concluded 6 months after an HIV exposure.