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in+care Newsletter  |  March 2012  


National Campaign to Improve Retention in HIV Care
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In This Issue
Upcoming Events
Journal Spotlight
Baltimore EMA Spotlight


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Campaign Updates
(as of 3/14/12)
February Average for Measure 1: Gap Measure
(n = 162 sites, 103,205 patients)
February Average for Measure 2: Visit Frequency Measure
(n = 95 sites, 58,248 patients)
February Average for Measure 3: New Patient Measure
(n = 156 sites, 8,628 patients)
February Average for Measure 4: Viral Load Suppression
(n = 156 sites, 119,388 patients)
Quick Links


Campaign Headquarters

National Quality Center (NQC)

New York State Department of Health AIDS Institute


90 Church Street, 13th floor
New York, NY 10007


Work: 212-417-4730
Fax: 212-417-4684





As a quick reminder, we have extended the submission deadline for the 2012 NQC Quality Awards to March 30, 2012. We hope Ryan White grantees are working on submitting an application to showcase their quality improvement. These awards offer an opportunity to recognize grantees' work and highlight outstanding grantee achievements. 



We also encourage you to get your consumers on board with our newly-launched Partners in+care component of the Campaign. Partners in+care activities are designed for and by people living with HIV/AIDS with the primary purpose of engaging people living with HIV/AIDS and their allies in the Campaign. The goal of this aspect of the Campaign is for participants to stay in care, get peers to come back into care, and partner with HIV programs to improve care. To learn more about the Partners in+care aspect of the Campaign, please visit the in+care Campaign website and click on the Partners tab.


Best regards,


Clemens Steinbock

National Quality Center 





Upcoming Events  

+ in+care Campaign Office Hours 

Every Monday and Wednesday 4-5pm ET

We are happy to introduce regularly scheduled Office Hours for in+care Campaign participants to directly communicate with NQC staff and consultants. Callers can ask general questions, request technical assistance or engage in dialogue about the Campaign.

Office Hours will be held from 4-5pm ET on:

  • Monday, April 2
  • Wednesday, April 4 - Retaining in Care Individuals Who are Transitioning to the Community from Incarceration
  • Monday, April 9
  • Wednesday, April 11 - Designing and Implementing Retention Projects

Dial-in#: 866.394.2346

Participant Code: 4182576142#

+ April in+care Webinar

Thursday, April 26, 2012 at 2pm ET

The webinar program will feature a presentation on the connection between homelessness and retention in HIV care. Emphasis will be placed on what provider and lead agencies can do to improve homeless patient retention, and participants will have an opportunity to discuss what methods they have used to meet these goals. The Webinar will also include discussion of the goals and findings of HRSA's Homelessness and Housing Workgroup. Finally, Campaign staff will review performance data submitted to the Campaign in April.


Dial-in#: 866.394.2346

Participant Code: 3971546368#

URL: http://www.nqcqualityacademy.org/incarecampaign


Keep up-to-date with the latest in+care events through our webpage: http://incarecampaign.org/index.cfm/75283
 Journal Spotlight: Mugavero et al. "Early Retention in HIV Care and Viral Load Suppression: Implications for a Test and Treat Approach to HIV Prevention"

Mugavero MJ, Amico KR, Westfall AO, Crane HM, Zinski A, Willig JH, Dombrowski JC, Norton WE, Raper JL, Kitahata MM, Saag MS. "Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention." J Acquir Immune Defic Syndr. 2012 Jan 1;59(1):86-93. 


Although many studies have examined the expansion of HIV testing and linkage of newly diagnosed patients to care, limited research exists for the period immediately following entry into care. The year following initial linkage to outpatient HIV medical care is a critical time for patients adjusting to a life-changing diagnosis.   During this stage, many patients are at their most vulnerable as they attempt to navigate a health care system with which they are often unfamiliar. At the same time, they are being asked to attend frequent medical visits and initiate ART treatment that requires high levels of sustained adherence. Research to date has shown that over 25-30% of patients became delinquent or eventually stopped attending scheduled appointments following initial enrollment in outpatient HIV care. Even after initial linkage to care occurs, subsequent retention in this early stage is important to suppressing viral load and avoiding resistance mutations.


Mugavero et al. examine this key period for HIV-infected individuals through the evaluation of time to virologic suppression (<50 copies/mL), as well as viral load (VL) burden over the first two years in care. They develop a new method for estimating the cumulative VL burden during the time patients were enrolled in the study through a novel measure called viremia copy years. Instead of using just one VL value at a specific point in time, they utilize all of the measured values and then assess the area under the longitudinal viral load curve. Employing this estimate of cumulative HIV burden, the relationship between retention over the first two years in care and longitudinal viral load burden is characterized.


Among study participants initiating outpatient HIV medical care at two clinics between January 2007 and September 2010, each missed visit translated to a 17% increased risk of delayed viral load suppression. During the first two years in care, visit non-adherence was associated with significantly greater cumulative VL burden. As visit adherence increased, lower cumulative VL burden was observed.


Mugavero et al. conclude that higher rates of retention in HIV care within the first two years are associated with achieving VL suppression and lower cumulative VL burden. These findings have implications for HIV prevention efforts, particularly in the context of a test and treat approach to HIV prevention, because retaining patients in these early stages can lead to sustained viral load suppression, which decreases the risk of HIV transmission. Thus, increased attention to patients new to care may have a major impact on improving health outcomes. Effective interventions in these early years following not only diagnosis, but linkage to care, can help patients to develop self-care skills related to visit and medication adherence, leading, in turn, to healthier individuals and communities.

The Synergy of Retention and Continuous Quality Improvement

The Baltimore Eligible Metropolitan Area (EMA) Part A grantee has a comprehensive medical system in place. However, the city continues to bear high HIV infection rates, and compounding factors such as poverty, racial inequities, mental health issues, illicit substance use, and homelessness.


Since 2001, the Baltimore City Health Department (Health Department) has been charged with conducting Part A Ryan White Clinical Quality Management (CQM). The CQM team has performed chart reviews at all primary medical care agencies providing service to people living with HIV/AIDS (PLWHA).  Each year CQM reviews primary medical care (PMC); other funded service categories are reviewed in rotation. For medical categories such as PMC and oral health, the Health Department engages consultants who are medical providers to review the charts. All reviews compare agency performance with both local standards and mean EMA-wide performance. The Health Department incorporated the HRSA/HAB clinical performance measures as they were released. Reviews also include consumer surveys and organizational assessments of program quality improvement activities. 


Results are shared in individual debriefings at each agency reviewed and also presented at collaborative meetings where programs prioritize performance measures for improvement. For example, in 2010 the Health Department presented performance data and "just-in-time" training, which occurs in stages to support the work of quality improvement teams, to agency staff who selected to 1) increase the rate of cervical cancer screening, 2) increase completion of medical case management psycho-social assessments, and/or 3) proactively reschedule missed medical appointments. Programs reported back on their individual improvement projects around these three initiatives at two subsequent collaborative meetings during the year.


Following the training, the Health Department generated comprehensive reports on each category reviewed and presented the reports to the Planning Council and funded agencies.  They also give each agency a report comparing their performance with the rest of the EMA. Agencies are required to develop improvement plans when their rates fall more than 10% below the EMA-wide mean on any individual performance measure.


The Health Department has identified challenges that include 1) initial reluctance of agencies to participate in CQM visits, 2) agency concern that performance would directly link to funding available, and 3) sporadic agency support for quality improvement activities.


When reviewing charts, the Health Department uses a modified version of the HIVQUAL sampling methodology.

The Health Department does not "oversample" women's charts and provides agencies with instructions that allows them to pull a random set of charts. The HIVQUAL sampling table is carefully followed so that they audit enough records to establish 90% confidence intervals in the performance measure rates.


Patient retention as measured by the HAB medical visits measure has increased from 87% in 2009 to 93% in 2011. Mean CD4 count has also increased from 423 cells in 2007 to 462 in 2011. The proportion of all HIV primary care clients with an undetectable viral load has increased from 42% to 51% from 2007 to 2011. And finally in 2011, 75% of primary care clients on HAART had viral loads of less than 200 copies.


Providers are also required to submit client-level data twice annually to BCHD.  Although the quality of these data vary, the Baltimore EMA can track clients that migrate from one provider to another and are still in care. Part A is also collaborating with Part B grantees on strategies for data sharing to better track retention in care.


Keys to the Baltimore EMA's continuous quality improvement program:

  • Gradually building a quality improvement culture and developing trusting relationships between CQM and agencies through collaborative efforts
  • Ongoing performance measurement linked with the shared mission of improving the quality of care
  • Non-punitive performance measurement and ongoing encouragement to improve from the grantee
  • Clear and consistent HIV measures applied to Ryan White funded agencies over time
  • Collaborative sharing and peer learning among agencies
  • Consistent QM leadership at the system and agency level.

Next steps for the Baltimore EMA:

  • Sharing cross-Part data
  • Mining client-level data.
Connect. With patients.
Collaborate. With a community of learners.
Change. The course of HIV. 

incareCampaign.org  |  212-417-4730