This Week in HIV Research: Teamwork Makes the Dream Work

A patient-centered care approach that integrates community-based pharmacies and primary care providers saves money in the long run, a study published in Journal of Acquired Immune Deficiency Syndromes showed.

In the approach, providers and pharmacists share patient data and decide collaboratively on treatment. The study was conducted at three sites, each of which included one or two specialized pharmacies and a medical clinic. It included 279 participants, 155 of whom were virally suppressed 12 months before model implementation. An additional 45 were virally suppressed 12 months after implementation.

Overall, the intervention cost $226,741 a year, but saved $1.28 million in lifetime HIV treatment costs by increasing the number of people living with HIV (PLWH) who are virally suppressed.

Most of the intervention’s cost was for additional labor at the pharmacies to review patient data, manage medications, and coordinate with the clinic. Study authors noted that the included pharmacies already had staff trained in HIV treatment and prevention; smaller clinics and non-specialized pharmacies may need help to defray the cost of such training and other implementation steps.

The study did not account for patient time and effort or other health care sector costs, nor did it evaluate sustained viral suppression.

Among unhoused people enrolled in a low-barrier, high-intensity HIV care program, neither care engagement nor viral suppression levels dropped during COVID-19 restrictions, an interrupted time-series analysis published in AIDS found.

The 85 participants in POP-UP, a program of Ward HIV Clinic in San Francisco, California, continued to access in-person services during the city’s shelter-in-place ordinance. Temporary housing in hotels as part of the city’s COVID-19 emergency program further facilitated service delivery to 15% of participants.

Prior to COVID-19 lockdowns (10/17/2019-3/16/2020), 48% of POP-UP participants were virally suppressed; during the first several months of the pandemic (3/17/2020-8/16/2020), viral suppression rates within POP-UP held steady at 47%. By comparison, in the general Ward 86 clinic, the odds of being viremic rose by 31%.

At POP-UP, mean visits per patient month also remained level: 1.6 in the pre-COVID study period versus 1.7 in the initial months of the U.S. pandemic.

While viral suppression rates did not drop among POP-UP clients, they are generally low, showing the need for additional interventions, study authors noted. Limitations included the non-randomized design and limited sample size.

“Multi-component interventions such as POP-UP may help maintain viral suppression despite introduction of unanticipated structural barriers, such as those associated with COVID-19,” study authors concluded.

Among a significant proportion of people who reported being adherent to PrEP, urine tests did not show recent use of the medication, researchers reported in Journal of Acquired Immune Deficiency Syndromes.

Two clinics, in Florida and Texas, included these tests in their standard operating procedures, although only for clients who said they had no problem taking their biomedical HIV prevention as prescribed. (Those who reported struggling to take the medication were routinely provided with enhanced adherence support.)

Fourteen percent of 3,987 tests indicated that no tenofovir had been taken within the last 48 hours, thus yielding 564 additional clients who might need help taking their PrEP on schedule.

“These findings suggest that objective adherence monitoring can be used clinically to enable providers to identify nonadherent patients and allocate support services accordingly,” study authors concluded. They noted that systemic discrimination, stigma, and a distrust of the medical system may lead to overestimating adherence during self-report.

Anecdotal evidence from the study suggests that the urine testing approach may also alleviate distrust and reduce bias in patient-providers’ conversations about barriers to adherence. Limitations included the lack of testing for those reporting adherence problems, possible “white coat dosing”—i.e., participants taking the medication just before a scheduled visit—and variance in how clinicians asked about adherence and interpreted the response.

Existing Centers for Disease Control and Prevention guidelines regarding when to prescribe PrEP to women would benefit from a recommendation to include their partner’s prior interactions with the criminal justice system, a modeling study published in AIDS concluded. Doing so may help close the racial disparity gap in U.S. HIV incidence, the researchers suggest.

The agent-based computer simulation considered four strategies regarding the approach to PrEP prescribing among Black women in Philadelphia:

• Prescribe based on current CDC indicators for partner characteristics.

• Prescribe if a male partner was recently in jail or prison.

• Prescribe if a male partner recently returned to the community from such a facility.

• Prescribe couples-based PrEP at return to the community.

The modeling study found that couples-based PrEP needed the fewest number of people on PrEP (147) to avert one seroconversion, while biomedical prevention for women with a recently released partner needed the most (300).

Study authors suggested integrating PrEP into HIV testing programs in jails or prisons and adding HIV prevention programs for couples to community supervision programs. They cautioned, however: “Additional research is needed to clarify how these interventions should be implemented without furthering stigma related to incarceration and HIV.”

Limitations included the lack of inclusion of several factors, including social factors such as poverty or unemployment; HIV drug resistance; or the consideration of whether the women themselves have a history of criminal justice involvement. Nonetheless, “These findings provide strong support for criminal justice informed interventions alongside efforts to end mass incarceration,” study authors concluded.