Health Care System and Policy Factors Influencing Engagement in HIV Medical Care: Piecing Together the Fragments of a Fractured Health Care Delivery System

Department of Medicine, Division of Infectious Diseases, School of Medicine, Universityof Alabama at Birmingham, Birmingham, Alabama, USA.
Clinical Infectious Diseases (Impact Factor: 8.89). 01/2011; 52 Suppl 2(Suppl 2):S238-46. DOI: 10.1093/cid/ciq048
Source: PubMed


Grounded in a socio-ecological framework, we describe salient health care system and policy factors that influence engagement in human immunodeficiency virus (HIV) clinical care. The discussion emphasizes successful programs and models of service delivery and highlights the limitations of current, fragmented health care system components in supporting effective, efficient, and sustained patient engagement across a continuum of care. A fundamental need exists for improved synergies between funding and service agencies that provide HIV testing, prevention, treatment, and supportive services. We propose a feedback loop whereby actionable, patient-level surveillance of HIV testing and engagement in care activities inform educational outreach and resource allocation to support integrated "testing and linkage to care plus" service delivery. Ongoing surveillance of programmatic performance in achieving defined benchmarks for linkage of patients who have newly diagnosed HIV infection and retention of those patients in care is imperative to iteratively inform further educational efforts, resource allocation, and refinement of service delivery.

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    • "No qualitative research was found, however, to explore links between ADAP use in the South and entry, linkage or retention in HIV care for low-income PLHIV and underlying social factors and determinants of health. Yet the complexity of individual-, social- and structural-level factors interacting in linkage to care for vulnerable groups lends itself well to qualitative methods [46-49]. "
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    ABSTRACT: In a significant geographical shift in the distribution of HIV infection, the US South - comprising 17 states - now has the greatest number of adults and adolescents with HIV (PLHIV) in the nation. More than 60% of PLHIV are not in HIV care in Alabama and Mississippi, contrasted with a national figure of 25%. Poorer HIV outcomes raise concerns about HIV-related inequities for southern PLHIV, which warrant further study. This qualitative study sought to understand experiences of low-income PLHIV on the AIDS Drug Assistance Program in engagement and retention in continuous HIV care in two sites in Alabama. The study was designed using grounded theory. Semi-structured interviews with 25 PLHIV explored experiences with care linkage, reported factors and behaviors affecting engagement/retention in continuous HIV care, including socio-economic factors. To triangulate sources, 25 additional interviews were conducted with health and social service providers from the same clinics and AIDS Service Organizations where clients obtained services. Across the narratives, we used the HIV care continuum to map where care delays and drop out occurred. Using open coding, constant comparison and iterative data collection and analysis, we constructed a conceptual model illustrating how participants described their path to HIV care engagement and retention. Most respondents reported delayed HIV care, describing concentric factors: psychological distress, fear, lack of information, substance use, incarceration, lack of food, transport and housing. Stark health system drop out occurred immediately after receipt of HIV test results, with ART initiation generally occurring when individuals became ill. Findings highlight these enablers to care: Alabama's 'social infrastructure': 'twinning' medical with social services, 'social enablers' who actively link PLHIV to care, and 'enabling spaces' that break down PLHIV isolation, facilitating HIV care linkage/retention. Ryan White-funded programs, together with housing, food and psychological support were pre-conditions for participants' entry and retention in HIV care. The path to achieving continuous HIV care for individuals at risk of lack of entry or delayed HIV care requires robust social-level responses, like in Alabama, that address physical and mental health of clients and directly engage the particular social and economic contexts and vulnerabilities of southern PLHIV.
    International Journal for Equity in Health 04/2014; 13(1):28. DOI:10.1186/1475-9276-13-28 · 1.71 Impact Factor
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    • "Rao et al. [11] noted that lack of engagement in HIV care presents a major clinical challenge in HIV care as well as a global public health challenge. Mugavero et al. [12] examined health care system and policy factors that influence engagement in HIV clinical care. Their discussion included a socioecological framework that includes salient health care system and policy factors that influence engagement in HIV clinical care. "
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    ABSTRACT: Engagement with care for those living with HIV is aimed at establishing a strong relationship between patients and their health care provider and is often associated with greater adherence to therapy and treatment (Flickinger, Saha, Moore, and Beach, 2013). Substance use behaviors are linked with lower rates of engagement with care and medication adherence (Horvath, Carrico, Simoni, Boyer, Amico, and Petroli, 2013). This study is a secondary data analysis using a cross-sectional design from a larger randomized controlled trial (n = 775) that investigated the efficacy of a self-care symptom management manual for participants living with HIV. Participants were recruited from countries of Africa and the US. This study provides evidence that substance use is linked with lower self-reported engagement with care and adherence to therapy. Data on substance use and engagement are presented. Clinical implications of the study address the importance of utilizing health care system and policy factors to improve engagement with care.
    AIDS research and treatment 04/2014; 2014:675739. DOI:10.1155/2014/675739
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    • "Providers might begin to consider whether or not to test patients if they will not have access to treatment [19, 20]. In addition, the presence of wait lists, or an inability to access antiretroviral medications, may reduce a person's motivation and ability to engage in HIV care [21]. "
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    ABSTRACT: AIDS Drug Assistance Programs, enacted through the Ryan White Comprehensive AIDS Resources Emergency Act of 1990, are the "payer of last resort" for prescription medications for lower income, uninsured, or underinsured people living with HIV/AIDS. ADAPs face declining funding from the federal government. State funding of ADAP is discretionary, but some states increased their contributions to meet the gap in funding. The demand for ADAP support is increasing as people living with HIV are living longer; the antiretroviral therapy (ART) guidelines have been changed to recommend initiation of treatment for all; the United States is increasing HIV testing goals; and the recession continues. In the setting of increased demand and limited funding, ADAPs are employing cost containment measures. Since 2010, emergency federal funds have bailed out ADAP, but these are not sustainable. In the coming years, providers and policy makers associated with HIV care will need to navigate the implementation of the Affordable Care Act (ACA). Lessons learned from the challenges associated with providing sustainable access to ART for vulnerable populations through ADAP should inform upcoming decisions about how to ensure delivery of ART during and after the implementation of the ACA.
    AIDS research and treatment 03/2013; 2013(8):350169. DOI:10.1155/2013/350169
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