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HIV-positive patients lost to follow-up successfully identified and re-engaged with care by programme in LA County
Michael Carter, 2016-01-11 07:20:00
A programme in Los
Angeles County successfully re-engaged and retained patients who dropped out of
HIV care, investigators report in the online edition of the Journal of Acquired Immune Deficiency
Syndromes. Called the Navigation Program, it was a collaboration between
health department staff and community organisations.
Public health databases
were used to identify patients who were lost to follow-up. Best practices from
programmes to trace hard-to-reach patients and a modified version of the CDC
Antiretroviral Treatment Access Study (ARTAS) were employed to re-engage
patients with care. Over 1000 patients lost to follow-up were identified, of which 36% were receiving care elsewhere and 29% could not be located. Of
the remainder, 78 people (8%) were successfully enrolled in the programme, most of whom re-engaged
with care and remained in care.
Estimates of the
proportion of HIV-positive patients in the US enrolled in long-term care range
between 37% and 55%. Failure to engage with care is associated with poorer
health outcomes and a higher risk of onward HIV transmission. A recent study
attributed almost two-thirds of new HIV infections in the US to persons not
engaged in care.
support engagement with and retention in care are therefore urgently needed.
The Patient Navigator model was developed for the care of cancer patients, but
is potentially a tool to support patients with HIV. Investigators therefore
designed a study to evaluate its utility and efficacy when applied to
HIV-infected individuals lost to HIV care in Los Angeles County.
involved seven HIV clinics, academic institutions and community support
organisations. Six patient “Navigators” were hired. All had a college degree,
experience of HIV case management, and most were bilingual in English and
worked closely with clinic staff to identify patients lost to follow-up.
intervention designed by the CDC (ARTAS) to engage patients newly diagnosed
with HIV care formed the basis for the study programme.
identified as lost to follow-up if they had no care visit for between six and
twelve months and a viral load greater than 200 copies/ml; or no care visit for
more than twelve months; or newly diagnosed and were never linked with care;
or had recently been released from jail or an institution and had no regular HIV care
had four components. These focused on building a relationship, needs assessment,
linking to resources and enhancing strengths, and addressing reasons for disengagement.
place between 2012 and 2014. During this period 1139 individuals who did not
establish contact with care or who dropped out of care were identified.
Of these patients,
over a third (36%) has established care with another provider, 29% could not be
contacted, 8% returned to the clinic independently, 7% no longer lived in the
study area, 6% had died, 3% were in prison or a mental health institution.
A total of 78
individuals (7%) were located and enrolled in the Navigation Program. Most
(78%) were male, 42% were aged 40 to 49 years, 50% self-identified as gay, 57% had
no health insurance and almost two-thirds had an annual income below $10,000.
been infected with HIV for an average of ten years, mean viral load was
approximately 57,000 copies/ml and 51% had an undetectable viral load. A third
of patients were taking HIV therapy at enrolment and 81% had taken
antiretrovirals at some point.
Many of the
patients had unmet needs at the time of enrollment. Over a third had unmet
HIV-related medical needs, 35% required assistance with food and other basic necessities,
42% required pharmacy/medication services, 43% were in need of benefits support
and 60% required dental care.
patients participated in five intervention visits lasting approximately eleven
hours. However, 46% needed only 1-3 intervention visits, suggesting that for many patients, "less resource-intensive interventions may be sufficient to re-engage many lost HIV clinic patients."
received an average of five referrals. The most common were for mental health
(24%), housing/transport (19%) and financial/employment (19%).
(68%) of patients enrolled in the programme were linked to care within three
months, 85% within six months and 94% within twelve months. The majority (82%)
of these individuals were retained in care (defined as attending second
appointments three to twelve months after linkage). The proportion of patients
with viral suppression increased from 51% at enrollment to 63% at the second
follow-up appointment (p < 0.01).
The authors stress the importance of combining surveillance data with efforts to re-engage people in care. Navigators had access to surveillance data that allowed them to trace the address and clinic records of people missing from care, which showed that just over half were either in care elsewhere, in prison, resident outside LA County or dead. This allowed a more targeted approach to those who could be located, of whom just over half agreed to take part in the intervention study.
Nevertheless the study found that 29% of people had disappeared and could not be located either through clinic records or through at least three attempts to contact them through their last known address, including home visits, and scanning of people-finder databases, homeless shelters, jails and parks.
“The use of this
combined approach is an effective model for identifying and re-engaging
HIV-infected persons who are not receiving adequate HIV medical care,” conclude
the authors. “The combined approach presented here has widespread utility
towards achievement of National HIV/AIDS Strategy goals to improve linkage,
re-engagement, retention, viral load suppression and to reduce forward HIV