Rumptz MH, Tobias C, Rajabiun S, Bradford JB, Cabral HJ, Young R, Cunningham WE. Factors associated with engaging socially marginalized HIV positive persons in primary care. (2007) AIDS Patient Care and STDs. 21(S1): S30-S39.

Utilizing interview and chart review data from 984 clients from 10 agencies, Rumptz et al. determine factors associated with engaging socially-marginalized HIV-positive persons in primary care. Each of the 10 urban sites in this study used various outreach approaches including street outreach, mobile vans, collaborations with partner clinics, and case management providers to reach underserved populations such as racial and ethnic minorities, women, youth, and individuals released from correctional facilities. All interventions had a common goal of engaging clients in HIV primary care by addressing them on their own terms and providing them with HIV education and resources to meet their health care needs.

At baseline

• about 40% of participants were "somewhat engaged in care," defined as less than two primary care visits in the past six months or two or more missed visits,
• 12% were "not engaged in care," meaning they had no HIV primary care visits in the previous six months, and
• 47% were "engaged in HIV primary care," defined as those who reported two or more HIV visits in the past six months and fewer than two missed visits without rescheduling.

At baseline, those who were somewhat engaged in care were very similar to those who were not engaged in care but very different from those who were fully engaged in care. Those who were not fully engaged in HIV primary care were more likely to be female, African American, not living in temporary housing arrangements, more recently diagnosed with HIV, less likely to have AIDS, and less likely to have received recent outpatient mental health care. They were also more likely to report recent drug use, structural and belief barriers, and unmet financial and housing needs. Participants who were not engaged or somewhat engaged in care at baseline were both less likely to engage in care at 12 months.

After programs employed their interventions to improve engagement in HIV care, 58% of those who were not or only somewhat engaged in primary care at baseline became engaged at 12-month follow-up. Discontinued drug use, decreased structural barriers (e.g., location of service, no convenient appointment times), decreased unmet needs (e.g., housing, transportation, food, mental health care), and stable belief barriers (e.g., feeling faith will help with HIV, not sick enough to go to doctor, side effects of medication are worse than disease, mistrust in health care system) over 12 months were significantly associated with engagement in care. Specifically, those who discontinued drug use were almost four times more likely than those who began or continued the use of drugs to become engaged in care. When structural barriers and unmet needs decreased, clients were almost three times as likely to become engaged in care campared to clients whose unmet needs increased.

All 10 of the outreach interventions used a multipronged approach that addressed the four main factors associated with engagement in care: drug use, unmet needs, structural barriers, and belief barriers. At the same time, staff used client-centered, non-judgmental and culturally sensitive empowerment approaches to work with clients to decrease barriers to care. This study provides support for interventions that focus on structural barriers, drug and mental health problems, and other unmet needs as promising strategies to retaining marginalized HIV patients in care. Additionally, further research is warranted to identify effective strategies to reach the 42% who were not engaged at baseline and did not become engaged during the study, which may further the innovation of future intervention strategies.

The in+care Campaign seeks to ensure that people living with HIV are consistently engaged in clinical relationships with medical providers, but how well is the Campaign meeting this goal? Campaign staff has been busy programming several evaluation activities to assess our progress, including focus groups and statistical analyses of submitted data. Additionally, we recently asked participants to complete an online survey to provide some feedback on Campaign activities so far. Thank you so very much to the 25% of Campaign participants who completed the survey! In this newsletter, we'll share some of the survey results. In future newsletters, we'll share additional findings and input we've received along the way as well as share changes that we make to the Campaign as a result of the evaluation activities.

The data submission component of the Campaign is the most utilized activity in play followed by monthly webinars.

The data submission aspect is by-and-large viewed as the greatest impact activity offered through the Campaign. Detailed responses tied to this question reveal that the Campaign measures helped participating sites think about retention critically. In addition, the Campaign database allows participants to compare themselves with others in their area, providers of similar size or type, and others across the country. The availability of these data comparisons has been helpful to many respondents in communicating their agency performance to senior leadership, consumers, board members, and other stakeholders.

Survey respondents who reported the webinars and regional group meetings as the highest impact explained that they appreciated the opportunity to learn from others. Face-to-face interactions and even virtual interactions and networking through webinar chat rooms have been important for many agencies to connect to others that face similar challenges.

Participation in the Campaign has affected provider agencies in many ways; including helping focus their retention efforts. At the same time, a good number of Campaign participants feel that it is too early to determine whether or not Campaign activities are leading to more patients being retained in HIV primary care - we need more time to tell!

Stay tuned to future newsletters for more survey results! Thanks again to all those who responded!! Please feel free to contact us with any questions, concerns or additional feedback! Mth02@health.state.ny.us.