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IBB 09-033 – HSR&D Study

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IBB 09-033
Developing an Intervention to Retain HIV-infected Veterans in HIV Care
Thomas P. Giordano MD MPH
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: July 2010 - December 2014

BACKGROUND/RATIONALE:
The VA is the largest single provider of HIV care in the US. To maximally benefit from HIV treatment, Veterans must navigate a continuum of HIV care. They must be diagnosed at an early stage of disease, access or link to HIV medical care, be retained in HIV care, and adhere to medications, especially antiretroviral therapy. We have shown that poor retention in HIV medical care is one of the primary reasons Veterans die of HIV/AIDS today. There are no interventions proven to better retain Veterans in HIV primary care.

OBJECTIVE(S):
Aim 1: To define where along the continuum of care Veterans with HIV infection experience the most challenges with retention in HIV care; and to identify where those Veterans having difficulty with retention in care eventually interface with the VA healthcare system. Aim 2: To identify the predictors of delayed linkage to care and poor retention in HIV care at care entry and over time, to identify the facilitators and barriers to successfully navigating the continuum of HIV care, and to identify methods to improve navigation of the continuum of care. Aim 3: To develop and preliminarily test an intervention to improve retention in HIV care in the VA. We expect that a reproducible, feasible intervention can be developed and tested.

METHODS:
We conducted retrospective cohort studies with the Clinical Case Registry HIV (a database of all Veterans with HIV infection who have used the VA since 1992) to complete Aim 1 and part of Aim 2. We used qualitative research methods with Veterans from the Michael E. DeBakey VAMC and the Birmingham VAMC to complete the remainder of Aim 2 and Aim 3. The qualitative work recruited Veterans in outpatient care, most of whom had some episode of poor retention in care in the past. We also recruited Veterans hospitalized with HIV infection in Houston who were presently out of HIV primary care. These mixed quantitative and qualitative methods resulted in a complete picture of the factors predictive of retention in HIV care so that interventions can be appropriately targeted. They also resulted in a comprehensive understanding of the facilitators and barriers to care, and the strategies to remedy these problems as recommended by Veterans themselves. These data were coalesced and presented to an Advisory Panel, and feasibility and acceptability testing of a pilot intervention was used to assess an intervention to improve retention in HIV primary care. This intervention will be fully tested and disseminated in subsequent work.

FINDINGS/RESULTS:
Regarding linkage to HIV care, 20,363 Veterans were identified; and overall, between 85% and 76% linked to HIV care (depending on the definitions used). No demographic, clinical, or facility characteristics predicted linkage to care at a level sufficient to justify targeting interventions to one or another sub-group of Veterans. Regarding retention in care, in any year, between 35% and 45% of veterans were not optimally retained in care (defined as having a visit in all 3 of the 4-month blocks during a year). There were no clinically relevant predictors of retention in care, except prior retention in care was a very strong predictor of subsequent retention, with adjusted odds ratios ranging from 20 to 40. The first 2 years of HIV care were shown to be the highest risk for falling out of care. In sum, these studies determined that linkage to care efforts must target essentially all veterans with HIV infection, and retention in care efforts need to focus on persons in the first 2 years of care, and Veterans with a history of poor retention. The qualitative data regarding Veterans' recommendations to improve retention in HIV care were analyzed, and relevant priorities from the Veterans included: developing an HIV friendly environment at the VA to reduce HIV stigma, increasing awareness about HIV care, making available resources to inform Veterans about HIV care at the VA, and providing mental health and substance use treatment support services concurrent with HIV clinical care. Veterans also identified delivery methods that they felt would be effective at helping HIV-infected Veterans. Those methods included video (whether online or delivered in clinic), brochures, pamphlets, and HIV-related posters in clinic, and mass media outlets. Patients felt that these methods would increase the knowledge of all VA patients about HIV care at the VA and decrease stigma associated with HIV, resulting in increased retention and adherence to HIV care overall. They also strongly endorsed peer supporters, i.e., having the opportunity to speak with another Veteran who has overcome struggles with retention in care, usually focused around mental health, substance use, stigma, and HIV fatalism. The Advisory Panel to design the pilot intervention was convened in the summer of 2013. They recommended leveraging the VA Peer Support Program as the foundation for a multi-faceted intervention by deploying a peer supporter in the Houston VA HIV clinic. That process was delayed by hiring and training problems, but the PSP is in place and evaluation is currently in progress.

IMPACT:
The research has identified many reasons why Veterans with HIV infection have difficulty remaining in HIV care. It will result in an intervention to improve retention in care. Ultimately, it may lead to improved adherence to care and outcomes for HIV infected Veterans. We have determined that linkage to care efforts must target essentially all Veterans with HIV infection, and retention in care efforts need to focus on persons in the first 2 years of care, and those with histories of poor retention.

PUBLICATIONS:

Journal Articles

  1. Minick SG, Stafford CL, Kertz BL, Cully JA, Stanley MA, Davila JA, Dang BN, Rodriguez-Barradas MC, Giordano TP. Correction: Veterans' Perspectives on Interventions to Improve Retention in HIV Care. PLoS ONE. 2016 Mar 3; 11(3):e0151011.
  2. Minick SG, Stafford CL, Kertz BL, Cully JA, Stanley MA, Davila JA, Dang BN, Rodriguez-Barradas MC, Giordano TP. Veterans' Perspectives on Interventions to Improve Retention in HIV Care. PLoS ONE. 2016 Feb 1; 11(2):e0148163.
Conference Presentations

  1. Stafford S, Minick S, Kertz B, Cully J, Stanley MA, Davila J, Rodriguez-Barradas M, Giordano TP. Veteran perspectives on interventions to improve retention in HIV care. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  2. Giordano TP, Davila J, Hartman C, Richardson PA, Rodriguez-Barradas M. Linkage to Care Impacts Survival with HIV Infection, but the Entire Spectrum of Care Determines Survival: A National Study of US Veterans. Poster session presented at: International Conference on HIV Treatment and Prevention Adherence; 2013 Jun 2; Miami, FL.
  3. Giordano TP, Rodriguez-Barradas M, Hartman C, Richardson PA, Davila J. Retention in HIV Care Predicts Subsequent Retention and Predicts Survival Well after the First Year of Care: A National Study of US Veterans. Poster session presented at: International Conference on HIV Treatment and Prevention Adherence; 2013 Jun 2; Miami, FL.
  4. Giordano TP, Hartman C, Davila J, Richardson P, Stafford C, Rodriguez-Barradas M. Linkage to care for Veterans with HIV infection. Poster session presented at: VA HSR&D National Meeting; 2012 Jul 16; Washington, DC.
  5. Giordano TP, Hartman C, Davila J, Richardson P, Stafford C, Rodriguez-Barradas M. Linkage to HIV care in the VA healthcare system. Poster session presented at: Retroviruses and Opportunistic Infections Annual Conference; 2012 Mar 5; Seattle, WA.


DRA: Infectious Diseases
DRE: Treatment - Observational
Keywords: Adherence, Complex care, Disparities, Ethnicity/Race, HIV/AIDS, HIV/AIDS, Hepatitis C
MeSH Terms: none

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