The Spectrum of Engagement in HIV Care and Its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection

Denver Public Health, Denver, Colorado, USA.
Clinical Infectious Diseases (Impact Factor: 8.89). 03/2011; 52(6):793-800. DOI: 10.1093/cid/ciq243
Source: PubMed


(See the editorial commentary by Lange, on pages 801–802.)

For individuals with human immunodeficiency virus (HIV) infection to fully benefit from potent combination antiretroviral
therapy, they need to know that they are HIV infected, be engaged in regular HIV care, and receive and adhere to effective
antiretroviral therapy. Test-and-treat strategies for HIV prevention posit that expanded testing and earlier treatment of
HIV infection could markedly decrease ongoing HIV transmission, stemming the HIV epidemic. However, poor engagement in care
for HIV-infected individuals will substantially limit the effectiveness of test-and-treat strategies. We review the spectrum
of engagement in care for HIV-infected individuals in the United States and apply this information to help understand the
magnitude of the challenges that poor engagement in care will pose to test-and-treat strategies for HIV prevention.

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Available from: Carlos Del Rio, Jan 03, 2014
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    • "Eighteen years into the era of highly active antiretroviral therapy (ART), medication adherence continues to be a serious barrier to effective treatment. Of the approximately 363,000 persons living with HIV in the US who are currently using antiretroviral therapy (ART), approximately 25% have detectable viral loads [1] [2]. With strong evidence across multiple conditions outside the HIV context indicating that patient-provider communication is related to patient adherence and health outcomes [3] [4], many have suggested that effective patient-provider relationships and communication are likewise of critical importance in HIV care and predictive of ART adherence [5] [6] [7] [8] [9] [10] [11] [12] [13]. "
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    ABSTRACT: Medication adherence is essential in HIV care, yet provider communication about adherence is often suboptimal. We designed this study to improve patient-provider communication about HIV medication adherence. We randomized 26 providers at three HIV care sites to receive or not receive a one-hour communication skills training based on motivational interviewing principles applied to medication adherence. Prior to routine office visits, non-adherent patients of providers who received the training were coached to discuss adherence with their providers. Patients of providers who did not receive the training providers were not coached. We audio-recorded and coded patient-provider interactions using the roter interaction analysis system (RIAS). There was more dialogue about therapeutic regimen in visits with intervention patients and providers (167 vs 128, respectively, p=.004), with the majority of statements coming from providers. These visits also included more brainstorming solutions to nonadherence (41% vs. 22%, p=0.026). Intervention compared with control visit providers engaged in more positive talk (44 vs. 38 statements, p=0.039), emotional talk (26 vs. 18 statements, p<0.001), and probing of patient opinion (3 vs. 2 statements, p=0.009). A brief provider training combined with patient coaching sessions, improved provider communication behaviors and increased dialogue regarding medication adherence. Copyright © 2015. Published by Elsevier Ireland Ltd.
    Patient Education and Counseling 05/2015; 98(9). DOI:10.1016/j.pec.2015.05.011 · 2.20 Impact Factor
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    • "Unlike attempts to depict the HIV treatment cascade with a population-based sampling method (Gardner et al., 2011), we aimed to describe patterns of engagement in HIV clinical care among Internet sex-seeking MSM in Latin America. Results demonstrated that approximately one-fourth of the sample had never been tested for HIV. "
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    ABSTRACT: HIV/AIDS in Latin America is concentrated among men who have sex with men (MSM). However, accurate estimates of engagement in HIV care in this population can be difficult to ascertain because many do not self-identify as MSM. Given evidence of decreased HIV transmissibility in the context of antiretroviral therapy (ART) adherence, identifying individuals not in care who are engaging in HIV transmission risk behavior is crucial for secondary prevention. Primary aims of this study were to examine engagement in care from testing to ART adherence among MSM using online social/sexual networking across Latin America, and whether individuals not in care at each step reported greater sexual transmission risk behavior than those in care. In the overall sample (n=28,779), approximately 75% reported ever being tested for HIV, and 9% reported having received an HIV diagnosis. Among known HIV-infected individuals, 20% reported not being in care, 30% reported not taking ART, and 55% reported less than 100% ART adherence. Over one-third of HIV-infected individuals reported sexual HIV transmission risk behavior, defined as unprotected anal intercourse (UAI) with a male partner of different/unknown HIV serostatus in the past three months. HIV-infected individuals not engaged in care more often reported UAI compared to those in care (OR=1.29; 95% CI=1.01-1.66). Although not statistically significant, HIV-infected individuals not on ART more often reported UAI compared to those on ART (OR=1.18; 95% CI=0.94-1.47). Individuals who reported less than 100% ART adherence more often reported UAI compared to individuals with 100% adherence (OR=1.55; 95% CI=1.26-1.90). Findings demonstrate that a substantial portion of HIV-infected MSM in Latin America who are likely not virologically suppressed from lack of ART use or adherence report sexual HIV transmission risk. Tailoring secondary HIV prevention for MSM in Latin America who are not in HIV care or adherent to ART may be warranted.
    AIDS Care 03/2015; 27(8):1-8. DOI:10.1080/09540121.2015.1017796 · 1.60 Impact Factor
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    • "Patient engagement in care and treatment adherence is critical to achieving the full benefits of antiretroviral therapy (ART) among people living with HIV or AIDS (PLWHA). Engaging PLWHA at all points along the cascade of care is central to transforming the management of the disease from a fatal condition to a chronic one (Gardner et al. 2011). Early engagement has pronounced implications for effective disease management, including the treatment and prevention of co-morbidities, CD4 monitoring and the timely initiation of ART (Smith et al. 2013). "
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    ABSTRACT: Many people newly diagnosed with HIV are lost to follow-up before timely initiation of antiretroviral therapy (ART). A randomised controlled trial (RCT), WelTel Kenya1, demonstrated the effectiveness of the WelTel text messaging intervention to improve clinical outcomes among patients initiating ART. In preparation for WelTel Retain, an RCT that will evaluate the effect of the intervention to retain patients in care immediately following HIV diagnosis, we conducted an informative qualitative study with people living with HIV (n = 15) and healthcare providers (HCP) (n = 5) in October 2012. Study objectives included exploring the experiences of people living with HIV who have attempted to engage in HIV care, the use of cell phones in everyday life, and perceptions of communicating via text message with HCP. Participants were recruited through convenience sampling. Semi-structured, qualitative interviews were conducted and recorded, transcribed verbatim and analysed using NVivo software. Analysis was guided by the Theory of Reasoned Action and the Technology Acceptance Model. Results indicate that while individuals have many motivators for engaging in care after diagnosis, structural and individual barriers including poverty, depression and fear of stigma prevent them from doing so. All participants had access to a mobile phone, and most were comfortable communicating through text messages, or were willing to learn. Both people living with HIV and HCP felt that increased communication via the text messaging intervention has the potential to enable early identification of problems, leading to timely problem solving that may improve retention and engagement in care during the first year after diagnosis.
    African Journal of AIDS Research 12/2014; 13(4):331-338. DOI:10.2989/16085906.2014.961939 · 0.79 Impact Factor
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