December 2019

AIDS – Still a World-wide Threat

World AIDS Day has taken place on December 1 every year since 1988 – and offers people around the world a chance to show their solidarity in the fight against HIV. Since 1984, more than 35 million people have died of HIV or AIDS, making it one of the most deadly pandemics in history.¹ Human immunodeficiency virus (HIV) is an infectious disease that attacks the human body’s immune system. If left untreated, the virus can lead to acquired immunodeficiency syndrome (AIDS). There is no cure for HIV, but it can be controlled with early detection and medications, particularly antiretroviral therapy (ART). However, of the estimated 1.1 million people in the United States who had HIV at the end of 2016, approximately 1 in 7 did not know they were infected.²  Moreover, nearly 40 million people were living with HIV/AIDS worldwide in 2018,³ with South Africa having the biggest HIV epidemic with 7.1 million people living with HIV. South Africa also has the biggest ART program in the world, and PrEP (pre-exposure prophylaxis) is now being made available to people at high risk of infection.⁴

VA is the single largest provider of HIV care in the United States, and VA leads the country in HIV screening, testing, treatment, research, and prevention. HSR&D has contributed to these achievements through the outstanding work of many investigators, including but not limited to the following studies.

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. 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 show:

• 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 2016;63(1):96-100.

Multimodal Intervention Increases HIV Testing in VA Primary Care

QUERI investigators previously developed, implemented, and evaluated a multimodal program to promote HIV testing, which more than doubled testing among at-risk Veterans. These results prompted a QUERI study that scaled up this intervention in a large number of diverse VA facilities providing primary care to nearly 200,000 Veterans previously untested for HIV. Investigators examined the effectiveness of promoting routine as well as risk-based HIV testing, and the effect of providing different levels of organizational support at study sites. Frequency of HIV testing in the six months prior to the intervention was then compared to the six months following the intervention. Study results show:

• The use of clinical reminders, provider feedback, education, and social marketing in this HIV-testing intervention significantly increased the frequency at which HIV testing was offered and performed within the VA healthcare system.
• Implementation of this intervention increased the rate of risk-based HIV testing two- to three-fold, and increased routine testing three- to four-fold.

Goetz M, Hoang T, Knapp H, et al., and the HIV/Hepatitis-QUERI Center. Central implementation strategies outperform local ones in improving HIV testing in Veterans Healthcare Administration facilities. Journal of General Internal Medicine. October 2013;28(10):1311-1317.

Internet and Personal Health Record Training Program Improves Use of MyHealtheVet among Low-income Veterans with HIV or Hepatitis C

Unfortunately, vulnerable populations, such as low-income patients with chronic diseases, face difficulties accessing and using the Internet and My HealtheVet (MHV), VA’s personal health record system, for health-related purposes. This study developed and evaluated a four-session training intervention to increase skills in health-related Internet and MHV use for Veterans with low incomes and little computer experience, who were receiving VA healthcare for HIV or hepatitis C. Findings show:

• The intervention increased Veterans’ health-related Internet use, especially their use of their personal health records, and empowered Veterans to raise questions with their clinicians.

The intervention also was adapted to use with rural Veterans with diabetes.

McInnes D, Solomon J, Shimada S, et al. Development and evaluation of an Internet and personal health record training program for low-income patients with HIV or hepatitis C. Brief Reports. Medical Care March 2013;51(3 Suppl 1):S62-S66.

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., VA provides an ideal setting to examine racial disparities in comprehensive measures of care, including those for common comorbid conditions. This study examined a national cohort of Veterans (n=23,974; 53% Black) in care for HIV in the VA healthcare system during 2013. Specifically, 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 show:

• 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%).

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.

Important publications on HIV/AIDS by HSR&D investigators include but are not limited to:

Dichter M, Ogden S, Clyatt K, and Roberts C. Missed opportunity for HIV prevention among a high-risk population of women experiencing intimate partner violence. Journal of General Internal Medicine. October 16, 2019: Epub ahead of print.

Chang C, Skanderson M, Patterson O, et al. Association between HIV infection and risk of heart failure with reduced ejection fraction and preserved ejection fraction in the antiretroviral therapy era: Results from the Veterans Aging Cohort Study. JAMA Cardiology. May 2017;2(5):536-546.

Callon W, Beach M, Saha S, et al. Assessing problematic substance use in HIV care: Which questions elicit accurate patient disclosures? Journal of General Internal Medicine. October 2016;(10):1141-1147.

Knapp H and Chan K. HIV rapid testing in a VA primary care department setting: Programmatic cost analysis at five years. Journal of AIDS & Clinical Research. April 2015;6:451.

References

1. About World AIDS Day. World AIDS Day 2019.
2. Basic Statistics. Centers for Disease Control and Prevention (CDC).
3. Global Health Observatory data. World Health Organization (WHO).
4. HIV and AIDS in South Africa. Avert. Global information and education on HIV and AIDS.

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