Curbing the HIV Epidemic by Supporting Effective Engagement in HIV Care: Recommendations for Health Plans and Health Care Purchasers

The United States is poised to dramatically reduce the scope of its HIV epidemic, but this demands increased leadership and attention from health plans and health care purchasers (including Medicaid, Medicare, marketplaces, and other private purchasers). This new amfAR report identifies changes in policy and practice in clinics, communities, and health care programs to reduce unnecessary health spending, increase the effectiveness of services, and increase the integration of services. Done right, the same steps that lead to appropriate management of care by health plans and purchasers also will help to achieve national public health goals

Social Determinants of Late Presentation to HIV Care

Background: In recent years, increased attention has shifted toward evaluating social determinants of health, and understanding how community, environment, and system factors affect health outcomes. HIV policies and guidelines emphasize the importance of earlier HIV diagnosis and presentation for care. This study evaluated the role of individual and community-level factors in late presentation to HIV care. Methods: HIV-infected patients newly initiating outpatient HIV medical care at an academic medical center between 2005-2010 were included. Patients\u27 self-reported addresses at their first clinic visit were geocoded using geographic information systems software to the appropriate United States census block group. Using data from the U.S. Census Bureau’s 2005-2009 American Community Survey, community-level data was recorded for each patient\u27s census block group. Poisson regression was used to evaluate associations between individual- and community-level factors with late presentation for HIV care, defined as an initial CD4 count /mm3. Results: Among 609 patients, 341 patients (56%) had an initial CD4 count /mm3. At a community level, late presentation was significantly associated with the proportion of African Americans in a census block group (RR=1.47; 95%CI=1.19-1.81); with proportion living in poverty, lack of fuel, and lack of vehicle demonstrating borderline statistical significance. At an individual level, older patients were more likely (1.12; 1.06-1.19), while white females were less likely (0.45; 0.24-0.84) to present with a CD4 count /mm3. Conclusion: Both individual and community-level characteristics were associated with late presentation for HIV medical care. Research and interventions to promote earlier HIV diagnosis and care entry should include geographical information and social determinants of health to define priority populations

Treatment simplification in HIV-infected adults as a strategy to prevent toxicity, improve adherence, quality of life and decrease healthcare costs

Since the advent of highly active antiretroviral therapy (HAART), the treatment of human immunodeficiency virus (HIV) infection has become more potent and better tolerated. While the current treatment regimens still have limitations, they are more effective, more convenient, and less toxic than regimens used in the early HAART era, and new agents, formulations and strategies continue to be developed. Simplification of therapy is an option for many patients currently being treated with antiretroviral therapy (ART). The main goals are to reduce pill burden, improve quality of life and enhance medication adherence, while minimizing short- and long-term toxicities, reducing the risk of virologic failure and maximizing cost-effectiveness. ART simplification strategies that are currently used or are under study include the use of once-daily regimens, less toxic drugs, fixed-dose coformulations and induction-maintenance approaches. Improved adherence and persistence have been observed with the adoption of some of these strategies. The role of regimen simplification has implications not only for individual patients, but also for health care policy. With increased interest in ART regimen simplification, it is critical to study not only implications for individual tolerability, toxicity, adherence, persistence and virologic efficacy, but also cost, scalability, and potential for dissemination and implementation, such that limited human and financial resources are optimally allocated for maximal efficiency, coverage and sustainability of global HIV/AIDS treatment

Clinical inertia in the management of low-density lipoprotein abnormalities in an HIV clinic

A retrospective cohort study evaluating the frequency of and factors related to clinical inertia in low-density lipoprotein (LDL) management was performed. Subjects were 90 patients that were not meeting National Cholesterol Education Program Adult Treatment Panel III LDL goals at the University of Alabama at Birmingham 1917 HIV/AIDS Clinic between 1 August 2004 and 1 August 2005. Clinical inertia was observed in 44% of cases. Patients with higher baseline LDL levels were less likely to experience inertia, whereas women and those in the highest coronary heart disease risk category were more likely to be affected

Nucleoside reverse-transcriptase inhibitor dosing errors in an outpatient HIV clinic in the electronic medical record era

Information on antiretroviral dosing errors among health care providers for outpatient human immunodeficiency virus (HIV)-infected patients is lacking. We evaluated factors associated with nucleoside reverse-transcriptase inhibitor dosing errors in a university-based HIV clinic using an electronic medical record. Overall, older age, minority race or ethnicity, and didanosine use were related to such errors. Impaired renal function was more common in older patients and racial or ethnic minorities and, in conjunction with fixed-dose combination drugs, contributed to the higher rates of errors in nucleoside reverse-transcriptase inhibitor dosing. Understanding the factors related to nucleoside reverse-transcriptase inhibitor dosing errors is an important step in the building of preventive tools

An Illustration of Inverse Probability Weighting to Estimate Policy-Relevant Causal Effects

Traditional epidemiologic approaches allow us to compare counterfactual outcomes under 2 exposure distributions, usually 100% exposed and 100% unexposed. However, to estimate the population health effect of a proposed intervention, one may wish to compare factual outcomes under the observed exposure distribution to counterfactual outcomes under the exposure distribution produced by an intervention. Here, we used inverse probability weights to compare the 5-year mortality risk under observed antiretroviral therapy treatment plans to the 5-year mortality risk that would had been observed under an intervention in which all patients initiated therapy immediately upon entry into care among patients positive for human immunodeficiency virus in the US Centers for AIDS Research Network of Integrated Clinical Systems multisite cohort study between 1998 and 2013. Therapy-naïve patients (n = 14,700) were followed from entry into care until death, loss to follow-up, or censoring at 5 years or on December 31, 2013. The 5-year cumulative incidence of mortality was 11.65% under observed treatment plans and 10.10% under the intervention, yielding a risk difference of −1.57% (95% confidence interval: −3.08, −0.06). Comparing outcomes under the intervention with outcomes under observed treatment plans provides meaningful information about the potential consequences of new US guidelines to treat all patients with human immunodeficiency virus regardless of CD4 cell count under actual clinical conditions