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Retention in HIV Medical Care or The Gorilla

This presentation reviews the importance of retention in HIV care, approaches to measuring and improving retention, and studies focused on retention in HIV care. It also presents two case studies and discusses the prevalence and impact of poor retention in care.

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Retention in HIV Medical Care or The Gorilla

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  1. Retention in HIV Medical Care orThe Gorilla by Thomas P. Giordano, MD, MPH Baylor College of Medicine DeBakey VA Medical Center Thomas Street Health Center Houston, TX

  2. Objectives • Review the importance of retention in HIV care • Learn approaches to measuring retention in care suitable for routine HIV care • Learn approaches to improving retention in care suitable for routine HIV care • Review studies underway focused on retention in HIV care

  3. Cases • Mr. W: 28 year-old Black man • Diagnosed with HIV in late 1998 • CNS toxoplasmosis, wasting, dementia, CMV esophagitis • CD4 cell count = 6 • Mr. T: 26 year-old Black man • Diagnosed with HIV while in Ben Taub in 1999 • Pulmonary tuberculosis • CD4 cell count = 265

  4. Which patient is still alive today? Rembrandt, The Raising of Lazarus, c. 1630

  5. Audience Response: What proportion of return patients to your clinic fail to attend their scheduled visit (“no show”)? • 0-10% • 11-20% • 21-30% • 31-40% • 41-50% • > 50%

  6. Prevalence and impact of poor retention in care

  7. The HIV Treatment Cascade

  8. The HIV Treatment Cascade 80% 77% 66% 89% 77%

  9. The HIV Treatment Cascade 72% 28%

  10. Of the 849,875 Non-suppressed: Slide courtesy of Rivet Amico

  11. Retention in care and mortality(n=2619) Giordano, CID 2007, 44:1493

  12. Retention in Care and Mortality(n=2619) Adjusted for age, race/ethnicity, baseline CD4 cell count, HAART use, hepatitis C virus coinfection, non-HIV-related comorbidity score, alcohol abuse, hard drug use, and social instability. Giordano, CID 2007, 44:1493

  13. Missed Visits and Mortality a Cox proportional hazards (PH) analysis also adjusts for sex, insurance, race/ethnicity, depression, anxiety, alcohol abuse, and substance abuse. Mugavero et al. Clin Infect Dis 2009;48:248-56

  14. Retention in Care

  15. Measuring Retention in Care

  16. *All can be misinterpreted if patients unknowingly transferred care elsewhere, were incarcerated, or died. Giordano TP (2012) Measuring retention in HIV care. www.medscape.com.

  17. Adherence *All can be misinterpreted if patients unknowingly transferred care elsewhere, were incarcerated, or died. Giordano TP (2012) Measuring retention in HIV care. www.medscape.com.

  18. Persistence or Constancy *All can be misinterpreted if patients unknowingly transferred care elsewhere, were incarcerated, or died. Giordano TP (2012) Measuring retention in HIV care. www.medscape.com.

  19. Audience Response: Epistemology is: • The study of letters • The study of how we know • The study of urine • “Damn it Giordano, I’m a doctor, not a philosopher!”

  20. Verrocchio, Florence (Orsanmichele) 1476-83.

  21. Verrocchio, Florence (Orsanmichele) 1476-83.

  22. Why don’t people stay in HIV care? • If untreated, HIV is fatal • Good treatments are available • Why would you not avail yourself of them?

  23. Audience Response: If you heat water past a certain point, you will see a substance rising from the water. That substance is: • Smoke from the water burning • Water in the gaseous phase

  24. Audience Response: If you heat wood past a certain point, you will see a substance rising from the wood. That substance is: Smoke from the wood burning Wood in the gaseous phase

  25. Why don’t people stay in HIV care? • If untreated, HIV is fatal • Good treatments are available • Why would you not avail yourself of them? Patients don’t “know” it the way we do

  26. Why don’t people stay in HIV care? • Disease severity • Lower perceived need for care • Fewer non-HIV comorbidities • Psycho-social characteristics • Substance use and mental health problems • Low perceived benefits of care (trust, past experiences) • Less social support • Stigma, fear and denial • Low literacy • System factors • Less ancillary services / greater unmet need (housing, transportation) • Confusing health care systems (transitions, multiple programs) • No or inadequate insurance • Cost (out-of-pocket, lost wages, opportunity) Patients don’t “know” it the way we do

  27. Situated Information-Motivation-Behavioral Skills Model Amico J Health Psych (2011) 1-11

  28. Randomized, controlled trials of interventions to improve retention in care

  29. Intervention to Improve Linkage: ARTAS 273 participants, 4 cities 78% diagnosed <6 m 90 d of strength-based case management Replicated in ARTAS II Percent Gardner, AIDS 2005, 19:423; Gardner AIDS Pt Care STD 2007, 6:418

  30. Preliminary Findings From CDC/HRSA Retention in Care Project CDC: Lytt Gardner, Gary Marks, Jason Craw HRSA: Faye Malitz, Laura Cheever, Robert Mills Mountain Plains AETC: Lucy Bradley-Springer, Marla Corwin Baltimore: Richard Moore, Jeanne Keruly Birmingham: Mike Mugavero, Mike Saag Boston: Meg Sullivan, Mari-Lynn Drainoni Houston: Tom Giordano, Jessica Davila Miami: Allan Rodriguez, Lisa Metsch New York City: Tracey Wilson, Susan Holman Gardner, 7th International Conf on HIV Treatment and Adh, June 2012

  31. Gardner, 7th International Conf on HIV Treatment and Adh, June 2012

  32. Constancy Result * Log binomial Gardner, 7th International Conf on HIV Treatment and Adh, June 2012

  33. Attended All HIV Primary Care Appointments * Log binomial, adjusted for # scheduled appointments Gardner, 7th International Conf on HIV Treatment and Adh, June 2012

  34. Appointment Adherence Gardner, 7th International Conf on HIV Treatment and Adh, June 2012

  35. That is it.

  36. 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).

  37. Audience Response: In what proportion of patient encounters do you discuss ART medication adherence? • 0-20% • 21-40% • 41-60% • 61-80% • 81-100%

  38. Audience Response: In what proportion of patient encounters do you discuss the importance of adherence to clinic visits? • 0-20% • 21-40% • 41-60% • 61-80% • 81-100%

  39. Audience Response: Imagine you missed your last dental cleaning and it has been a year. I’m your dentist. I tell you, “You know, your really need to get your teeth cleaned every 6 months. Bad things could happen to your teeth if you don’t. They might even fall out.” This statement from me makes you feel: • More knowledgeable • Guilty and imperfect • More motivated • Mad, like you are being treated like a child

  40. Given Accurate Adherence Data, How Do Physicians Talk To Their Patients? Data to provider included: MEMS and SR adherence; reminder use; reasons for missed doses; beliefs about ART; alcohol and drug use; and depression Two routine office visits per subject Wilson JAIDS 2010; 53:338

  41. Given Accurate Adherence Data, How Do Physicians Talk To Their Patients? • Adherence dialogue increased • Little problem solving • Most was “directive” • Adherence no different Wilson JAIDS 2010; 53:338

  42. SPNS Model for Opportunities to Improve Adherence to Care Persons in Care Interventions to Prevent Falling out of Care Interventions to Engage in Care Pivotal Points Opportunities Persons Unstable in Care Rajubian, AIDS Pt Care STD 2007, 21:S-20

  43. Gardner, Clin Infect Dis. 2012 Oct;55(8):1124-34

  44. Phase 1: Features of Clinic-Wide Intervention • Theme: “Stay Connected for Your Health” • Provider messages about importance of regular care and keeping appointments • Working as a team • Keeping you healthy • Best possible care • Staying ahead of the virus • Brochure • Posters (waiting room, exam rooms) Gardner, Clin Infect Dis. 2012 Oct;55(8):1124-34

  45. Gardner, Clin Infect Dis. 2012 Oct;55(8):1124-34

  46. Gardner, Clin Infect Dis. 2012 Oct;55(8):1124-34

  47. Gardner, Clin Infect Dis. 2012 Oct;55(8):1124-34

  48. Gardner, Clin Infect Dis. 2012 Oct;55(8):1124-34

  49. Gardner, Clin Infect Dis. 2012 Oct;55(8):1124-34

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