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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