Spotlight: Improving Health and Care for Veterans with HIV/AIDS
December 1, 2014 is World AIDS Day. Human Immunodeficiency Virus (HIV) infection causes a chronic, progressive disease that leads to Acquired Immune Deficiency Syndrome (AIDS) and early death if untreated. HIV/AIDS remains one of the world's most significant public health challenges. At the end of 2013, 11.7 million people were receiving antiretroviral therapy (ART) in low- and middle-income countries, representing 36% of the 32.6 million people living with HIV in these countries.1 In the United States, more than 1.1 million people are living with HIV infection, and almost 1 in 6 (16%) are unaware of their infection.2 VA is the single largest provider of HIV care in the U.S.; in 2013, nearly 27,000 Veterans with HIV were receiving HIV care in the VA healthcare system.3
VA/HSR&D's HIV/Hepatitis Quality Enhancement Research Initiative (QUERI) works to improve the identification and care of Veterans with HIV or the Hepatitis C Virus, and has several ongoing projects that work to expand HIV testing among Veterans by promoting routine screening in novel settings such as primary care clinics, substance use disorder clinics, and VA emergency departments.
HSR&D and QUERI Research on HIV/AIDS
Following are descriptions of just a few select studies that HSR&D and QUERI investigators conduct on research to improve the quality of health and care for Veterans with HIV/AIDS.
Multimodal Intervention Increases HIV Testing in VA Primary Care
HIV/Hepatitis-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 between 6/09 and 9/11. 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.
Linking Veterans Newly Diagnosed with HIV to VA Care
In the VA healthcare system, risk-based, routine and HIV rapid-testing research projects and programs, as well as changes in policy (e.g., verbal consent replaced written consent, standard of care became routine testing, standing orders for nurse-based testing), have led to a substantial increase in the rates of HIV testing. However, although positive HIV tests have increased at all VA facilities, it is not known to what degree expanded testing has identified patients with previously unknown HIV infection, or whether newly diagnosed patients are being promptly linked to appropriate medical care. This QUERI study has three main goals:
- Refine and validate an algorithmic decision tool to identify Veterans newly diagnosed with HIV;
- Assess geographical, facility-level and patient-level differences in both risk-based and routine HIV testing; and
- Identify any geographical, facility-level and patient-level predictors of HIV care.
Using the algorithm, investigators evaluated the rates of identifying newly diagnosed HIV-infected patients seen from August 2006 to July 2012 in 15 VA facilities during the periods of risk-based and routine HIV testing. The algorithm identified 1,153 Veterans with newly diagnosed HIV with a sensitivity of 83%, specificity of 86%, positive predictive value of 85%, and negative predictive value of 90%. There were no meaningful demographic or clinical differences between newly diagnosed Veterans who were correctly or incorrectly classified by the algorithm. Preliminary analyses regarding the timing of linkage to care indicates that 82% of Veterans with a new diagnosis of HIV were seen by an HIV specialist within three months of the diagnosis.
This validated method to identify cases of new diagnosis of HIV infection will help inform the development of programs to increase the efficiency of efforts to promote HIV testing â€“ and to analyze rates at which newly diagnosed patients are linked to HIV care.
Goetz M, Hoang T, Kan V, et al. Development and validation of an algorithm to identify patients newly diagnosed with HIV infection from electronic health records. AIDS Research and Human Retroviruses. July 2014;30(7):626-33.
Improving Access and Outcomes for Rural Veterans with HIV
Approximately 16% of the 26,000 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. This ongoing QUERI study, part of an HSR&D Career Development Award, seeks to develop, evaluate, and implement an innovative delivery model to improve the accessibility, quality, and outcomes of care for Veterans with HIV living in rural settings.
Thus far, study results show 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. Pilot data 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.
In collaboration with the Office of Rural Health's Promising Practices Initiative, future work will evaluate the potential for the TCC model to scale up and spread to other VA facilities caring for Veterans with HIV in rural and outlying urban areas. Thus, this project is advancing the development and implementation of healthcare delivery models that serve Veterans with HIV infection in rural and outlying urban communities. This directly addresses the VA operational mandate and HSR&D research priority to improve access to care for rural Veterans.
Ohl M, Moekli J, Ono S, et al. Mixed methods evaluation of a telehealth collaborative care program for persons with HIV infection in a rural setting. Journal of General Internal Medicine. September 2013;28(9):1165-1173.
Ohl M, Richardson K, Kaboli P, et al. Geographic access and use of infectious diseases specialty and general primary care services by Veterans with HIV infection: Implications for telehealth and shared care programs. The Journal of Rural Health. September 2014;30(4):412-421.
Integrating HIV Specialty Care within VA's Patient Aligned Care Teams
VA's Office of Specialty Care Services has prioritized the integration of specialty care and PACT (Patient Aligned Care Team), but how to do this remains unclear. While historically Veterans with HIV have received the bulk of their care from HIV specialists in VA medical centers, the setting of optimal HIV care is shifting. As the needs of Veterans with HIV shifts more towards chronic illness and comorbidity management, traditional models of care in specialty clinics may require new initiatives. Understanding how care for Veterans with HIV varies across the VA is critical to the development and spread of such initiatives to integrate specialty HIV care with primary care in order to provide the best PACT-principled care to all of these Veterans.
The primary objective of this new, ongoing study is to better characterize the current structures, processes and patterns of care being provided for Veterans with HIV â€“ and to understand how these relate to the quality of care provided to these Veterans. The findings will inform how to tailor ongoing initiatives to the needs of different care sites in order to provide the best care in line with PACT principles. Investigators will first use administrative data to ascertain the quality of HIV and comorbidity care being provided at medical centers throughout the nation. They also will survey HIV clinicians across all VA facilities regarding staffing, structure of care, and adherence to PACT principles in their setting of care. Investigators will then conduct site visits at 12 VA facilities, so they can generate a typology of sites of HIV care within VA, including processes of care coordination and how teams implement PACT principles for Veterans with HIV.
This project is supported by both VA's Office of Clinical Public Health and the Office of Specialty Care Services. The findings will inform future organization of HIV care, as well as how high-quality, PACT-principled care can be provided to Veterans receiving specialty care throughout the VA healthcare system.
No publications at this time.
Managing HIV as a Chronic Disease
Veterans with HIV who receive care in the VA healthcare system are older and have more comorbidities than do other populations of patients with HIV. Cardiovascular disease, chronic kidney disease, and co-infection with hepatitis C virus (HCV) all complicate treatment for HIV, and make management decisions regarding antiretroviral therapy (ART) especially complex. This ongoing QUERI study will evaluate:
- Comparative effectiveness and cost-effectiveness of treatment for Veterans with HIV and risk factors for chronic kidney disease or established chronic kidney disease;
- Health outcomes, costs, comparative effectiveness and cost-effectiveness of HIV antiretroviral regimens in Veterans with HIV and HCV; and
- Practice patterns, utilization, and cost-effectiveness of new antiretrovirals.
Study investigators will assess whether specific antiretroviral regimens and classes of antiretroviral drugs are associated with worse outcomes in Veterans with HIV and cardiovascular disease, kidney disease or HCV co-infection. They also will evaluate the comparative effectiveness and cost-effectiveness of alternative antiretroviral regimens using models of HIV disease that account for major comorbid conditions. Using VA data, investigators identified 42,357 Veterans who were prescribed ART medication, of which 33,171 VA patients initiated ART on or after January 1996. Treatment is being assessed for dually-infected patients.
By examining how comorbidities and choice of antiretroviral regimens affect outcomes in Veterans who have HIV, this study will help VA clinicians tailor treatment of HIV to achieve the best health outcomes and provide cost-effective care.
Bayoumi A, Barnett P, Joyce V, et al. Cost-effectiveness of newer antiretroviral drugs in treatment-experienced patients with multidrug-resistant HIV disease. Journal of Acquired Immune Deficiency Syndromes. December 2013;64(4):382-391.
For general information about HIV/Hepatitis-QUERI:
Please contact Vera Yakovchenko, M.P.H., HIV/Hepatitis-QUERI Administrative Coordinator, at Vera.Yakovchenko@va.gov.
1. 10 Facts on HIV/AIDS. World Health Organization. November 3, 2014.
2. HIV/AIDS Basics. U.S. Statistics. AIDS.gov. November 3, 2014.
3. HIV/Hepatitis-QUERI Fact Sheet. July 2014.