MHSc Associate Professor of Medicine University of Alabama at Birmingham May 20 2015 Engagement in HIV Care From Cascade to Continuum to Control To describe conceptual frameworks for the continuum of HIV care treatment cascade ID: 673861
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Slide1
Michael J. Mugavero, MD, MHScAssociate Professor of MedicineUniversity of Alabama at BirminghamMay 20, 2015
Engagement in HIV Care: From Cascade to Continuum to ControlSlide2
To describe conceptual frameworks for the continuum of HIV care (“treatment cascade”)To describe the individual & population health implications of HIV care engagementTo describe approaches to measuring engagement and ART adherenceTo describe evidence based approaches proven to improve engagement in care & ART adherenceObjectivesSlide3
HPTN 052 Press release, May 12, 2011
96% reduction in new HIV infections
HPTN 052Slide4
HIV Treatment as
PreventionSlide5
MMWR; 63(47);1113-1117,
Available
at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a5.htm
US HIV Care Continuum, 2011
50%Slide6
08/2009
09/2009
11/2009
02/2010
HIV VL
c/
mL
115,000
384
<48
<48
CD4 count
78
251
376
455
21 y/o AAM diagnosed with HIV 06/2009
Established care and started ART 08/2009
Excellent initial response to treatment
Case presentationSlide7
02/2010
11/2010
11/2012
04/2013
HIV VL
c/
mL
<48
22,700
80,300
200,000
CD4 count
455
248
108
64
Sporadic visits and then lost to care
Re-engaged after lengthy gap…
Cough, weight loss, night sweats, KS lesions
Case presentationSlide8
X - RaySlide9
HRSA Continuum of Care
Unaware of HIV status
Aware of HIV status
May be receiving other medical care but
not
HIV care
Entered HIV medical care but dropped out
In and out of HIV care or infrequent user
Fully engaged in HIV medical care
Cheever.
Clin
Infect Dis
2007;44:1500-1502
Not in Care
Fully engagedSlide10
http://www.whitehouse.gov/the-press-office/2013/07/15/executive-order-hiv-care-continuum-initiative
National HIV/AIDS StrategySlide11
National HIV/AIDS Strategy
Increase linkage to care w/in 3 months of
Dx
from 65% to 85%
Increase HIV
serostatus
awareness from 79% to 90%
Increase RW clients in continuous care from 73% to 80%
Increase proportion of HIV
Dx’d
persons with undetectable VL by 20%
Ulett
et al.
AIDS Pt Care STDS
2009;23:41-49,
Mugavero
et al.
Clin
Infect Dis
2011;52(S2). Slide12
Adapted from:
Mugavero
et al.
Clin
Infect Dis
2011;52(S2)
Engagement LevelsSlide13
Individual LevelDelayed ART receipt & ART non-adherenceInferior CD4 count & viral load outcomesEmergence of HIV resistance mutationsIncreased risk for clinical events & mortalityCommunity Level Contributor to health care disparitiesRole in HIV transmission Change in risk transmission behaviorsImpact of ART in reducing transmission
Implications of poor engagement
Keruly
et al.
AJPH
2002;92, Robbins et. al.
JAIDS
2007;44, Park et al.
J Intern Med
2007;261, Giordano et al.
Clin Infect Dis 2007;44, Mugavero et al. JAIDS 2009;50, Marks et al. AIDS 2006;20,
Metsch et al. Clin Infect Dis 2008;47, Cohen et al. N Engl J Med 2011;365Slide14
Hall HI et al.
JAMA Intern Med
. 2013;173(14):1337-1344
CDC: Disparities on HIV Care
ContinuumSlide15
MMWR; 63(47);1113-1117, Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a5.htm
CDC: HIV Care Continuum,
2011Slide16
Undiagnosed HIV infection: Hidden threatTransmission rates 3-7x higher in undiagnosed20% undiagnosed 49% of new infectionsHIV testing influence on linkage to careRapport, information quality & counseling providedActive vs. passive referral for servicesDelayed linkage w/ testing in community settings
HIV Testing & Linkage to Care
Hall HI et al.
AIDS
2012;6:26 Garland et al.
AIDS Education and Prevention
2011;23:117,
Hightow
-Weidman et al.
AIDS Pt Care and STDs
2011;S1:S31, Torian et al. Arch Intern Med 2008;168:1181Slide17
Temporal trends in late diagnosis
Lesko
et al.
Clin
Infect Dis
2013;57Slide18
MMWR; 63(47);1113-1117, Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a5.htm
CDC: HIV Care Continuum, 2011Slide19
MMWR; 63(47);1113-1117, Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a5.htm
US HIV Care Continuum,
2011Slide20
Diagnosed but not in HIV care… Engagement: 3 distinct componentsSlide21
http://www.effectiveinterventions.org/en/highimpactprevention/publichealthstrategies/DatatoCare.aspx
Surveillance DataSlide22
Hall HI, et al. (2013);
PLoS
ONE 8(12): e84318.
doi:10.1371/journal.pone.0084318
http
://www.plosone.org/article/info:doi/10.1371/journal.pone.0084318
Figure. Kaplan-Meier survival curve for time from HIV diagnosis to viral suppression, by entry to care within 3 months of HIV diagnosis.Slide23
Mugavero
, Davila,
Nevin
& Giordano.
AIDS Pt Care STDs
2010;24
Missed Visits
Appt. Adherence
Visit Constancy
Gap in Care
HRSA HAB Measure
Patient A
Yes; 1
80%
100%
No
Yes
Patient B
Yes; 4
33%
50%
Yes
Yes
Patient C
No; 0
100%
75%
No
Yes
Patient D
Yes; 1
67%
25%
Yes
No
Patient
Case StudiesSlide24
Measure
Missed visit data?
Ease of calculating
Follow-up time
Missed visit
Yes
Easy
~1 day
Appointment adherence
Yes
Moderate
~1 yr
No-show rate
Yes
Moderate
~1
yr
Constancy:
Visit per 3, 4 or 6 mo intervals
No
Moderate
~1 yr
Gaps
No
Easy
~1
yr
HRSA/HAB
No
Moderate-to-difficult
1
yr
DHHS
No
Moderate-to-difficult
2
yrs
Adapted from: Giordano TP (2012) Measuring retention in HIV care. www.medscape.com.
Retention in Care TableSlide25
Study of UAB 1917 Clinic patients initiating outpatient HIV care, 2000 – 2005 (N=543)Early missed visits and mortality
Mugavero
et al.
Clin
Infect Dis
2009;48
Characteristic
HR (95%CI)
a
“No show” visit in 1
st year2.90 (1.28- 6.56) Age (HR per 10 years)
1.58 (1.12-2.22)
CD4 count <200 cells/mL
2.70 (1.00-7.30)
Log
10
plasma HIV RNA
1.02 (0.75-1.39)
ART started in 1
st
year
0.64 (0.25-1.62)
a
Cox proportional hazards (PH) analysis also adjusts for sex, race/ethnicity, insurance, affective mental health disorder, alcohol abuse, and substance abuse.Slide26
Missed “No Show” Visits
Retained
(Zero “no show” )
Not
Retained
(
>
1 “no show”)
HRSA HAB Quality Indicator
Retained
1725 (41%)
1753 (42%)
Not
Retained
251 (6%)
433 (10%)
Mortality by cross-tab of HRSA HAB & Missed Visit Measures, CNICS n~4000 Slide27
Missed “No Show” Visits
Retained
(Zero “no show” )
Not
Retained
(
>
1 “no show”)
HRSA HAB Quality Indicator
Retained
1725 (41%)
Referent
1753 (42%)
Not
Retained
251 (6%)
HR=1.01;0.54-1.87
433 (10%)
Mortality by cross-tab of HRSA HAB & Missed Visit Measures, CNICS n~4000 Slide28
Missed “No Show” Visits
Retained
(Zero “no show” )
Not
Retained
(
>
1 “no show”)
HRSA HAB Quality Indicator
Retained
1725 (41%)
Referent
1753 (42%)
HR=1.72;1.33-2.21
Not
Retained
251 (6%)
HR=1.01;0.54-1.87
433 (10%)
HR=1.48;1.33-1.65
Mortality by cross-tab of HRSA HAB & Missed Visit Measures, CNICS n~4000 Slide29
Zinski
A et al,
AJPH
(in press)
CDC/HRSA RIC: Missed Visits by RaceSlide30
Missed Visits: Disparities Target?
Zinski
A et al,
AJPH
(in press)Slide31
Guidelines: Engagement in CareRecommendation
Strength/Quality
Monitor entry into HIV care
IIA
Monitor retention in HIV care
IIA
Brief, strength-based CM for linkage (ARTAS model)
IIB
Intensive outreach for retention
IIIC
Peer of paraprofessional patient navigation for retention
IIIC
Thompson MA et al.
Ann Intern Med
2012;156Slide32
http://www.cdc.gov/hiv/prevention/research/compendium/lrc/index.html
CDCEvidence
-Based InterventionsSlide33
http://aidsetc.org/engagement-toolkit
AETC Engagement
ToolkitSlide34
MMWR; 63(47);1113-1117, Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a5.htm
CDC: HIV Care Continuum,
2011Slide35
Thompson MA et al.
Ann Intern Med
2012;156
Recommendation
Strength/Quality
Self-reported adherence
IIA
Pharmacy refill data (MPR)
IIB
NOT
drug concentrations
IIIC
NOT
pill counts
IIIC
NOT
electronic devices (MEMs)
IC
Plasma HIV RNA is the biological correlate of the adherence behavior,
NOT
a screening tool
Guidelines for Monitoring AdherenceSlide36
Although it commonly overestimates ART adherence, self-reported
NON
-adherence has high predictive value
Self-reported ART
NON
-adherenceSlide37
Recommendation
Strength/Quality
Reminder devices & interactive communication technologies
IB
Education & counselling using adherence-related tools
IA
Various individual, group & peer education & counselling
IIA-IIIC
CM services (
eg
, food / housing)
IIIB
Integration of med management into pharmacy systems
IIIC
Thompson MA et al.
Ann Intern Med
2012;156
ART Adherence
StrategiesSlide38
Michael J. Mugavero,1 K. Rivet Amico,2 Andrew O. Westfall,1
Heidi M. Crane,3 Anne Zinski,
1 James H. Willig,1 Julie Dombrowski,3 Wynne E. Norton,
4
James L.
Raper
,
1
Mari M. Kitahata,3 Michael S. Saag1
1Department of Medicine, University of Alabama at Birmingham (UAB),
2University of Connecticut, 3Department of Medicine, University of Washington, 4Department of Health Behavior, UABImpact of Early Retention in Care onViral Load Suppression among Patients Newly Initiating Outpatient HIV Care
Supported by grants 1R21AI087360-01, 3K23MH082641-02S1 and 1R24AI067039-04Slide39
Area under the curve estimate of cumulative viral load burden over timeExample: 10,000 copy-years1,000 c/mL per day for 10 years10,000 c/mL per day for 1 yearVCY approximated as time-weighted sum using trapezoidal rule: Viremia Copy-Years (VCY)
Cole et al.
Am J Epidemiology
2010;171Slide40
Viral Load GraphsSlide41
Relationship between 2 year visit adherence and cumulative VL burden measured by
viremia
copy-years (VCY) among 258 patients initiating HIV care; UAB 1917 Clinic & UW Madison Clinics
Visit adherence 0-79% (n=83): mean VCY=143,038; 80-99% visit
adherence
(n=95): mean VCY=56,894; 100% visit adherence (n=80): mean VCY=35,754 copy x years/mL, respectively.
Relationship Between 2 Year Visit Adherence and Cumulative VL BurdenSlide42
“VCY predicted mortality independent of most recent CD4 count, suggesting cumulative HIV replication causes harm independent of its effect on the degree of immunodeficiency.”VCY & Mortality after ART Initiation
Characteristic
HR (95%CI)
a
Viremia
copy-years
1.44 (1.07-1.94)
24-week viral load
1.07 (0.87-1.32)
Most recent viral load
1.15 (0.94-1.41)
Age (per 10 years)
1.51 (1.18-1.94)
Most recent CD4 count
0.72 (0.61-0.86)
Mugavero
et al.
Clin
Infect Dis
2011;53Slide43
04/2013
07/2013
12/2013
03/2014
HIV VL
c/
mL
200,000
79
525
<20
CD4 count
64
253
226
365
Resumed ART & chemo with good response
VL rebound & no show visit
personal call
Improved retention, sustained VL suppression, triathlon summer 2014!
Back to our case…Slide44
State of Alabama HIV Surveillance 2012 Annual Report;
http://www.adph.org/aids/assets/Finalized_2012HIVSurveillance.pdf
COMMUNITY
CLINIC
Continuum
of Care Jefferson County HIV/AIDS Community CoalitionSlide45
FAMILY CLINIC
Jefferson County
HIV/AIDS Community CoalitionSlide46
Jefferson County HIV/AIDS Community Coalition StaffSlide47
Q&ASlide48
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Conclusion
Slide