Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.
Many patients with HIV experience interruptions in care at some point in their disease.
Effective management of HIV relies on continuity of care and continued viral suppression, but many patients face interruptions in care at some point in their disease. A new study examines why and what steps physicians can take to help.
The study, published in the Journal of Acquired Immune Deficiency Syndromes, examined a survey of patients with HIV in Atlanta who had received continuous, uninterrupted care for several years compared to another cohort with recent gaps in care.
Jonathan Colasanti, MD, MSPH
Uninterrupted care in HIV patients is associated with better viral suppression, and fewer hospitalizations and complications, according to the report. The reality, however, is that many patients living with HIV face interruptions in care for a variety of reasons, and about 60% of new HIV infections are caused by patients who are out of care.
Jonathan Colasanti, MD, MSPH, assistant professor of medicine at Atlanta’s Emory University School of Medicine and lead author of the report, told Medical Economics the study highlights the numerous factors that affect care retention in patients with HIV.
“It serves as a reminder that our patients often have a host of social determinants that underlie poor retention in care. I hope that it reminds the physician that it is our job to care for the whole patient, not solely treat the disease,” Colasanti said. “In order to do this we have to see the entire picture from our patient’s perspective. HIV remains a highly stigmatized disease and this may vary from one community to the next. It is important that we as the physician understand the support system-or lack thereof-that our patients may have.”
Patients who faced interruptions in care were typically younger, but there was little other demographic difference. Payer methods varied among the two groups, however, with 72% of the group that had continuous care receiving Medicare/Medicaid, and 63% of the unretained cohort having Ryan White coverage at the time of the study. Patients who experienced interruptions in care also had a lower average income, with 33% having no income at the time of the study compared to 6% in the continuous care group.
In terms of therapy, patients in the unretained cohort were without care for an average of 17 months and off anti-retroviral therapy (ART) for nearly a year. At the time of the study, all of the continuous care patients reported taking ART compared to just 7.4% of the unretained patients. Just one unretained patient self-reporting continuing ART for the entire time he was out of care, according to the report. Researchers also found that CD4 counts were more than four times higher in patients receiving continuous care than in those with interruptions.
As far as what kept patients from receiving continuous care, researchers found that 72% of the continuous care cohort had high levels of social support compared with 33% in the group with care interruptions. Fewer than half of the patients in the unretained cohort had shared their HIV status with all or most of their family, while 78% of the continuous care group shared their HIV status, the report notes. Unretained patients also reported higher rates of depression and alcohol or drug use, and had more systemic barriers in terms of access to healthcare, housing, and food. This data supports the increasing body of evidence that poverty is a factor in poor retention of care, according to the report.
Meeting social determinants head-on
Colasanti said it’s easy for clinicians to focus on the biomedical aspects and achieving the care continuum goal of viral suppression in patients with HIV, but they have to remember to ask the difficult questions that go beyond the exam room.
“When barriers such as substance use, food insecurity or unstable housing are identified, it is critical to link those individuals to the services that can address that barrier,” Colasanti said. “Furthermore, are we asking who the patient has at home or in his or her life to discuss their disease with? If a patient has not disclosed his or her diagnosis to anyone, one can imagine how hard it must be to consistently take a daily medication in secrecy or get to frequent medical appointments.”
Another aspect of interrupted care was a higher prevalence in the unretained cohort to have phone number changes or disruptions in cellphone service and reliability, according to the report. As many HIV management programs rely on phone contact, the study authors note that this signals a need for more “on-the-ground” outreach for patients with disruptions in care. Colasanti said the revelation that something as seemingly minor as cell phone reliability could impact care is novel, and one that can be simply addressed in the exam room. Find out how these patients can be reliably contacted and link them to social services, he suggested.
Better outreach and recognition of early warning indicators that patients are likely to face disruptions in care are key to managing HIV patients, according to the report. While interventions to manage these patients may be resource-intensive, they have been shown to be cost effective in the long run by reducing new infections and complications, according to the report.
“I hope that the study reminds medical practices and healthcare settings of the complex interplay of factors that may affect a patient’s ability to remain consistently in care and drives those health care settings to develop more supportive and patient-centered systems to guide him or her through the care process,” Colasanti said.