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Since 1984, more than 35 million people have died from acquired immune deficiency syndrome (AIDS), which is the last stage of infection with human immunodeficiency virus (HIV).[1] HIV is an infectious disease that attacks the human body’s immune system. While preventive efforts and widespread education have helped to curb HIV infection, there is still no known cure. However, research efforts over the past 35 years have resulted in a combination of medications that can help control HIV, as well as prevent and reduce the risk of transmission. Medication therapies known as antiretroviral therapies (ART) can help those with HIV live longer, healthier lives. Pre-exposure prophylaxis (PrEP)—which involves taking a specific combination of HIV medicines daily—is a prevention method for people who are HIV negative but are at high risk for HIV infection
As the single largest provider of HIV care in the United States, [2] VA leads the country in HIV screening, testing, treatment, research, and prevention. Investigators within VA’s Health Services Research and Development Service (HSR&D) continue to help improve the lives of, and care for, Veterans with HIV through an active research program that dates to the early years of the HIV/AIDS pandemic. The following funded studies represent just some of the ongoing research being conducted by HSR&D investigators.
Implications
Veterans infected with human immunodeficiency virus (HIV) face many challenges and, to live a healthy life, need to be proactive in self-management of both their HIV and any comorbid conditions. The use of personal health records (PHRs) may have the potential to facilitate better disease self-management, improve health outcomes, and reduce unnecessary healthcare utilization. However, there has not yet been an examination of use of VA’s PHR, MyHealtheVet (MHV), and its relationship to health outcomes among Veterans with HIV. The results of this study may have considerable implications regarding the linkage—at the individual Veteran level—of highly detailed PHR activity data with VA medical record data. Further, understanding how MHV can facilitate improved self-management of HIV would have tremendous benefit for Veterans with other chronic conditions. Using study data to develop a PHR-supported intervention that optimizes health outcomes by targeting patients and providers will also help improve healthcare processes for all Veterans.
About the Study
At 26%, Veterans with HIV make up the largest proportion of any Veteran chronic disease group to adopt MHV. Investigators have been conducting an in-depth examination of MHV use by HIV-infected Veterans and their providers, including quantitative analysis that will offer linkage of MHV self-management tool use to care processes and outcomes. Additional qualitative analysis has helped to discern why Veterans do or do not adopt MHV and what benefit they derive from using specific MHV tools. The role providers have in facilitating (or discouraging) Veteran use of MHV is also being explored.
Investigators have conducted both the quantitative and qualitative arms of the study using a multiphase design, and preliminary findings show demographic differences in use of MHV tools. HIV-infected Veterans who registered for MHV are slightly younger than their unregistered counterparts, with an average age of 50 compared to 55. The cohort is primarily made up of black/African American and white Veterans. Preliminary, unadjusted measures suggest that the black/African American Veterans are less likely to register for MHV than white Veterans (42% vs 51%). Unadjusted measures also show that among those registered for MHV, black/African American users show less utilization of MHV tools than white Veterans. Among white and among black/African American MHV-using Veterans respectively, 47% and 34% used Blue Button, 40% and 24% used Secure Messaging, 55% and 38% used Rx Refill, and 57% and 43% viewed appointments. Additional analysis and final data collection are expected during late 2022.
Principal Investigator
Amanda Midboe, PhD, is an investigator with the HSR&D Center for Innovation to Implementation in Palo Alto, CA.
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Implications
Cigarette smoking remains a leading preventable cause of death and poor health in the United States. Veterans living with human immunodeficiency virus (HIV) have particularly high smoking rates; and due to HIV infection, smoking disproportionately affects their health. To date, there have been no randomized controlled trials of smoking cessation interventions for Veterans living with HIV. This study is anticipated to yield a new and potentially efficacious tailored intervention for smoking cessation among people living with HIV. If evidence supports the intervention, it would have tremendous value in terms of reducing health risks and healthcare costs among Veterans with HIV.
About the Study
This five-year HSR&D Career Development Program award project is developing and testing a mobile health (mHealth) intervention called Mobile Contingency Management plus Evidence-Based Smoking Cessation for HIV-positive Veterans (MESH). The MESH intervention uses mHealth and telehealth technology to:
Investigators will qualitatively explore smoking cessation treatment preferences among Veteran smokers living with HIV. Semi-structured qualitative interviews with HIV patients and quantitative rapid online surveys will be conducted during the course of the project. Results will be used to refine design and content of the proposed intervention. The study will also involve a successive cohort design to develop and obtain patient feedback on an mHealth smoking cessation intervention that uses computerized algorithms to personalize treatment. Finally, the feasibility and acceptability of MESH will be determined. After thorough evaluation and design refinement, the mHealth app will be tested via a randomized trial in which Veteran smokers with HIV will be assigned to either MESH or to a comparable smoking cessation program (VA Quitline and SmokefreeVET). Outcomes include feasibility of the overall approach and acceptability of the intervention. Results will enable future examination of whether MESH may help overcome existing disparities.
Principal Investigator
Sarah M. Wilson, PhD, is an investigator at the HSR&D Center of Innovation to Accelerate Discovery and Practice Transformation in Durham, NC.
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Implications
VA is the country’s largest provider of care for individuals with human immunodeficiency virus (HIV). Veterans with HIV use significantly more healthcare services, and their risk for atherosclerotic cardiovascular disease (ASCVD) is almost two times higher than Veterans who do not have HIV. Since high blood pressure is a major contributing factor for ASCVD, the goal of this study is to improve blood pressure treatment for Veterans with HIV in order to reduce ASCVD risk. If shown to be effective, investigators expect this intervention to have substantial impact among high-risk Veterans, potentially reducing ASCVD events by more than a quarter.
About the Study
Investigators are conducting a randomized controlled trial to determine if a VA adapted, nurse-led intervention will result in a clinically significant (6mmHg) reduction in systolic blood pressure over 12 months compared to those receiving only enhanced education. Critically, this intervention was designed with a “downstream implementation” in mind. Investigators have structured the intervention to include fully remote delivery to facilitate access and widespread implementation and guidance for a selection of nurses with education/experience levels that match those of health coaches delivering interventions within VA.
The study is being conducted in three VA clinics with 300 HIV+ Veterans who are on suppressive anti-retroviral therapy and who have a confirmed systolic (SBP) of greater than 140 mmHg. Study participants have been randomized 1:1 to intervention vs. education control. The intervention involves four evidence-based components: (1) nurse-led care coordination; (2) nurse-managed medication and adherence support; (3) home blood pressure monitoring; and (4) administered VA Video Connect. The education control is receiving enhanced education and usual care. The primary outcome measure will be the difference in 12-month SBP in the intervention arm vs. control. A secondary outcome measure will be the 12-month difference in non-high-density lipoprotein cholesterol.
Principal Investigator
Hayden B. Bosworth, PhD, is the Associate Director of HSR&D’s Center of Innovation to Accelerate Discovery and Practice Transformation in Durham, NC.
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Implications
As human immunodeficiency virus (HIV) has become a chronic condition—and Veterans with HIV are living longer—comorbidities are often of greater importance to their overall health than HIV status alone, and this is a major concern for healthcare providers. Further, VA is transforming to a patient-centered care (PCC) model—where care is personalized and based within a patient’s own life context. Complex patients, such as those with HIV, may experience particular benefit; however, most of VA’s PCC effort has been in primary care, with little attention paid to specialty care. This study will identify key ways to incorporate patient context into care planning and decision-making for Veterans with HIV, which, in turn should contribute to reduced comorbidities and improved quality of life for these individuals.
About the Study
In this study, investigators will conduct an ethnographic exploration to understand how Veterans with HIV engage in health behaviors within the context of their daily lives. Investigators will also examine how HIV providers attend to and incorporate patient contexts and comorbidities when providing care. General HIV clinic functioning will be observed and providers will be interviewed. Finally, investigators will examine communication between HIV providers and their aging patients to understand how they attend to context and comorbidities.
Principal Investigator
Gemmae Fix, PhD, is an investigator with the HSR&D Center for Healthcare Organization and Implementation Research in Boston, MA.
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Implications
As the largest provider of HIV care in the country, it is critical that VA understand and address barriers to multidisciplinary care for Veterans with HIV. Using VA Video Connect (VVC)—VA’s video telehealth platform—may help increase retention in HIV treatment programs by improving Veterans’ access to the major VA medical centers in which most HIV care is delivered. This work could also lead to accelerated uptake of VVC; improve overall health for Veterans with HIV; and may serve as an effective remote care delivery model for other complex, chronic conditions requiring multidisciplinary treatment.
About the Study
Improving Veterans’ retention in HIV care is associated with improved survival and overall health outcomes. However, treating a complex condition like HIV requires multidisciplinary care and monitoring at regular clinic visits with multiple providers. In VA, that care is located and delivered primarily in larger VA medical centers. However, access to those medical centers may be limited by barriers ranging from lack of reliable transportation to geographic location. VA’s VVC allows Veterans and providers to complete clinical visits from any location— including the home—and has the potential to transform delivery of multidisciplinary care for HIV and other chronic conditions by increasing access to care. In this study, investigators will determine if multidisciplinary care delivered by VVC can improve retention in care and clinical outcomes for vulnerable Veterans in need of specialty medical care require to treat HIV. During the recent COVID-19 pandemic, within six weeks of the emergency declaration of the pandemic, 100% of VA providers (n=27) participating in a an investigation had adopted VTH (video telehealth to home) to treat Veterans with HIV. Overall, the pandemic increased awareness of the growing need for change in how healthcare is delivered.
Investigators will evaluate the effectiveness of VVC-delivered, multidisciplinary HIV care—as compared to routine care—on retention. Further, investigators will conduct a mixed-methods evaluation to: refine an implementation facilitation strategy (IF) to improve the reach of VVC-delivered HIV care; increase provider and Veteran adoption; and determine the program’s potential for sustainability.
Investigators expect data to show VVC will improve engagement and clinical outcomes and be acceptable to HIV patients and their providers. Further, data generated from this project should help to identify effective IF strategies.
Principal Investigator: Thomas Giordano, MD, MPH, is a physician investigator with the HSR&D Center for Innovations in Quality, Effectiveness and Safety in Houston, TX.
[1] NIH HIV “Understanding HIV and AIDS: What’s the difference?” infographic. https://hivinfo.nih.gov/understanding-hiv/infographics/hiv-and-aids-whats-difference
[2] Department of Veterans Affairs HIV Care website. https://www.hiv.va.gov/about-index.asp
