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Meet the AuthorWebinar

November 21, 2011

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Ground Rules for Webinar Participation

• Actively participate and write your questions into the chat area during the presentation(s)

• Do not put us on hold• Mute your line if you are not speaking

(press *6, to unmute your line press #6)• Slides and other resources are available

on our website at incareCampaign.org• All webinars are being recorded

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Agenda

• Welcome & Introductions, 5min• Campaign Update, 5min• Meet the Author: Dr. Edward Gardner,

30min• Q & A Session, 15min• Campaign Next Steps, 5min

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This in+care Campaign is designed to facilitate local, regional and state-level efforts to retain more HIV patients in care and to prevent HIV patients falling out of care while building and sustaining a community of learners among Ryan White providers.

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315 HIV providers representing

266 HIV programs in 165 cities and across 44 States/Territories

have joined the Campaign so far

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caring for 356,556 people living with HIV

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in+care Participants by Zip Code (as per Nov 15, 2011)

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Campaign Measures

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• Download the performance indicator definitions and review them carefully with your team

• Develop agency-specific data collection strategies

• Register for the in+care Campaign database

• Conduct your data queries based on the proposed measurement periods

• Validate your performance measurement data

• Enter the results in the Campaign database before or on December 1

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Quality Champions Wanted!

Responsibilities of Quality Champions:• Conduct at least 2 face-to-face meetings/calls• Reach out to local HIV providers; NQC will

assist• Provide logistical support for these meetings• Facilitate the discussions and chair the

meetings• Report activities back to Campaign staff

Sign-up to become a Quality Champions – incare@NationalQualityCenter.org

Gardner et al, “The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV

Infection”

Clin Infect Dis. 2011; 52 (6): 793-800.

Edward Gardner, MDAssociate Professor of MedicineUniversity of Colorado Denver

Denver Public Health

Outline

• Engagement in HIV Care• Test and Treat for HIV Prevention• The Spectrum of Engagement in HIV Care• Engagement Simulations• Conclusions

• Financial Disclosures: None

HIV Care Continuum

Adapted from Eldred et al AIDS Patient Care STDs 2007;21(Suppl1):S1-S2Cheever LW 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

Kaplan-Meier plot of cumulative survival grouped by the number of quarters with an HIV primary care visit during the first year after the index visit (P

= .02)

Giordano T P et al. Clin Infect Dis. 2007;44:1493-1499

© 2007 by the Infectious Diseases Society of America

Kaplan-Meier survival for patients establishing initial HIV care at the University of Alabama at Birmingham 1917 HIV/AIDS Clinic categorized by missed visits

Mugavero M J et al. Clin Infect Dis. 2009;48:248-256

© 2009 by the Infectious Diseases Society of America

Test and Treat for HIV Prevention

Das M et al. PLoS One 2010;5:e11068

HIV Treatment as Prevention

NEJM 2011;365:493-505.

HPTN-05296% reductionIn HIV incidence

Review Search Strategy• PubMed search - cross-match of HIV or AIDS with

– Prevalence United States– Incidence United States– Late diagnosis– Linkage to care– Retention in care– Engagement in care– Adherence– Persistence– Resistance

• Bibliographies of pertinent articles were reviewed• Emphasis was based on population based studies

over cohort or single institution studies

Model Demonstrating the Spectrum of Engagement in HIV Care in the United States

Model Demonstrating the Spectrum of Engagement in HIV Care in the United States

Model Demonstrating the Spectrum of Engagement in HIV Care in the United States

Model Demonstrating the Spectrum of Engagement in HIV Care in the United States

Model Demonstrating the Spectrum of Engagement in HIV Care in the United States

Model Demonstrating the Spectrum of Engagement in HIV Care in the United States

Model Demonstrating the Spectrum of Engagement in HIV Care in the United States

19%

Simulations of the Engagement in HIV Care Spectrum to Account for Inaccuracy in our Engagement Estimates

66%

21%28%34%22%19%

0

200000

400000

600000

800000

1000000

1200000

Current Dx 90% Engage 90% Treat 90% VL<50 in 90% Dx, Engage,Tx, and

VL<50 in 90%

(a) (b) (c) (d) (e) (f)

Nu

mb

er o

f In

div

idu

als

Un-Diagnosed HIV

Not Linked to Care

Not Retained in Care

ART Not Required

ART Not Utililzed

Viremic on ART

Undetectable Viral Load

Newer Data for Discussion

• Marks et al. estimated that 29 – 34% of HIV-infected individuals in the U.S. have an undetectable viral load (Clin Infect Dis 2011;53:1168–9)

• Dombrowski et al. estimate that 42 – 45% in Seattle King County are undetectable (AIDS 2011;epub ahead of print)

• In a cohort of newly diagnosed individuals in Denver, 28% are undetectable 12 – 18 months after diagnosis.

Limitations

• Unable to assess the impact of financial barriers to HIV care in the U.S.

• Overlap in the stages of engagement in HIV care

• Cross-sectional depiction of a longitudinal process

• The review applies to the U.S. and not to resource-poor settings

Conclusions• Engagement in care is critical to the successful

management of HIV infection– For the individual– For the population

• Deficiencies in the spectrum of engagement in care present formidable barriers to ‘test and treat’ for HIV prevention:– Failure to diagnose– Failure to link to care– Failure to be retained in care– Failure to receive and adhere to antiretroviral therapy

• Research is needed on ways to improve transitions across all steps in the engagement in care cascade

Thank You

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Time for Questions and Answers

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• Data Collection Submission Deadline: December 1, 2011

• Next Webinar: December 7, 2011 at 1pm ET

• Improvement Update Submission Deadline: December 15, 2011

• Next Meet the Author: Dr. Thomas GiordanoJanuary 12, 2012 at 12pm ET

• Webinar on Incarceration: Dr. Brian MontagueMarch 14, 2012 at 3:00pm ET

Next Steps

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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone 212-417-4730incare@NationalQualityCenter.org

incareCampaign.orgyoutube.com/incareCampaign