Improving Quality Care for Marginalized HIV-Positive Patients

1. Improving Quality Care for Marginalized HIV-Positive Patients • The Prevention and Access to Care and Treatment (PACT) Project A Complementary Community-Based HIV Disease Management Model Heidi Behforouz, MD and Jessica Aguilera-Steinert, LICSW 03/10/05

2. AIDS MORTALITY DESPITE OUR ADVANCING TECHNOLOGY… In Roxbury, a black women is 16x more likely to die from her AIDS than a white man in Boston.

3. The Outcome Gap Grows Improved Outcomes High SES Low SES Time Introduction of effective technology

4. Why the disparities in outcome? • Poverty forces priorities other than health • Poor access to care (eg insurance) • Poor utilization of care (eg not getting tested till late in disease) • System problems • Differential treatment once in care • Problems with adherence

5. The relationship between adherence and AIDS progression

6. Impact of ART on Hospitalization Rates in HIV-Infected PatientsGilbert et al, New York Presbyterian Hospital AIDS Research and Human Retroviruses. 18(7):501, 2002 Hospital Admissions Per 100 Pt-Yr

7. ART is Cost-Effective K. Freedberg et al. NEJM 2001 344: 824 Greater than benefit of thrombolytic therapy in acute MI, XRT for early stage breast CA, and anti-hyperlipidemics Adherence Interventions are cost effective Sue Goldie et al. Any intervention that increases ART adherence by 30% will be cost effective

8. Prevention and Access to Care and Treatment (PACT) Project • Started in 1999 through Partners In Health; Now a joint project of PIH & the DSMHI at BWH • Participant-driven • Health promoters improve access to care for marginalized HIV patients in Boston’s inner city as well as promote harm reduction in the community • Health promoters work in conjunction with physicians, medical students, social scientists.

9. PACT Organizational Structure

10. PACT PROJECT • Harm Reduction Initiative • Knowledge is important but not enough • Prevention case management services • Peer leader outreach and harm reduction in hot zones • Media campaigns, needle exchange, accompaniment • Working with adults in early recovery and inner city youth

11. PACT Project • Health Promotion Initiative • Low intensity: Monitored self- administration with monthly health promotion • Moderate intensity: Weekly health Promotion • High intensity: DOT-Plus initiative

12. WHAT HEALTH PROMOTERS DO… • Accompaniment to appointments…more than just getting the patient there • Home based support to pt and network • Work in concert with clinicians and other social service personnel to coordinate care • Health education and translation of treatment recommendations into the home • Facilitate access to and utilization of resources • Extensive adherence counseling • Surrogate support network and sounding board • Normalization/setting new norms • Advocacy • Empowerment

13. DOT-Plus • In addition to the weekly services of a health promoter, patients receive daily visits from the DOT specialist who assists them in taking their once daily ART medication • Designed with instruction from patients

14. Cristina at work…

15. Movement through PACT

16. Outcomes of Interest for HP Program • Improved clinical outcomes (CD4/VL/OI) • Improved engagement with health care • Improved practice of harm reduction • Improved self management • Improved health care utilization • Number of referrals to PACT • Number graduated to successful self administration • Number of relapses • Length of time in each arm and number of movements between arms over time • Resource utilization • Sustainability

17. PACT and the PDSA Cycle • Participant action plans • Quarterly personal objectives for peer prevention leaders • Patient progress (eg Q patient report cards) • Health promoter report card • Program goals: eg referral rates, retention rates, etc.

18. PACT ALONE GRAPHS Viral Load (thousands/ml) • Insert Ariel Cruz graph -4 4 Months Pre and Post PACT CD4 in ( ) = hospitalization

19. 160 120 Viral Load (thousands /ml) 80 40 MONTHS CD4= ( ) = hospitalization = EW visit

20. Data to date Health Promotion • Of those 31 meeting our new eligibility criteria at entry who have been enrolled for at least one year: • (Baseline mean CD4 =131 with mean VL 61K) • 10 with VL<assay at present • Mean –1.35 log decrease in VL • Mean increase in CD4 after 1 year=79 cells/µl

21. Data to date: DOT-Plus • Of 20 enrolled into DOT Plus for at least one year… • (Baseline mean CD4 122 with mean VL of 57K) • Retention rate at one year= 85% • 11 achieving VL<assay to date • Mean increase in CD4= 108.5 cells/µl • Means VL reduction = –1.13 log

22. Yearly Expenditures for Care of HIV/AIDS Patients • Today we estimate annual expenditures for patients with CD4<50 to be around $40,000 • CD4 count measures immune strength • PACT CD4 eligibility criteria: <350, most PACT patients have CD4 <200 at enrollment Source: Bozette, S et. al. Expenditures for the Care of HIV-Infected Patients in the Era of Highly Active Antiretroviral Therapy. NEJM, 2001.

23. What does this mean in terms of medical cost savings? Average cost of PACT/patient = $3200/month (across all three programs) Patients whose CD4 counts have risen from <50 to >200…medical savings of up to $17,000/ year

24. Sustainability/ Funding Challenges • PACT is primarily a service organization as opposed to focusing on research or policy • Care gets less attention than prevention • PACT staffing ratios are deemed too costly • It takes time and resources to prove ourselves and become competitive for funding • Shrinking federal, state, and private funds- particularly for HIV service programs and harm reduction programs • Not much interest in the plight of poor minority individuals with HIV or substance abuse

25. Spread Challenges First establish best practice…develop the package…curricula, training manuals, process guides THEN barriers include: Lack of similar organizations from whom to learn collaboratively, politics, money BUT The proof is in the pudding…do the work, show the data, always strive for quality in a systematic way

26. For more HIV-related resources, please visit www.hivguidelines.org