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Overcoming Challenges in HIV Treatment Success

Explore key determinants affecting HIV treatment outcomes and the importance of adherence, monitoring, and patient support. Learn about guidelines, interventions, and strategies for better care and improved health.

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Overcoming Challenges in HIV Treatment Success

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  1. ADDRESSING THE ACHILLES’ HEEL OF HIV TREATMENT SUCCESSJosé M. Zuniga, PhD, MPHInternational Association of Physicians in AIDS CareWashington, DC

  2. ROAD MAP • What We Know • IAPAC Guidelines • Resources

  3. Key Determinants of HIV Treatment Success and Outcomes: The Big Picture Increased Immune Activation Immunologic Decline Disease Progression ↑ Community Transmission Poor QOL and High Mortality Potent ART (properly prescribed combinations) Ongoing Viral Replication • Pharmacokinetics • Absorption • Metabolism • Drug Interactions Acceptance Uptake Adherence Retention in Care Viral Replication Capacity Virulence and Resistance Toxicity, Adverse Effects, Tolerability Treatment Fatigue Host Immune and Intrinsic Factors Systemic and Intracellular Concentration Access to Care Stigma Behavioral Socioeconomic and Cultural Factors Inhibited Viral Replication Decreased Immune Activation Immune Reconstitution Halted Disease Progression ↓ Community Transmission Improved QOL and Survival Cost-Efficiency of ART Nachega JB et al. Infect Disord Drug Targets. 2011;11:167-174.

  4. Mct delivery of integrated care • METHOD: Retrospective analysis of clinical data sets on 2,647 patients at the CORE Center, Chicago, from 1997-1998 • CONCLUSIONS:“Our findings validate the multidisciplinary team model of HIV care, and suggest that health services that are tailored to the express needs of patients lead to better care and improved health outcomes.” Sherer R et al. AIDS Care. 2002;14(Suppl 1):S31-S44 Lab Tech CHW Peer Educator MCH Specialist Social Worker

  5. Task shifting Writ large Task shifting II Task Shifting I Non-Physician Clinicians Task Shifting III Registered Nurses REGULATION Supervision, Delegation, Substitution, Enhancement, Innovation Enrolled Nurses Physicians Community Health Care Workers Task shifting 0 Specialized Physicians Task Shifting IV Peer Educators Courtesy of SebleFrehywot, MD, MHSA

  6. Quality measures • Use of quality measures is an important driver to optimize chronic disease management • HealthQUAL International, HRSA HAB Core Clinical Competencies

  7. IAPAC GUIDELINES Until June 5, 2012, there had not been a full evaluation of the evidence base for how to best monitor or support engagement in HIV care and ART adherence The “Guidelines for Improving Entry into and Retention in Care and Antiretroviral Adherence for Persons with HIV” are our evidence-based response

  8. METHODS • A systematic literature search was conducted to produce an evidence base restricted to randomized controlled trials (RCTs) and observational studies with comparators that had at least 1 measured biological or behavioral endpoint. • A total of 325 studies met the criteria. • Panel members drafted recommendations based on the body of evidence for each method or intervention and then graded the overall quality of the body of evidence and strength for each recommendation.

  9. GRADING SCALE: QUALITY OF EVIDENCE

  10. GRADING SCALE: STRENGTH OF RECOMMENDATION

  11. GUIDELINES ADDRESS • Entry and retention in HIV care • Monitoring ART adherence • ART strategies • Adherence tools for patients • Education and counseling interventions • Health system and service delivery interventions • Special populations (pregnancy, substance use, mental health, incarceration, homeless, children/adolescents)

  12. RECOMMENDATIONS:ENTRY INTO/RETENTION IN CARE • Systematic monitoring of successful entry into HIV care is recommended for all individuals diagnosed with HIV (II A). • Systematic monitoring of retention in HIV care is recommended for all patients (II A). • Brief, strengths-based case management for individuals with a new HIV diagnosis is recommended (II B). • Intensive outreach for individuals not engaged in medical care within 6 months of a new HIV diagnosis may be considered (III C). • Use of peer or paraprofessional patient navigators may be considered (III C).

  13. RECOMMENDATIONS:ADHERENCE TOOLS FOR PATIENTS • Reminder devices and use of communication technologies with an interactive component are recommended (I B). • Education and counselling using specific adherence-related tools is recommended (I A).

  14. RECOMMENDATIONS:EDUCATION/COUNSELING • Individual one-on-one ART education is recommended (II A). • Providing one-on-one adherence support to patients through 1 or more adherence counselling approaches is recommended (II A). • Group education and group counselling are recommended; however, the type of group format, content, and implementation cannot be specified on the basis of the currently available evidence (II C). • Multidisciplinary education and counselling intervention approaches are recommended (III B). • Offering peer support may be considered (III C).

  15. RECOMMENDATIONS:HEALTH SYSTEM/SERVICE DELIVERY • Using nurse- or community counsellor-based care has adherence and biological outcomes similar to those of doctor- or clinic counsellor-based care and is recommended in under-resourced settings (II B). • Interventions providing case management services and resources to address food insecurity, housing, and transportation needs are recommended (III B). • Integration of medication management services into pharmacy systems may be considered (III C). • Directly administered ART is not recommended for routine clinical care settings (I A).

  16. Resources www.IAPAC.org

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