Developing an Intervention to Retain HIV-infected Veterans in HIV Care
Thomas P. Giordano MD MPH
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: July 2010 - June 2014

BACKGROUND/RATIONALE:
The VA is the largest single provider of HIV care in the United States, caring for about 5% of all HIV-infected persons in care in the US. Modern HIV treatment has transformed this deadly infection into a treatable chronic condition. To maximally benefit from HIV treatment, Veterans must navigate a continuum of HIV care. They must be diagnosed at an early stage of disease, access or link to HIV medical care, and be retained in HIV care, adherent to appointments and medications. We have shown that poor retention in HIV medical care is one of the primary reasons Veterans die of HIV/AIDS today. There are no proven interventions to better retain Veterans in HIV primary care.

OBJECTIVE(S):
Aim 1: To define where along the continuum of care Veterans with HIV infection experience the most challenges with retention in HIV care; and to identify where those Veterans having difficulty with retention in care eventually interface with the VA healthcare system. Aim 2: To identify the predictors of delayed linkage to care and poor retention in HIV care at care entry and over time, to identify the facilitators and barriers to successfully navigating the continuum of HIV care, and to identify methods to improve navigation of the continuum of care. Aim 3: To develop and preliminarily test an intervention to improve retention in HIV care in the VA. We expect that a reproducible, feasible intervention can be developed and tested.

METHODS:
We are conducting retrospective cohort studies with the VA's Clinical Case Registry HIV (CCR HIV, a database of all Veterans with HIV infection who have used the VA since 1992) to complete Aim 1 and part of Aim 2. We are using qualitative research methods of Veterans from the Michael E. DeBakey VAMC and the Birmingham VAMC to complete the remainder of Aim 2 and Aim 3. The qualitative work recruits Veterans in outpatient care, most of whom will have had some episode of poor retention in care, and Veterans hospitalized with HIV infection who are presently out of HIV primary care. These mixed methods will result in a complete picture of the factors predictive of retention in HIV care so that interventions can be appropriately targeted. They will also result in a comprehensive understanding of the facilitators and barriers to care, and the strategies to remedy these problems as recommended by HIV-infected Veterans themselves. These data will be coalesced and presented to an Advisory Panel, and through an iterative pilot testing process we will develop a preliminary intervention to improve retention in HIV primary care. This intervention will be fully tested and disseminated in subsequent work.

FINDINGS/RESULTS:
Regarding linkage to HIV care, 20,363 Veterans were identified; and overall, 75.7% linked to HIV care. Transfers to the VA with HIV viral suppression were more likely to link to care (91.9% vs. 73.8%; p<0.001); other variables were statistically significant predictors but absolute differences in linkage were 6%. No important facility effects were identified. In multivariate analysis, predictors of linkage were age, race/ethnicity, year of VA HIV date, prior VA outpatient visits, and baseline CD4 cell count, but only transfer with VS had an adjusted OR>2 (3.65 [3.1, 4.3]; p<0.0001). We conclude that linkage to HIV care within the VA is below the National HIV/AIDS Strategy goal, and interventions targeting all HIV-infected Veterans, with the possible exception of transfers with suppressed VL, are needed. Findings on retention in care are not yet available. Findings on the qualitative studies are not yet available.

IMPACT:
The research will identify where and why Veterans with HIV infection are having difficulty remaining in HIV care. It will result in an intervention to improve retention in care. Ultimately, it may lead to improved adherence to care for HIV infected veterans. We have determined that linkage to care efforts must target essentially all veterans with HIV infection, and are disseminating these results. Other results are pending.

PUBLICATIONS:

Journal Articles

1. Panwar B, Johnson VA, Patel M, Balkovetz DF. Risk of Vancomycin-Induced Nephrotoxicity in the Population with Chronic Kidney Disease. The American journal of the medical sciences. 2012 Oct 25.
2. Hochreiter J, Lapham J, Wong-Staal F, McKelvy J, Sulkowski M, Glesby MJ, Johnson VA, Morse GD. ITX 5061 quantitation in human plasma with reverse phase liquid chromatography and mass spectrometry detection. Antiviral Therapy. 2012 Sep 6.

Conference Presentations

1. Giordano TP, Hartman C, Davila J, Richardson P, Stafford C, Rodriguez-Barradas M. Linkage to care for Veterans with HIV infection. Poster session presented at: VA HSR&D National Meeting; 2012 Jul 16; Washington, DC.
2. Giordano TP, Hartman C, Davila J, Richardson P, Stafford C, Rodriguez-Barradas M. Linkage to HIV care in the VA healthcare system. Poster session presented at: Retroviruses and Opportunistic Infections Annual Conference; 2012 Mar 5; Seattle, WA.

DRA: none
DRE: Treatment - Observational
Keywords: Adherence, Complex care, Disparities, Ethnicity/Race, HIV/AIDS, HIV/AIDS, Hepatitis C
MeSH Terms: none