Intensive Intervention Re-Engages Patients Lost to Care in Inner-City Philadelphia Clinic
Actively identifying patients living with HIV who have been lost to care and then implementing a brief, focused, patient-oriented bundled intervention in two dedicated office visits improved re-engagement in HIV care at a large urban HIV clinic in Philadelphia, according to a poster presented at IDWeek 2014.
The intervention is simple and costs little in this comprehensive care clinic context, but, "if done routinely, lost-to-care time can be decreased, potentially improving patient outcomes and decreasing secondary transmission," according to Dong Heun Lee, M.D., of Drexel University College of Medicine, who presented the poster.
As a consequence of scaled-up HIV screening programs and the expansion of the antiretroviral therapy treatment guidelines, the number of patients requiring regular HIV care is growing in industrialized settings. But campaigns to get more people living with HIV into care -- for treatment and prevention -- may achieve little if people are not retained in care.
Approximately one-third of people diagnosed with HIV who are linked to care become lost to follow-up, according to data from the United States Centers for Disease Control (CDC).
Practical strategies are needed to re-engage people who drop out of care. Lee and colleagues hypothesized that if patients lost to care could be brought back into the clinic for two office visits focused on the reasons for falling out of care, the clinic might be able to retain a substantial proportion.
The Clinic Context
The intervention took place in Drexel's Partnership Comprehensive Care Practice, which was founded in 1993 in order to enhance the quality of life for persons living with HIV by providing comprehensive, integrated HIV care to all individuals regardless of their ability to pay.
It currently serves over 1,800 patients living with HIV, and has a full complement of staff including physicians and nurse practitioners, mental health practitioners, researchers, an OB/GYN service, case managers, a pharmacist and a nutritionist.
Clinic records from August 2012 to January 2014 were reviewed to identify people living with HIV who had been attending the clinic but who had not been seen in more than 12 months.
Attempts were made to contact the patient, and schedule two separate dedicated office visits within one month. The patient's demographics and clinical information were reviewed.
Lost-to-care (LTC) clinic visit #1: Clinic staff spoke to the patients to identify the reasons they were lost to care, evaluated insurance status, and arranged case management and behavior health counselor services as necessary. Laboratory work was also performed.
LTC clinic visit #2: Clinic staff reviewed laboratory results and attempted to address barriers to engagement with the patient, who also met with a nutritionist during the visit. The patient was then linked to ongoing care.
Patients who reconnected to care were supported to achieve viral load suppression and have an improved quality of care.
A total of 59 consecutive patients were identified and evaluated. Of those, 46 (78%) were male, the median age was 44, and median time from last visit was 32 months.
At their last clinic visit, seven (12.1%) patients previously had a CD4 count below 200 (and thus were at high risk of an opportunistic infection or death), while 24 (41.4%) individuals had a detectable viral load.
Additionally, 33 (55.9%) of the patients completed both LTC clinic visits within a one-month period (with an average of 21 days before the visits).
Lab results from the first LTC visit showed that eight (13.8%) patients had CD4 counts below 200, while 24 (43.6%) had detectable viral loads. Only 31 (52.5%) had been taking antiretroviral therapy at the first visit and 15 (25.4%) did not have insurance.
The most common reasons for loss-to-care were determined to be:
- Incarceration (36%).
- Substance abuse (17%).
- Psychiatric illness (6%).
- Lack of motivation (16%).
- Lack of insurance (6%).
- Transportation (4%).
- Provider issues (9%).
- Other (6%).
Patients who were using drugs or alcohol were significantly less likely to remain engaged in care compared to others (30.8% versus 71.7%, P = 0.01).
After Implementation of the LTC Visits
Overall, 37 of the 59 (62.7%) remained engaged in care (seen within a 6-month period after two visits).
One LTC visit was enough to re-engage some in care; however, patients who completed two visits in a one-month period were more likely to stay engaged in care (84.8% versus 34.6%, P < 0.001), and were more likely to have an undetectable viral load (86.4% versus 42.9%, P = 0.038) within a 6-month follow-up period.
Substance abuse and incarceration were a particular problem within this community. Although Lee said that most patients eventually received care while in prison, they did not make a seamless transition back into care once they were released.
"Addressing both the transition from incarceration to HIV care in the community and substance abuse may be high yield in retaining this high-risk population in HIV care," Lee said.
Theo Smart is an HIV activist and medical writer with more than 20 years of experience. You can follow him on Twitter @theosmart.