HIV Care Coordination promotes care re-engagement and viral suppression among people who have been out of HIV medical care: an observational effectiveness study using a surveillance-based contemporaneous comparison group

Abstract

Background Medical care re-engagement is critical to suppressing viral load and preventing HIV transmission, morbidity and mortality, yet few rigorous intervention studies address this outcome. We assessed the effectiveness of a Ryan White Part A-funded HIV Care Coordination Program relative to ‘usual care,’ for short-term care re-engagement and viral suppression among people without recent HIV medical care. Methods The Care Coordination Program was launched in 2009 at 28 hospitals, health centers, and community-based organizations in New York City. Designed for people with HIV (PWH) experiencing or at risk for poor HIV outcomes, the Care Coordination Program provides long-term, comprehensive medical case management utilizing interdisciplinary teams, structured health education and patient navigation. The intervention was implemented as a safety-net services program, without a designated comparison group. To evaluate it retrospectively, we created an observational, matched cohort of clients and controls. Using the HIV surveillance registry, we identified individuals meeting program eligibility criteria from December 1, 2009 to March 31, 2013 and excluded those dying prior to 12 months of follow-up. We then matched clients to controls on baseline status (lacking evidence of viral suppression, consistently suppressed, inconsistently suppressed, or newly diagnosed in the past 12 months), start of follow-up and propensity score. For this analysis, we limited to those out of care at baseline (defined as having no viral load test in the 12 months pre-enrollment) and still residing within jurisdiction (defined as having a viral load or CD4 test reported to local surveillance and dated within the 12-month follow-up period). Using a GEE model with binary error distribution and logit link, we compared odds of care re-engagement (defined as having ≥ 2 laboratory events ≥ 90 days apart) and viral suppression (defined as having HIV RNA ≤ 200 copies/mL on the most recent viral load test) at 12-month follow-up. Results Among 326 individuals out of care at baseline, 87.2% of clients and 48.2% of controls achieved care re-engagement (Odds Ratio: 4.53; 95%CI 2.66, 7.71); 58.3% of clients and 49.3% of controls achieved viral suppression (Odds Ratio: 2.05; 95%CI 1.30, 3.23). Conclusions HIV Care Coordination shows evidence of effectiveness for care and treatment re-engagement.

HTPN 078: an enhanced case management study to achieve viral suppression among viremic HIV-positive men who have sex with men in the United States

“…Although there is some observational evidence that improved care coordination and patient navigation can have a positive impact on HIV care engagement and viral suppression [12] and also evidence for case management reducing sexual risk behaviors and syphilis among MSM with HIV [13], there is a paucity of evidence for enhanced case management having a direct effect on HIV viral suppression in rigorous controlled trials. One study showed that patient navigation, with or without financial incentives, did not have a beneficial effect on HIV viral suppression among hospitalized patients with HIV and substance use [14], with the literature suggesting that multiple factors are associated with lower odds of sustained HIV viral suppression, including demographic factors, drug and alcohol use, mental health symptoms, homelessness, transportation to appointment needs, as well as provider characteristics [15].…”

Evaluation of the Revised Versus Original Ryan White Part A HIV Care Coordination Program in a Cluster-Randomized, Stepped-Wedge Trial

“…43 The investigators suggest their null results may be tied to unrecognized commonalities between the adapted intervention and "usual care" in Baltimore. 43 It is not clear whether our trial's findings reflect a null difference in effectiveness between the revised and original CCP (which has already shown superiority to usual care 20,21,44 ) or reflect incomplete implementation of revised-CCP components during the trial. Analyses to date have not detected significant implementation variability in relation to the outcome, but our implementation measure may be insufficiently sensitive to such variability.…”