Today a number of effective antiretroviral therapy (ART) options are available to treat HIV, yet failure to diagnose, link, or retain patients in care remains an obstacle to ending the HIV epidemic.1 The CDC HIV Prevention Progress Report highlights progress toward reaching national targets of reducing the number of new infections and addressing disparities in HIV care seen across population subgroups.2 According to the 2019 report, only 12 out of 38 states with complete lab reporting met the 2020 target for linkage to care, and no states with complete reporting met the 2020 targets for care retention or viral suppression.
INCREASE KNOWLEDGE OF HIV-POSITIVE STATUS
HIV testing is a critical step in connecting people to care and in preventing new transmissions.2 In 2016, approximately 1 in 7 people living with HIV in the US were unaware of their status. Increased testing efforts—including routine opt-out screening in clinical settings and targeted testing in non-clinical settings—are needed, along with the identification of structural barriers for getting tested and entering care.
Barriers to HIV testing include3:
High perceived cost
Experience of racism, homophobia, or other bias in the healthcare setting
The implementation of social distancing measures during COVID-19 has been an additional barrier to HIV testing, and decreases in testing have been seen in both clinical and non-clinical settings.3 On March 31, 2020, one Oregon-based study implemented a pilot home-based HIV testing program targeted to men who have sex with men (MSM) and observed rapid uptake of free, mail-order, self-testing kits. Study participants described the program as easy, convenient, discreet, and safe.
Approximately 40% of HIV transmissions are attributed to people who don't know their status2
INCREASE LINKAGE TO HIV CARE
In 2016, 75.9% of people living with HIV in the US were linked to medical care within 1 month of receiving an HIV diagnosis, an increase of 8% since 2010.2 Linkage remained lowest among African-Americans, Hispanics/Latinos, and young people aged 13-24 years. Continued efforts in the following areas may help improve progress in this area: supporting health departments and community-based organizations in affected communities to link newly diagnosed people to immediate care, increasing the number of primary care providers offering HIV screening, and using public health data to target persons who haven’t entered care or who have fallen out of care.
Linkage to care may be hindered by various factors such as1:
Insufficient socioeconomic resources
Active substance use
Mental health challenges
Disease severity (asymptomatic HIV)
Data to Care (D2C) is one strategy that uses HIV surveillance and other data to improve linkage to care.4 Successful implementation of D2C depends on the ability to integrate and share quality data and the availability of local staff personnel who can provide culturally competent outreach and medical services. Healthcare professionals (HCPs) can initiate D2C by identifying lost patients and working with health care departments to locate and relink them to medical care.
The Anti-Retroviral Treatment and Access to Services (ARTAS) intervention is another strategy cited in the Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV for improving linkage to care.1 ARTAS is a strength-based intervention based on case management that encourages patients to identify and use personal strengths and skills to link to care. Training modules for ARTAS can be accessed on the Centers for Disease Control and Prevention (CDC) website.
From 2010 to 2016, the percentage of people retained in HIV care in the US increased 5%, to a total of 57.2%.2 Fundamental approaches to help patients stay adherent to HIV care and treatment include: providing a supportive care environment; assisting patients with mental health, drug and alcohol issues, transportation, housing and/or other needs; helping patients build support networks; and working with health departments to reach patients who fall out of care.
Patient-provider relationships may also impact care retention.5 HCPs have an opportunity to connect with patients during medical visits to uncover treatment barriers, facilitate access to services and resources, and reinforce positive behaviors.6 Initiating brief conversations with patients at every visit, using a direct, nonjudgmental, and supportive tone, may help patients take positive steps and stay engaged in care over the long term.
The COVID-19 pandemic and resulting expansion of telemedicine to replace a good portion of in-person visits presents new challenges in care retention.7 While some patients may prefer the convenience of virtual visits and opportunity to avoid potential stigmatizing clinic experiences, other patients have reported feeling rushed, less involved, and less comfortable asking sensitive questions due to privacy concerns. Telemedicine may also worsen disparities in care for those with limited technology access or literacy.
Opportunities to address retention challenges during COVID-197:
Continually solicit patient feedback on telemedicine practices
Focus on increasing access for at-risk populations
Consider provider training on communication to enhance trust and connection
INCREASE VIRAL SUPPRESSION
People living with HIV who stay virally suppressed have effectively no risk of transmitting HIV.2 In 2016, the percentage of people living with HIV in the US who were virally suppressed was 59.8%, an increase of 30% since 2010. Providing adherence interventions and tools to help those who are experiencing treatment regimen challenges, along with realizing progress at earlier stages of the continuum—increased knowledge of HIV status, linkage to care, and retention in care—may help close the gap that remains in this endpoint target.
1. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. Department of Health and Human Services. https://clinicalinfo.hiv.gov/sites/default/files/inline-files/AdultandAdolescentGL.pdf. Accessed September 27, 2020.
2. Centers for Disease Control and Prevention. CDC HIV Prevention Progress Report, 2019. Accessed September 27, 2020.
3. Menza TW, Garai J, Ferrer J, et al. Rapid uptake of home-based HIV self-testing during social distancing for SARS-CoV2 infection in Oregon. AIDS and Behav. Published online June 2020. doi: 10.1007/s10461-020-02959-2.
4. Sweeney P, DiNenno EA, Flores SA, et al. HIV data to care—using public health data to improve HIV care and prevention. J Acquir Immune Defic Syndr. 2019;82(1)S1-S5.
5. Talking to your patients. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/clinicians/treatment/patient-provider.html. Accessed October 3, 2020.
6. Retention in care. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/clinicians/treatment/care-retention.html.html. Accessed October 3, 2020.
7. Mgbako O, Miller EH, Santoro AF, et al. COVID-19, telemedicine, and patient empowerment in HIV care and research. AIDS and Behav. 2020:1-4. doi:10.1007/s10461-020-02926-x [Epub ahead of print].
HVUWCNT200012 November 2020
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