Meet the Author Webinar November 21, 2011

1. Meet the AuthorWebinar November 21, 2011 Welcome to the first in+care Campaign Journal Club - I am Clemens Steinbock, Director for the National Quality Center; great pleasure to welcome all Campaign Participants on this webinar and other Ryan White grantees - We believe this is the biggest QI collaborative effort in HIV care to improve a specific aspect of HIV care, given the number of programs that have signed up - we have a great national opportunity a head of us with great potential to make a difference; retention is an important aspect of HIV care; learn from peers and change the course of HIV care together If you have not signed up, please do so since our announcements will only go to those you have joined our mailing list or signed up for Campaign (see website) Type in the Chat Room What is the most important improvement idea that you have implemented to improve your retention rate?Welcome to the first in+care Campaign Journal Club - I am Clemens Steinbock, Director for the National Quality Center; great pleasure to welcome all Campaign Participants on this webinar and other Ryan White grantees - We believe this is the biggest QI collaborative effort in HIV care to improve a specific aspect of HIV care, given the number of programs that have signed up - we have a great national opportunity a head of us with great potential to make a difference; retention is an important aspect of HIV care; learn from peers and change the course of HIV care together If you have not signed up, please do so since our announcements will only go to those you have joined our mailing list or signed up for Campaign (see website) Type in the Chat Room What is the most important improvement idea that you have implemented to improve your retention rate?

2. 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 Welcome to the first in+care Campaign Journal Club - I am Clemens Steinbock, Director for the National Quality Center; great pleasure to welcome all Campaign Participants on this webinar and other Ryan White grantees - We believe this is the biggest QI collaborative effort in HIV care to improve a specific aspect of HIV care, given the number of programs that have signed up - we have a great national opportunity a head of us with great potential to make a difference; retention is an important aspect of HIV care; learn from peers and change the course of HIV care togetherWelcome to the first in+care Campaign Journal Club - I am Clemens Steinbock, Director for the National Quality Center; great pleasure to welcome all Campaign Participants on this webinar and other Ryan White grantees - We believe this is the biggest QI collaborative effort in HIV care to improve a specific aspect of HIV care, given the number of programs that have signed up - we have a great national opportunity a head of us with great potential to make a difference; retention is an important aspect of HIV care; learn from peers and change the course of HIV care together

3. Agenda Welcome & Introductions, 5min Campaign Update, 5min Meet the Author: Dr. Edward Gardner, 30min Q & A Session, 15min Campaign Next Steps, 5min Reminder to post questions in the Chat Room � we have individuals lined up to respond to your chat room commentsReminder to post questions in the Chat Room � we have individuals lined up to respond to your chat room comments

4. 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.

6. Over 35% of all Ryan White grantees have signed up so farOver 35% of all Ryan White grantees have signed up so far

7. Representing 44 states and territories (DC and PR)Representing 44 states and territories (DC and PR)

8. Campaign Measures Update from CareWareUpdate from CareWare

9. 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 Download the performance indicator definitions and review them carefully with your team (know the numerator, denominator and exclusions). You can find these in the in+care Campaign Measurement Document Ensure that you fully understand them before you start the data collection process. Any questions regarding these measures may be directed to Michael Hager - mth02@health.state.ny.us. Develop agency-specific data collection strategies You should query your electronic data system(s) and include as many indicators as you can in this review. Please ensure that you are aware of the various measurement periods, which can be found on the last page of the in+care Campaign Measurement Document. If you need to conduct chart reviews, we suggest that you use the following sampling strategy - Sampling Document. Register for the in+care Campaign database by visiting www.incarecampaign.org/database. Please note that only one login per agency is suggested. Be aware that control of existing facility data cannot be transferred from one user account to the next so it is important that you keep your login and password in a place where you will remember it! Conduct your data queries based on the proposed measurement periods Validate your performance measurement data by ensuring that each patient reported is consistent with the denominator, numerator and exclusion definitions. Enter the results in the Campaign database before or on December 1 using the Campaign database at www.incarecampaign.org/database. List any limitations or concerns with the data in the data entry screens. � For additional guidance and tips: Download and review the in+care Campaign Frequently Asked Questions Download and review the in+care Campaign Data Submission Guide �Download the performance indicator definitions and review them carefully with your team (know the numerator, denominator and exclusions). You can find these in the in+care Campaign Measurement Document Ensure that you fully understand them before you start the data collection process. Any questions regarding these measures may be directed to Michael Hager - mth02@health.state.ny.us. Develop agency-specific data collection strategies You should query your electronic data system(s) and include as many indicators as you can in this review. Please ensure that you are aware of the various measurement periods, which can be found on the last page of the in+care Campaign Measurement Document. If you need to conduct chart reviews, we suggest that you use the following sampling strategy - Sampling Document. Register for the in+care Campaign database by visiting www.incarecampaign.org/database. Please note that only one login per agency is suggested. Be aware that control of existing facility data cannot be transferred from one user account to the next so it is important that you keep your login and password in a place where you will remember it! Conduct your data queries based on the proposed measurement periods Validate your performance measurement data by ensuring that each patient reported is consistent with the denominator, numerator and exclusion definitions. Enter the results in the Campaign database before or on December 1 using the Campaign database at www.incarecampaign.org/database. List any limitations or concerns with the data in the data entry screens. � For additional guidance and tips: Download and review the in+care Campaign Frequently Asked Questions Download and review the in+care Campaign Data Submission Guide �

10. 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

11. 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, MD Associate Professor of Medicine University of Colorado Denver Denver Public Health Edward M. Gardner, MD Dr. Gardner is an Infectious Diseases/HIV physician at Denver Public Health and Associate Professor of Medicine at the University of Colorado Denver. He completed medical school at the University of Chicago - Pritzker School of Medicine and his internal medicine training at the University of North Carolina Hospitals in Chapel Hill, NC. After four years in community health and correctional medicine he completed his infectious diseases training at the University of Colorado Denver in 2005. His main areas of research interest are engagement in HIV care and adherence to antiretroviral therapy. He is NIH funded in both of these areas through the National Institute of Mental Health (NIMH, R34) and the National Institute of Allergy and Infectious Diseases (NIAID, K01). His other areas of research interest include cost-effectiveness analysis, the impact of symptoms and adverse events on health outcomes in HIV infected patients, and the diagnosis and treatment of HIV infection. His clinical interests include diagnosis, treatment, and management of HIV infection and its complications with a special interest in the care of persons in correctional facilities.Edward M. Gardner, MD Dr. Gardner is an Infectious Diseases/HIV physician at Denver Public Health and Associate Professor of Medicine at the University of Colorado Denver. He completed medical school at the University of Chicago - Pritzker School of Medicine and his internal medicine training at the University of North Carolina Hospitals in Chapel Hill, NC. After four years in community health and correctional medicine he completed his infectious diseases training at the University of Colorado Denver in 2005. His main areas of research interest are engagement in HIV care and adherence to antiretroviral therapy. He is NIH funded in both of these areas through the National Institute of Mental Health (NIMH, R34) and the National Institute of Allergy and Infectious Diseases (NIAID, K01). His other areas of research interest include cost-effectiveness analysis, the impact of symptoms and adverse events on health outcomes in HIV infected patients, and the diagnosis and treatment of HIV infection. His clinical interests include diagnosis, treatment, and management of HIV infection and its complications with a special interest in the care of persons in correctional facilities.

12. Outline Engagement in HIV Care Test and Treat for HIV Prevention The Spectrum of Engagement in HIV Care Engagement Simulations Conclusions Financial Disclosures: None

13. HIV Care Continuum Adapted from Eldred et al AIDS Patient Care STDs 2007;21(Suppl1):S1-S2 Cheever LW Clin Infect Dis 2007;44:1500-2

14. Kaplan-Meier plot of cumulative survival of the cohort, grouped by the number of quarters with an HIV primary care visit during the first year after the index visit (P = .02). Survival estimates begin 1 year after the index visit, because, by definition, all patients had to survive the first year.Kaplan-Meier plot of cumulative survival of the cohort, grouped by the number of quarters with an HIV primary care visit during the first year after the index visit (P = .02). Survival estimates begin 1 year after the index visit, because, by definition, all patients had to survive the first year.

15. Kaplan-Meier survival plot for patients establishing initial outpatient HIV care at the University of Alabama at Birmingham (UAB) 1917 HIV/AIDS Clinic from 1 January 2000 through 31 December 2005, categorized by missed visit status during the first year of care.Kaplan-Meier survival plot for patients establishing initial outpatient HIV care at the University of Alabama at Birmingham (UAB) 1917 HIV/AIDS Clinic from 1 January 2000 through 31 December 2005, categorized by missed visit status during the first year of care.

16. Test and Treat for HIV Prevention

17. HIV Treatment as Prevention NEJM 2011;365: 493-505.

18. 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

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

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

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

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

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

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

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

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

27. 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.

28. 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

29. 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

30. Thank You

32. Insert Form Progress Form � Dec 15 A) What recent interventions have you tried to improve retention rates? What measurable results, if any, did you have? Focus on identifying those out of care; re-engaging individuals back into care; preventing those in care from falling out of care B) What are the major recent barriers/challenges you are facing in achieving higher retention rates? Focus on barriers your consumers have identified, challenges that your providers have identified; underlying system issues in your organization C) What lessons did you learn that would be helpful to others? Focus on recent discoveries that made a vast difference to your retention efforts; tools, forms (please attach); observations from provider and consumers D) What technical assistance needs to you have for NQC, HAB and our Campaign coaches? Insert Form Progress Form � Dec 15 A) What recent interventions have you tried to improve retention rates? What measurable results, if any, did you have? Focus on identifying those out of care; re-engaging individuals back into care; preventing those in care from falling out of care B) What are the major recent barriers/challenges you are facing in achieving higher retention rates? Focus on barriers your consumers have identified, challenges that your providers have identified; underlying system issues in your organization C) What lessons did you learn that would be helpful to others? Focus on recent discoveries that made a vast difference to your retention efforts; tools, forms (please attach); observations from provider and consumers D) What technical assistance needs to you have for NQC, HAB and our Campaign coaches?