This Week in HIV Research: Unlocking Secrets of Engagement in Care
In recent years, the HIV treatment universe has increasingly focused on improving the continuum of care for people living with HIV. Research priorities have followed suit, as most of our highlighted studies this week can attest: A growing number of published studies seek to better understand the nuances of patient engagement, and to pinpoint factors that improve the likelihood that people with HIV will remain in care and on suppressive treatment.
This week, we highlight the following findings:
- Primary care provider continuity is good for adherence -- especially if that provider is not an infectious disease specialist. (That's right, we said not!)
- HIV patient engagement is reliant on provider empathy, respect, and ability to offer one-stop care.
- The benefits of financial incentives on adherence extend beyond the end of those incentives.
- Case reports have emerged of cluster headache-like symptoms on tenofovir disoproxil fumarate/emtricitabine (TDF/FTC, Truvada).
Let's engage ourselves in a deeper look at these studies. To beat HIV, you have to follow the science!
Provider Continuity, Non-ID Specialization Improve Adherence
HIV-positive patients are more likely to adhere to treatment if they stay with the same primary care provider over time -- and if that provider is not an infectious diseases specialist, an analysis published in AIDS found.
Researchers developed random effects models based on 111,013 patient years of Medicaid enrollees living with HIV in 14 U.S. states. Each year with the same primary care provider was associated with 6% higher adherence, and seeing a non-ID specialist/generalist was linked to a 5% adherence increase compared to visiting an infectious disease specialist. That latter finding might be explained by non-ID physicians' better care coordination of multiple chronic conditions faced by many people living with HIV, especially as they age, study authors hypothesized.
They also found that participants attended by an M.D. rather than a non-physician, such as a nurse-practitioner, had a 1.6% greater adherence rate. However, that slight difference does not mean that care by nurse practitioners or physician assistants is not an option in areas with a shortage of HIV-experienced M.D.s, study authors said.
"To improve [antiretroviral treatment] adherence for patients living with HIV, structural aspects of care should be considered," the authors concluded. They called for further research to determine the specific characteristics that influence adherence.
Provider Respect, One-Stop Services Important to Engagement in Care
A systematic review and synthesis of results from 41 studies published in Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports identified the following characteristics of primary care practices that keep people living with HIV engaged in care:
- They are a respectful, empathetic, holistic partner in care.
- They actively guide and assist their patients through transitions.
- They help their patients understand their illness and their health care needs.
- They provide destigmatizing, one-stop care that welcomes people from diverse cultures.
The authors recommended that providers be educated in patient-centered care; that patient input be solicited to improve clinic quality, as well as to develop and select support tools; that patient navigation services be expanded; and that additional research be conducted into the impact of provider education and navigation services on health outcomes.
"Providers should use common language, not medical jargon, to educate patients about HIV, medications and how they can live a healthy life," lead author Andrea Norberg of Rutgers School of Nursing recommended in an associated press release. She also noted that many people who are recently diagnosed still think that HIV is a death sentence, rather than the chronic disease it has become with proper treatment -- hence the need to educate people in order to get and keep them in care.
Financial Incentives Positively Affect Viral Loads Even After the Incentives End
The effect of financial incentives on viral load suppression and engagement in care often continues after such payments end, a U.S. analysis published in Journal of Acquired Immune Deficiency Syndromes showed.
The parent HPTN 065 study had found a 3.8% increase in viral suppression rates at study sites -- 20 in the Bronx, New York, and 17 in Washington, D.C., encompassing nearly 52,000 patients -- that offered gift cards to those who sustained viral suppression for three months compared to sites that did not provide such an incentive. Nine months after that intervention was discontinued, sites that had provided the cards still saw a 2.7% higher viral suppression rate.
Similarly, post-intervention, 7.5% more participants at the incentive sites remained in care compared to control sites, a slight drop from the 8.7% increase during the intervention. Qualitative interviews showed emotional benefits for both providers and patients when gift cards were provided.
The goal of incentive programs such as this is to help participants develop habits that will continue in the absence of the incentives, study authors explained. The study's findings are important for policy makers and funders, especially in the context of concerns about the sustainability of such payments, the authors concluded.
Two Cases of Cluster Headache-Like Symptoms Reported With TDF/FTC
The development of cluster headache-like symptoms while taking tenofovir disoproxil fumarate/emtricitabine (TDF/FTC, Truvada) among two people was reported in a recent issue of AIDS.
Both individuals were in their early 20s, with no history of migraines. One was an HIV-positive man who also used tobacco and cannabis, and took ketamine between the first and second dose of Truvada. The other was a woman occupationally exposed to HIV. In both cases, reactions occurred within 30 minutes to a few hours of taking the medication and included headache, weeping eye and nasal congestion.
Tests excluded other causes of these symptoms, which abated when the person was taken off Truvada and re-appeared when a second (and in one case, third) dose of the drug was given. Changing HIV regimens resolved the problem in both people. "As the combination of [TDF/FTC] has become one of the most used treatments in HIV care, physicians should be warned about this rare adverse effect which occurs at the start of treatment," the authors concluded.