Category Archives: Quality Matters

February 9, 2015 – HIV Care Updates for the Indianapolis-Carmel Metropolitan Statistical Area

Source: Marion County Public Health Department, Epidemiology Request DR2370
Prepared by: Morgan T. Rebeck (MRebeck@MarionHealth.org) and Tammie L. Nelson (TNelson@MarionHealth.org)

The Marion County Public Health Department’s1 Ryan White Services Program (RWSP)2 oversees the Ryan White Part A, Part C (Outpatient Early Intervention Services) and Minority AIDS Initiative grants in the Indianapolis-Carmel Metropolitan Statistical Area (MSA). These programs serve the needs of persons newly infected with HIV, living with HIV/AIDS (PLWH/A) and out of care, and/or uninsured or medically underserved. RWSP goals are based on the HIV continuum of care3 and the National HIV/AIDS Strategy.4 The goal discussed this month is linkage to care.

Importance of Linkage to Care: Linkage to care is defined as having attended one’s first HIV medical visit within 90 days of HIV diagnosis (measured by receipt of first CD4 or viral load).5 Delayed linkage to HIV care has been associated with increased risk of HIV transmission, accelerated progression to AIDS, and increased morbidity and mortality.6,7,8,9

RWSP Target: Among MSA residents newly diagnosed with HIV during 2013, 79.2% (N=187 of 236) were linked to care within 90 days.10 RWSP’s goal is to increase this measure to 85% of those newly diagnosed with HIV.

Guidelines for Improving Linkage to Care: When informed of their diagnoses, all patients should be educated about the importance of receiving HIV medical care in terms of maximizing personal health outcomes and preventing secondary transmission.11 In addition, strengths-based case management is recommended for most newly diagnosed PLWH.12 Routine monitoring of successful engagement in care could lead to significant increases in linkage to care.8,12 Moreover, for those patients who have not entered HIV medical care within six months, intensive outreach can be considered if patient circumstances warrant such action.12

Increasing Awareness to HIV Care and Treatment (IAHCT) Best Practices: The U.S. Department of Health and Human Resources Administration’s (HRSA) IAHCT Best Practices Initiative13 recommends the following practices to increase the number of PLWH being linked to care.

  • Endeavoring to get all patients to enter HIV medical care within five days of HIV diagnosis
  • Promoting close contact between newly diagnosed patients and the provider’s linkage staff
  • Hiring of additional staff experienced in HIV primary care and/or expansion of medical provider service hours
  • Use of social media to encourage engagement in care

Additional Considerations: Less overt actions can be taken to improve linkage to care. Items to consider include:

  • Psychosocial support14
  • Increased awareness of supportive services (e.g., mental health, medical transportation, short term housing)14
  • Utilization of peer or paraprofessional patient navigators for support and counseling12,14

Barriers to Care: Reduction of barriers is vital to improving linkage to care. Three categories of barriers to care identified as being related to linkage to, and retention in, HIV care. The categories identified are:

  • Financial Barriers
    • May include those uninsured/underinsured or competing subsistence needs such as food and housing.15
  • Structural and Administrative Barriers
    • May refer to unavailable or inconveniently located services; long wait times for appointments; unemployment or job insecurity; lack of transportation; and/or language barriers.16
  • Personal Barriers
    • Includes, but is not limited to, stigma related to HIV/AIDS and/or sexual identity; substance use; mental health issues; lack of trust in the medical system; and, low health literacy.16

The effects of barriers to care can be especially detrimental with regard to linkage to care among youth 13-24 years of age.16 When evaluating linkage to care among MSA residents, the largest single disparity was among those of younger age. Residents 20-24 years of age experienced the worst outcomes in linkage to care with only 67.3% (N=37 of 55) linked to care within 90 days of diagnosis.10 More disheartening was the nearly 22% (N=12) who received no HIV primary care during the year following their diagnosis. Among adolescents 15-19 years of age, about 80% were linked to care within 90 days;10 however, nearly 15% had received no HIV primary care during their first post-diagnosis year.


 

1 Marion County Public Health Department, http://www.mchd.com/

2 Ryan White Services Program, http://www.ryanwhiteindytga.org/

3 Nelson, T. L. (2014, December 5). HIV care updates for the Indianapolis-Carmel Metropolitan Statistical Area. MATEC Indiana Newsletter, 65.

4 National HIV/AIDS Strategy, https://www.aids.gov/federal-resources/national-hiv-aids-strategy/.

5 U.S. Department of Health & Human Services. (n.d.). Common indicators for HHS-funded HIV programs and services. Retrieved from https://www.aids.gov/pdf/hhs-common-hiv-indicators.pdf.

6 Antiretroviral Therapy Cohort Collaboration. (2008) Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet, 2008(372), 293-299.

7 Cohen, M. S., Chen, Y. Q., McCauley, M., Gamble, T., Hosseinipour, M. C., Kumarasamy, N., . . . HPTN 052 Study Team. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med, 365(6), 493-505.

8 Centers for Disease Control and Prevention. (2013). Prevention benefits of HIV treatment. Available at http://www.cdc.gov/hiv/prevention/research/tap/.

9 Gardner, E. M., McLees, M. P., Steiner, J. F., del Rio, C., and Burman, W. J. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis, 52(6), 793-800.

10 Centers for Disease Control and Prevention. (2014). Enhanced HIV/AIDS Reporting System (eHARS).

11 Centers for Disease Control and Prevention. Linkage to and retention in HIV Medical Care. 2012. Available at http://www.cdc.gov/hiv/prevention/programs/pwp/linkage.html.

12 Thompson, M. A., Mugavero, M. J., Amico, K. R., Cargill, V. A., Chang, L. W., & Gross, R., . . . Nachega, J. B. (2012). Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: Evidence-based recommendations from an International Association of Physicians in AIDS Care panel. Ann Intern Med, 156(11), 817-833.

13 U.S. Department of Health & Human Services. (2014). Increasing Access to HIV Care and Treatment.

14 Liau, A., Crepaz, N., Lyles, C. M., Higa, D. H., Mullins, M. M., DeLuca, J., … & Marks, G. (2013). Interventions to promote linkage to and utilization of HIV medical care among HIV-diagnosed persons: A qualitative systematic review, 1996–2011. AIDS and Behavior, 1-22.

15 Bauman, L. J., Braunstein, S., Calderon, Y., Chhabra, R., Cutler, B., Leider, J., … & Watnick, D. (2013). Barriers and facilitators of linkage to HIV primary care in New York City. J Acquir Immune Defic Syndr, 64, S20-6.

16 Philbin, M. M., Tanner, A. E., Duval, A., Ellen, J., Kapogiannis, B., & Fortenberry, J. D. (2014). Linking HIV-positive adolescents to care in 15 different clinics across the United States: Creating solutions to address structural barriers for linkage to care. AIDS Care, 26(1), 12-19.

January 12, 2015 – HIV Care Updates for the Indianapolis-Carmel Metropolitan Statistical Area

Marion County Public Health Department, Epidemiology Request DR2370
Prepared by: Tammie L. Nelson

The Marion County Public Health Department’s1 Ryan White Services Program (RWSP)2 oversees Ryan White Part A, Part C (Outpatient Early Intervention Services) and Minority AIDS Initiative grants in the Indianapolis-Carmel Metropolitan Statistical Area (MSA). These programs serve the needs of persons newly infected with HIV, living with HIV/AIDS (PLWH/A) and out of care, and/or uninsured or medically underserved. RWSP goals are based on the HIV continuum of care (Link to HIV continuum) and the National HIV/AIDS Strategy.3 The goal discussed this month is prescription of HIV antiretroviral therapy (ART) to PLWH/A.

Importance of Antiretroviral Therapy – ART reduces viral replication leading to delayed disease progression, preservation of immune function and reduced likelihood of viral resistance.4 This results in improved quality and length of life,5,6 and reduction of HIV transmission to newborns and sex partners.4,7,8 It is important to increase access to and utilization of ART among PLWH/A in the MSA.

RWSP Target – Among MSA residents living with HIV and aware of their status on December 31, 2013, only 45.1% (2,439 of 5,411) had ever received a prescription for ART.9 Even when considering only those in care,10 only 47.8% (1,846 of 3,859) had received ART. RWSP strives to ensure access to ART for 100% of PLWH/A in the MSA. Because some are out of care or opt out of ART, RWSP’s goal is to increase the percentage of PLWH/A who receive a prescription for ART during FY 2015-2016 to 95% of those who are in care.

Antiretroviral Therapy Recommendations – Current guidelines recommend ART for all HIV-infected individuals.4 While the strength of this recommendation varies based on CD4 T lymphocyte (CD4) count, it is strongly recommended for all to prevent transmission of HIV. Some situations require further consideration prior to ART administration.

  • Pregnancy – Special considerations arise in the treatment of HIV during pregnancy; however, guidelines strongly recommend that all HIV-infected pregnant women receive, “a maximally suppressive antiretroviral regimen to reduce the risk of perinatal transmission of HIV.”11,12 In addition, Indiana’s Communicable Disease Rule requires discussion of and access to ART in the treatment of HIV-infected pregnant women.13
  • Perinatal and/or Infant HIV – If perinatal HIV exposure occurs, antiretroviral prophylaxis should be initiated immediately.14 Additionally, it is strongly recommended that all HIV-infected infants (<1 year), as well as any child with AIDS or significant symptoms, receive ART.14 For ART-naïve children one or older, strong recommendation of ART depends on age and CD4 count and/or percent; however, guidelines provide a moderately strong recommendation of ART for all children, regardless of CD4 value.14
  • Older Patients – Approximately half the PLWH/A in the MSA are 50+ years of age. ART is important in these patients due to weakened immune systems;15 however, close monitoring is recommended because of increased risk of adverse events and drug interactions.14
  • Comorbidities – Certaincomorbid conditions present treatment providers with special considerations with regard to ART. Current guidelines should be referred to in the treatment of such cases. Threecomorbidities common in the MSA include:
    • An estimated 25%-30% have been diagnosed with hepatitis C (HCV)16,17
    • More than 4% were diagnosed with chlamydia, gonorrhea or early syphilis during 20139,18,19
    • At least 1% of PLWH/A have been diagnosed with Mycobacterium tuberculosis (TB)20

Improving Adherence to ART – Reluctance to begin, or poor adherence to, ART can result from many situations. HIV medication is expensive and sometimes requires complicated regimens that are difficult to maintain. Many have side effects that are not well tolerated. Stigma, mental health, substance abuse and other issues can also lead to poor adherence. Strategies to improve adherence can be found in the guidelines’ Limitations to Treatment Safety and Efficacy: Adherence to Antiretroviral Therapy (p. K-1). In addition, a summary of recent International Association of Physicians in AIDS Care (IAPAC) suggestions21 can be found online.22

“If it wasn’t documented, then it didn’t happen.” – This adage is true with regard to ART as recorded in eHARS. ART is a control factor used in the prevention of AIDS.4,23 As such, it is important to provide your local health department and/or Indiana State Department of Health with information regarding prescription of ART (i.e., patient ID, date, medication name). If this information is not provided, true prevalence of ART prescriptions cannot be ascertained. Please take a few moments to report prescriptions of ART to your local health department and/or Indiana State Department of Health.


Sources:

1 Marion County Public Health Department, http://www.mchd.com/

2 Ryan White Services Program, http://www.ryanwhiteindytga.org/

3 National HIV/AIDS Strategy, https://www.aids.gov/federal-resources/national-hiv-aids-strategy/

4 U.S. Department of Health & Human Services. (2014). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf.

5 Schackman, B. R., Gebo, K. A., Walensky, R. P., Losina, E., Muccio, T., Sax, P. E., . . . Freedberg, K. A. (2006). The lifetime cost of current human immuno-deficiency virus care in the United States. Medical Care. 2006(44): 990-997.

6 Antiretroviral Therapy Cohort Collaboration. (2008) Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet. 2008(372): 293-299.

7 Cohen, M. S., Chen, Y. Q., McCauley, M., Gamble, T., Hosseinipour, M. C., Kumarasamy, N., . . . HPTN 052 Study Team. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 365(6): 493-505.

8 Centers for Disease Control and Prevention. (2013). Prevention benefits of HIV treatment. Available at http://www.cdc.gov/hiv/prevention/research/tap/.

9 According to the Center for Disease Control and Prevention’s Enhanced HIV/AIDS Reporting System (eHARS).

10 Persons with an HIV diagnosis and at least one CD4 or viral load test during CY 2013

11 U.S. Department of Health & Human Services. (2014). Recommendations for use of antiretroviral drugs in pregnant HIV-1-Infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/peri_recommendations.pdf.

12 U.S. Department of Health & Human Services. (2014). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents: Considerations for antiretroviral use in special patient populations acute and recent (early*) HIV infection. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf.

13 Indiana General Assembly. (2014). Indiana administrative code: Title 410 Indiana State Department of Health: Article 1. Communicable disease control: Rule 7. HIV counseling and testing of pregnant patients (410 IAC 1-7-7.3). Available at http://www.in.gov/legislative/iac/T04100/A00010.PDF.

14 U.S. Department of Health & Human Services. (2014). Guidelines for the use of antiretroviral agents in pediatric HIV infection. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/pedarv_recsonly.pdf.

15 U.S. Department of Health & Human Services. (2014). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents: HIV and the older patient. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf.

16 Indiana State Department of Health. (2014). Hepatitis B and C among residents of the TGA. Alexander, L. Epidemiology, 26-Aug-2014.

17 National Alliance of State & Territorial AIDS Directors. (2011). HIV and viral hepatitis co-infection. Available at http://nastad.org/Docs/031236_HIV%20VH%20CoInfection%20Final.pdf.

18 Includes primary, secondary and early latent stages of syphilis

19 Indiana State Department of Health. (2014). State wide investigating, monitoring and surveillance system (SWIMSS).

20 Nelson, T. L. (2014). Epidemiologic profile of HIV/AIDS, Indianapolis transitional grant area: 2013. Indianapolis: Marion County Public Health Department. Available at http://www.ryanwhiteindytga.org/wp-content/uploads/2014/06/DR2277-RWG-Epi-Profile-Presentation_2014-06-05_Final.pdf.

21 Thompson, M. A., Mugavero, M. J., Amico, K. R., Cargill, V. A., Chang, L. W., Gross, R., . . . Nachega, J. B. (2012). Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: Evidence-based recommendations from an international association of physicians in AIDS care panel. Ann Intern Med.156(11): 817-833.

22 IAPAC Summary, http://www.iapac.org/uploads/IAPAC_Entry_Retention_Adherence_Guidelines_Summary_Table_05JUN12.pdf

23 Heymann, D. L. (Ed.). (2008). Control of communicable diseases manual. Washington, DC: American Public Health Association.

December 5, 2014 – HIV Care Updates for the Indianapolis-Carmel Metropolitan Statistical Area

Marion County Public Health Department, Epidemiology Request DR2370
Prepared by: Tammie L. Nelson

Continuum of Care – Delayed linkage and poor engagement in care among people living with HIV (PLWH) has been associated with increased transmission, drug resistance, quicker progression to AIDS, increased morbidity (i.e., hospitalizations, opportunistic infections) and increased mortality.[1],[2],[3] For this reason, it is vital to monitor and improve engagement in each step of the HIV continuum of care. Figure 1 illustrates the engagement among PLWH at EOY 2013 in the Indianapolis-Carmel Metropolitan Statistical Area (MSA)[4] as compared to all PLWH in the U.S. at EOY 2011 (includes the MSA).[5],[6]National data reflect engagement in care prior to implementation of initiatives that may be reflected in the more recent MSA data.

Figure 1: HIV Continuum of Care among People Living with HIV/AIDS, Indianapolis-Carmel Metropolitan Statistical Area vs. U.S.
Figure 1: HIV Continuum of Care among People Living with HIV/AIDS, Indianapolis-Carmel Metropolitan Statistical Area vs. U.S.

The Marion County Public Health Department’s Ryan White HIV Services Program (RWSP) employs a continuum of care based on common indicators[7] published by the Health Resources and Service Administration’s HIV/AIDS Bureau (HAB). This method encourages similarity in jurisdictional reporting. Locally they are used to provide RWSP staff, Planning Council, providers and consumers with information to measure program efficacy.

Figure 2 and Table 1 are based on HAB common indicators and reflect engagement in care among PLWH in the MSA vs. the rest of the U.S. (MSA excluded from U.S. data). As in Figure 1, the U.S. data in Figure 2 is not a direct comparison to MSA data and should not be construed as such. Definitions used to construct Figure 2 can be viewed at [Definitions Table]. 

Figure 2: HAB Measures Continuum of Care among People Living with HIV/AIDS, Indianapolis-Carmel Metropolitan Statistical Area vs. U.S.
Figure 2: HAB Measures Continuum of Care among People Living with HIV/AIDS, Indianapolis-Carmel Metropolitan Statistical Area vs. U.S.

 

Table 1: HAB Measures 2013 Continuum of Care Data for the Indianapolis-Carmel Metropolitan Statistical Area
Table 1: HAB Measures 2013 Continuum of Care Data for the Indianapolis-Carmel Metropolitan Statistical Area


Additional performance measures
[8] serve as indicators of health and engagement in care among PLWH in the MSA. Some are discussed below, while others will be highlighted in future MATEC Indiana newsletters.

Late Diagnoses – Of 236 MSA residents diagnosed with HIV during CY 2013, 25.0% (N=59) received AIDS diagnoses within 90 days of initial HIV diagnosis. Among those diagnosed late, 86.4% (N=51) received concurrent HIV and AIDS diagnoses.

Gap in Medical Visits – Among PLWH in the MSA, 17.9% (N=579) experienced a gap in HIV medical care visits during 2013. This gap occurs when an individual has at least one medical visit in the first six months, but not during the last six months, of the measurement year.

Undetectable Viral Load – Among PLWH in the MSA who attended at least one HIV medical visit during 2013 (N=3,859), 54.7% (N=2,110) had undetectable viral loads (<50 copies/mL). These residents are included in the suppressed viral load calculation for Figure 2.

Unmet Need – Among 5,384 PLWH in the MSA on March 31, 2014, 26.3% (N=1,417) received no HIV primary medical care during the preceding 12-months (Table 2). [5],[9],[10],By AIDS status, 31.5% of residents living with HIV non-AIDS were out of care; whereas, 21.6% of residents living with AIDS were out of care.

Table 2: Unmet Need among People Living with HIV/AIDS, Indianapolis-Carmel MSA: 01-Apr-2013 thru 31-Mar-2014
Table 2: Unmet Need among People Living with HIV/AIDS, Indianapolis-Carmel MSA: 01-Apr-2013 thru 31-Mar-2014

 


Sources:

[1] Branson, B. M., Handsfield, H. H., Lampe, M. A., Janssen, R. S., Taylor, A. W., Lyss, S. B., and Clark, J. E. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR, 2006;55(RR14): 1-17.

[2] Gardner, E. M., McLees, M. P., Steiner, J. F., del Rio, C., and Burman, W. J. (2011). 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.

[3] Centers for Disease Control and Prevention. (2011). Vital signs: HIV prevention through care and treatment – United States. MMWR, 2011;60(47):1621.

[4] The Indianapolis-Carmel MSA is congruent with the RWSP transitional grant area and includes: Boone, Brown, Hamilton, Hancock, Hendricks, Johnson, Marion, Morgan, Putnam, and Shelby Counties.

[5] Centers for Disease Control and Prevention. (2014). Enhanced HIV/AIDS Reporting System (eHARS).

[6] U.S. Department of Health & Human Services. (2013). HIV/AIDS care continuum.

[7] U.S. Department of Health & Human Services. (2013). Common indicators for HHS-funded HIV programs and services.

[8] U.S. Department of Health & Human Services. (2013). HIV/AIDS Bureau performance measures.

[9] Indiana Office of Medicaid Policy and Planning. (2014). Indiana health coverage program HIV/AIDS enrollment. Available from Indianapolis: Indiana State Department of Health.

[10] Total HIV-positive, aware, not receiving HIV primary medical care services (quantified estimate of unmet need).

 

Is our Care Quality?

HIV-related morbidity and mortality has dropped dramatically due to advances in HIV/AIDS treatment. But reductions are uneven across HIV-infected populations due to unequal access to care and variable quality of services provided. Quality management seeks to enhance the quality of HIV care provided and increase access to services. They do so by measuring how health and social services meet established professional standards and user expectations.

HRSA’s HIV/AIDS Bureau’s (HAB’s) quality initiatives, which focus on the service delivery system at various levels are designed to help grantees implement quality management programs that target clinical, administrative, and supportive services.

HRSA is committed to improving the quality of care and services and ultimately the quality of life for people living with HIV and AIDS. This commitment is made evident by the variety and depth of efforts undertaken by HAB to address the quality of care, treatment and training across all programs administered by the Ryan White HIV/AIDS Program.

Stay tuned to learn how Indiana’s Transitional Grant Area (TGA) is doing when it comes to the Quality of the HIV/AIDS care we provide.