FEATURE

Adherence to the Continuum of Care

PATIENT CARE

Adherence to the Continuum of Care

In 2017, the US Department of Health and Human Services Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV revised and renamed the Adherence to Antiretroviral Therapy section to expand the discussion of adherence beyond treatment.1 The new section—Adherence to the Continuum of Care—considers a range of steps including HIV testing, linkage to care, initiation of antiretroviral therapy (ART), adherence to treatment, retention in care, and virologic suppression, and encourages collaboration among healthcare professionals and multidisciplinary care teams to better understand challenges at each step to help keep patients engaged in care.

The HIV care continuum—which includes various care touch points between HIV diagnoses and successful treatment—illustrates gaps in testing, linkage to care, retention in care, and virologic suppression.3, 4 CDC uses two methods to measure US progress: the prevalence-based HIV care continuum, which shows each step as a percentage of the total number of people living with HIV, and the diagnosis-based continuum, which shows each step as a percentage of the number of people diagnosed with HIV. The first is better for looking at broad populations, while the second is more useful in analyzing subgroups or local data.

Viral suppression is the end goal on the continuum for individual and public health.1, 5 While progress is being made—overall suppression rates rose from 28% to 49% between 2010 and 2014—outcomes still vary by age group, sex, race, geographic region, and HIV risk factors. Young adults and adolescents aged 13-24 years, for example, are less likely to be diagnosed, linked to care, or retained in care, and consequently have the lowest rate of viral suppression.

Continued efforts are needed from healthcare providers and other professionals throughout the healthcare system to ensure all patient types are linked quickly to HIV care and sustained in care to improve viral suppression rates across the board.1, 5

Next: Linkage to Care >

References: 1. Guidelines for the use of antiretroviral agents in adults and adolescents living with HIV. AIDSinfo website. https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/0. Published May 30, 2018. Accessed June 20, 2018.
2. Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2015. HIV Surveillance Supplemental Report 2017;22(No. 2). http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published July 2017. Accessed May 18, 2018.
3. HIV continuum of care, U.S., 2014, overall and by age, race/ethnicity, transmission route and sex. NCHHSTP Newsroom. Centers for Disease Control and Prevention website. https://www.cdc.gov/nchhstp/newsroom/2017/HIV-Continuum-of-Care.html. Published July 27, 2017. Accessed March 23, 2018.
4. Understanding the HIV care continuum. Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/pdf/library/factsheets/cdc-hiv-care-continuum.pdf. Published July 2017. Access April 4, 2018.
5. More people with HIV have the virus under control. NCHHSTP Newsroom. Centers for Disease Control and Prevention website. https://www.cdc.gov/nchhstp/newsroom/2017/2017-HIV-Continuum-Press-Release.html. Published July 27, 2017. Accessed March 23, 2018.

PATIENT CARE

Retention and Re-engagement

Once patients are linked to care, the focus shifts to keeping them in care, as poor retention is associated with poor HIV outcomes.1 Healthcare providers along with nurses and clinic staff play a role in optimizing the patient experience during each clinic visit and helping patients problem-solve for ways to remain in care.

Common barriers at this stage of the continuum include1:

Substance use Mental health problems Stigma/fear of disclosure Incarceration Socioeconomic needs (housing, transportation, food) Financial insecurity or lack of insurance Scheduling convenience, availability and timeliness of appointments Low trust or low satisfaction with providers or clinics

Strategies to improve retention1:

Providing a positive patient experience Expanded clinic hours Flexible appointment scheduling Appointment reminders Clinic-wide promotion of keeping scheduled appointments Rescheduling of missed appointments Nonjudgmental, problem-solving approach to improve attendance Case management and outreach services Financial and insurance assistance Opioid replacement therapy for opioid users

Efforts can also be made to re-engage out-of-care patients by implementing a "Data to Care" approach, which uses clinic and public health data to identify at-risk patients.1 One such effort published on the Centers for Disease Control and Prevention website is the evidence-based intervention Clinic-Based Surveillance-Informed Patient Retracing.2 In this study of 1,399 clinic participants who met criteria for re-engagement, not only were the intervention cohort patients relinked more quickly to HIV care with the assistance of a linkage specialist, significantly greater percentages were relinked and retained in continuous HIV care for 12 months.

Next: Adherence to ART >

References: 1. Guidelines for the use of antiretroviral agents in adults and adolescents living with HIV. AIDSinfo website. https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/0. Published May 30, 2018. Accessed June 20, 2018.
2. Clinic-based surveillance-informed patient retracing. The Centers for Disease Control and Prevention website. https://www.cdc.gov/hiv/pdf/research/interventionresearch/compendium/lrc/cdc-hiv-Clinic-Based_Surveillance-Informed_Patient_Retracing_LRC_EI_Retention.pdf. Published April 27, 2016. Accessed March 23, 2018.