Benefits and Barriers to Decentralized HIV Care for Patients in Underserved Communities

People living with HIV who must travel long distances to their HIV care providers -- or are out of care due to a shortage of local providers -- are highly vulnerable to disease progression, which increases the likelihood of transmitting HIV. Residents of Washington state face time, transportation and other barriers to accessing care in urban areas of the state, leaving Seattle's rural neighbors largely underserved.

To address this problem, beginning in 2007, a unique partnership was developed between an academic medical center, the Washington State Department of Health and individual community health care centers. At IDWeek 2016 in New Orleans, I spoke with Brian Wood, M.D., a faculty member of the division of allergy and infectious diseases at the University of Washington, who presented this model for offering HIV care in rural areas.

Thanks so much for speaking with me, Dr. Wood. Tell us what this partnership was meant to accomplish.

What we found in Washington state is that, in the rural parts of the state, outside of Seattle and the urban areas, many patients who were being asked to travel all the way to the academic medical center in Seattle simply weren't coming and weren't engaged in care.

This initiative, which was led by one of my mentors, Dr. Bob Harrington, involved partnering with our state Department of Health and several community partners to launch satellite clinics in the less populated parts of Western Washington. The idea was that we could reduce barriers and help patients engage in care by having a provider go out to that site, as opposed to asking the patient to come all the way into Seattle.

We've now launched four of these satellite clinics in various sites in Western Washington. The model involves an HIV provider from the university going out to that clinical site, to the clinic of a community partner or to the public health department, and then setting up shop and offering a full day of HIV clinic to patients from that part of the state.

What have been the results in the communities being served, in terms of uptake as well as clinical outcomes?

What we've found is that the patients have been incredibly appreciative of this model. Our number of enrollees in each clinic and our number of visits continue to go up every year. We've now managed to engage in these clinics almost 700 patients -- almost 6,000 visits -- including a number of patients who previously were totally not engaged in care and a number who were previously being asked to drive over 50 miles to receive care.

We've looked at our viral load suppression rates as a snapshot in 2015. We've seen over time, after launching these satellite clinics, the rates of viral suppression increase for those who are engaged in the satellite clinics, compared with patients in the same counties who are not engaged.

We looked at some quality of care markers at these satellite clinics and found that they were equivalent to the same clinical care markers at the academic medical center. So, we believe that care out of these satellite clinics is equally as safe and effective and of an equally high quality.

In the poster, we also provide an example of the costs of implementing and maintaining these satellite clinics, with the important point being that funding from our state Department of Health has really been key to the implementation and sustainability of this program.

This is a model of implementing satellite clinics in rural areas that we found to really help to engage patients and to improve local viral suppression rates. The key for us has been partnership with both local partners and our state Department of Health. It's certainly a model that could be expanded to other regions.

This partnership appears to be a win for everyone involved. What are some of the barriers to implementing this kind of model?

The biggest barrier is probably funding. Financial support is important. But once that funding obstacle is overcome, one of the barriers that we experienced was because our provider is only going out to these clinics one day per week. Coordinating the care on the other days, coordinating hospitalizations, coordinating all the other needs, was a challenge. We've overcome that challenge by partnering with community clinics and primary care providers who have agreed to provide the care for these patients on the days when we are not there. Most have been very willing to do that.

There's been a lot of support from the community clinics, because these are predominantly patients who previously were not engaged in any kind of care at all, and not on antiretroviral therapy, and presumably were using emergency rooms and urgent-care facilities for all of their needs. So, although we weren't able to objectively look at systemic costs of care in this analysis, I really believe that this is cost effective. It's engaging people in care, getting them on meds; they're less reliant on their local ERs and urgent cares. So, our community partners have been very motivated, as has our state Department of Health, to support this program.

The other challenge that we had is that, after we launched this program, our numbers increased to the point where the wait time to get in was a number of weeks or even a number of months. We've overcome that by adding more care providers. At two of our clinics, we now have two providers, instead of one, who go out regularly. We've simply had to increase our capacity.

It's the "if you build it, they will come" phenomenon. We opened these satellite clinics out in the community. Patients love it. They no longer have to travel to Seattle. The community partners are very supportive. The state Department of Health has seen the benefits and is very supportive. And now we have had to increase our capacity at these clinics to help serve more and more patients.

Is there a testing component, as well? It seems that having a satellite clinic brings opportunities not only for engagement in care for folks who are already living with HIV, but also to raise HIV awareness at large in a community that may be isolated from urban testing resources.

There are two important points that brings up: one about testing and the other about prevention. A key part of this program has been partnering with the local case management groups to help support patients who have very complex needs. As part of that partnership, we've worked to be able to provide testing not only for patients' partners, but for other people with these needs.

We've also implemented the ability to provide PrEP [pre-exposure prophylaxis] and to see HIV-negative individuals, whether they are partners of our patients or other at-risk individuals, in order to do PrEP visits and provide preventive counseling, as well as PrEP prescriptions.

Absolutely, a key focus of these satellite clinics, in addition to engaging those who are positive into treatment, is expanding the ability in these rural parts of the state to do testing and prevention.

This transcript has been lightly edited for clarity.