Spotlight: World AIDS Day

December 2017

December 1 is World’s AIDS Day. The first ever global health day, begun in 1988, it is dedicated to remembering those who have died from this disease – and to raising awareness about AIDS and the global spread of the Human Immunodeficiency Virus (HIV). HIV infection causes a chronic, progressive disease that leads to Acquired Immune Deficiency Syndrome (AIDS) and early death if untreated. Globally, more than 35 million people have died of HIV or AIDS since it was identified in 1984, making it one of the most destructive pandemics in history,¹ and HIV/AIDS remains one of the world's most significant public health challenges. In the United States, more than 1.1 million people are living with HIV infection, and almost 1 in 6 (16%) are unaware of it.² VA is the single largest provider of HIV care in the U.S.; in 2015 nearly 27,000 Veterans with HIV were receiving HIV care in the VA healthcare system.³

Studies funded by HSR&D address many aspects of caring for HIV-positive Veterans, including access to care, screening and testing, and long-term HIV care management. The following study summaries represent just some of the work being conducted by HSR&D researchers around HIV care in VA.

Improving Access and Outcomes for Veterans with HIV Living in Rural Settings

Approximately 16% of the 27,000 Veterans in care for HIV infection in the United States live in rural areas, and more than one in four live more than a one-hour drive from the nearest infectious disease specialty clinic. Prior work by HSR&D researchers demonstrated that, compared to their urban counterparts, Veterans with HIV infection who live in rural settings enter care with more advanced illness, are less likely to be early adopters of important advances in HIV therapy, and experience higher mortality. In this HSR&D study, part of a Career Development Award, investigators are developing, evaluating, and implementing an innovative delivery model to improve the accessibility, quality, and outcomes of care for Veterans with HIV who live in rural settings.

Findings: Thus far, study results indicate that geographic access to HIV clinics is associated with Veterans' retention in HIV care. As the estimated travel time for Veterans to an HIV clinic increases, the retention in HIV (VA) care decreased from 80% to 68%. This supports the development of telehealth-based models for delivering HIV care that can overcome geographic barriers to access. Based on interviews with Veterans and other stakeholders, investigators also developed and pilot-tested a telehealth collaborative care (TCC) model for Veterans with HIV in both rural and outlying urban settings. Initial results indicate that Veterans with HIV living in these areas prefer TCC over "usual care" (i.e., driving to HIV specialty clinic for all care). For example, in the Iowa City VAMC, 41 (95%) of 43 Veterans who live nearer to a VA community-based outpatient clinic (CBOC) than to the HIV specialty clinic have chosen TCC over usual care. Moreover, TCC has maintained the previously existing high quality of HIV care that existed in the specialty clinic—as evidenced by high rates of antiretroviral therapy and virologic suppression.

Implications: Investigators are rapidly applying knowledge gained thus far to design and test an innovative care system that uses VA telehealth resources to extend interdisciplinary-team-based specialty care for Veterans with HIV in rural settings. In addition to improving access and outcomes of care for rural Veterans with HIV, this work may inform care systems for rural Veterans with other chronic conditions requiring ongoing specialized care. This work directly addresses both VA’s operational and research priorities to improve access to care for rural Veterans.

Moeckli J, Stewart K, Ono S, et al. Mixed-study of update of the Extension for Community Health Outcomes (ECHO) telemedicine model for rural Veterans with HIV. The Journal of Rural Health. June 2017;33(3):323-331.

Korthuis P, McGinnis K, Kraemer K, et al. Quality of HIV care and mortality rates in HIV-infected patients. Clinical Infectious Diseases. January 15, 2016;62(2):233-9.

Integrating HIV Care in VA: Extending PACT Principles to Specialty Care

VA transformed primary care through implementation of Patient-Aligned Care Teams (PACT), based on core principles including patient-centered, team-based and well-coordinated care. It is less clear how PACT can be extended to specialty care. The setting of optimal HIV care is shifting as the needs of Veterans with HIV shift towards chronic illness and co-morbidity management. Understanding variations in HIV care across VA is critical to the development and spread of initiatives to insure Veterans with HIV receive the best care possible for all their health needs. This ongoing HSR&D study aims to:

• Characterize patterns and structures of HIV care at low- and high-patient volume sites and examine the association between structures of care, adherence to PACT principles, and outcomes of care for HIV and comorbid conditions; and
• Qualitatively characterize how different types of sites and their corresponding structures of care achieve integration, coordination, and team functioning by capturing the behaviors, experiences, and perspectives of providers and patients.

VA administrative data was analyzed to assess quality of care outcomes for Veterans with HIV and comorbidities. HIV clinicians from 10 VA facilities were surveyed regarding structure and processes of care and adherence to PACT principles.

Findings:

• Based on an analysis of patient data, VA performance is very high for quality measures of HIV care.
• Survey findings indicate that the majority of Veterans with HIV receive HIV and comorbidity care in an infectious disease/HIV specialty clinic.
• Analyses indicated that no PACT domain contributed more significantly than others when predicting HIV-related outcomes.
• Increases in Patient-Centered Care were associated with decreased risk of not receiving cART (combination antiretroviral therapy), while higher Care Coordination and Continuity of Care scores were associated with decreased likelihood of poor viral control.
• African American Veterans were more likely than white Veterans to be diagnosed with hypertension, substance abuse, Hepatitis C, and chronic kidney disease, and were less likely to receive cART, have lipid monitoring, or have viral, hypertension, or diabetes control.

Implications:

Findings from this research will inform recommendations to VA operations on transformational initiatives targeted to specific care contexts and tailored to support implementation of PACT-principled care. Findings also have been presented at two IDWeek conferences, to VA operational partners, and to the VA HIV Technical Advisory Group. Disparities findings presented to the HIV, Hepatitis, and Public Health Pathogens Programs (HHPHP) led to a working group to address HIV disparities.

Appenheimer A, Bokhour B, McInnes D, et al. Should human immunodeficiency virus specialty clinics treat patients with hypertension or refer to primary care? An analysis of treatment outcomes. Open Forum Infectious Diseases. February 3, 2017;34(1).

Study Identifies Racial Disparities in HIV Quality of Care that Extend to Common Comorbid Conditions

As the largest provider of HIV care in the U.S., with approximately 25,000 Veterans in care, VA provides an ideal setting to examine racial disparities in comprehensive measures of care, including those for common comorbid conditions. Thus, this HSR&D-funded study examined a national cohort of Veterans (n=23,974; 53% Black) in care for HIV in the VA healthcare system during 2013. Investigators quantified racial variation in a set of widely used quality measures related to antiretroviral therapy, common medical comorbidities, depression, and substance use disorder treatment. In addition to patient demographics, investigators also examined how neighborhood social disadvantage influenced racial disparities in HIV care.

Findings:

• Racial disparities were identified in quality of care specific to HIV infection – and in the care of common comorbid conditions. Blacks were less likely than whites to receive combination antiretroviral therapy (90% vs. 93%) or to experience viral control (85% vs. 91%), hypertension control (62% vs. 68%), diabetes control (86% vs. 90%), or lipid monitoring (82% vs. 85%).
• Black Veterans were more likely than white Veterans with HIV to be diagnosed with hypertension, substance abuse, Hepatitis C, and chronic kidney disease.
• Black Veterans with HIV were more likely to live in very highly socially disadvantaged neighborhoods (44% vs. 17%) and in the South (63% vs. 42%), while white Veterans with HIV were more likely than black Veterans to live in low or very low socially-disadvantaged neighborhoods (38% vs. 22%), and in the West (30% vs. 10%).

Implications: Although performance on quality measures was generally high, racial disparities in HIV care for Veterans remain problematic and extend to comorbid conditions. Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.

Richardson K, Bokhour B, McInnes D, et al. Racial disparities in HIV care extend to common comorbidities: Implications for implementation of interventions to reduce disparities in HIV care. Journal of the National Medical Association. Winter 2016;108(4):201-210.

New Guidelines May Significantly Decrease Cost for Testing Immune Function in Veterans with HIV

Routine evaluation of immune function with CD4 testing has long been regarded as an essential part of care for patients with HIV. However, recent studies suggest that patients who are not immuno-compromised and successfully use anti-retroviral therapy to suppress HIV do not benefit from periodic CD4 testing. In 2012, the Department of Health and Human Services recommended CD4 testing every 3 to 6 months – except in patients with consistently suppressed virus and sustained CD4 cell count, who could be tested every 6 to 12 months. In 2014, updated guidelines recommended that in individuals with viral suppression, CD4 testing be considered either optional or annual, depending on the cell count. This study evaluated how these recommendations might affect Veterans with HIV who receive care from the largest provider of HIV care in the United States – the VA healthcare system. Using VA data, investigators analyzed CD4 and viral load tests for 28,530 Veterans who received VA care for HIV from FY2009 through FY2013, evaluating trends in CD4 testing frequency and the number, cost, and results of CD4 tests considered optional under the guidelines.

Findings:  Results showed that VA providers decreased the frequency of CD4 testing by 11% between 2009 and 2012, reducing the direct cost of testing by $196,000 per year. In addition:

• Veterans participated in this study for a mean of 3.5 years, and had an average of 3.3 CD4 tests and 3.4 viral load tests per year. At the end of the study, 20% were eligible for optional monitoring, 16% were eligible for minimal monitoring, while 65% did not qualify for reduced monitoring.

Implications: VA has made substantial progress in reducing the frequency of optional CD4 testing, but it could be reduced a further 29% by full implementation of new treatment guidelines, with an expected annual savings of $600,000. Reduced CD4 monitoring also would likely reduce patient anxiety with little or no impact on quality of care.

Barnett P, Schmitt S, Yu W, et al. How Will New Guidelines affect CD4 Testing in Veterans with HIV? Clinical Infectious Diseases. July 1, 2016;63(1):96-100.

References:

1. About World AIDS Day. November 20, 2017.
2. 10 Facts on HIV/AIDS. World Health Organization. November 3, 2014.
3. HIV/AIDS Basics. U.S. Statistics. AIDS.gov. November 3, 2014.

Resources:

• HIV/AIDS. For Veterans and the Public. U.S. Department of Veterans Affairs.
• National HIV/AIDs Strategy: Overview.

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