The in+care Campaign is excited to announce that members of its Technical Working Group are authoring articles for a new Medscape Today News Series on Retention in HIV care. The Technical Working Group is made up of nationally renowned researchers and providers who have a strong track record in researching or promoting patient retention in HIV care. Bruce Agins, MD MPH, New York State Department of Health AIDS Institute Medical Director, wrote the opening article in the series, which is now available at the link below. We recommend that you subscribe to HIV/AIDS MedPlus to be informed of new and exciting articles in this series!

http://www.medscape.com/viewarticle/768102 

http://www.medscape.com/viewcollection/32550

The University of California San Francisco (UCSF) HIV/AIDS Division at San Francisco General Hospital was founded in 1983 and immediately became the center of care and treatment for the San Francisco AIDS epidemic throughout the 1980s. Annually, the Division provides primary medical care to 3,000 clients (approximately one-third of the individuals living with HIV seeking publicly funded HIV care in San Francisco). Their comprehensive care and treatment model has been widely adopted around the world and includes:

     * An emphasis on outpatient primary/specialty HIV care

     * Immediate access to routine and urgent care
     * A broad array of social services, including case management, substance use counseling, and 

       psychiatric support

     * Integration of patient care and clinical research

     * Ongoing education for patients, providers, and community.

At the center of the Division's quality improvement efforts is their electronic medical record, HERO (Health Electronic Record Organizer), which was created at San Francisco General Hospital by Division faculty and staff. Quality Improvement staff annually use a report specifically built for them in HERO to find any clients that have not kept a medical visit in twelve months or longer. The list of individuals is then given to a team of nurse case managers and peer advocates who are charged with locating and bringing the clients back into medical care. This task can be complicated as many clients struggle with mental health, substance use, and homelessness. Once located, the multidisciplinary team works with the client to identify and address the barriers that interfered with the client receiving HIV medical care over the past year. They also work with the client by providing ongoing support for re-engaging in medical care.

If the multidisciplinary team determines that the client's barrier is related to substance abuse or mental health issues, they refer the client to a medical case manager (RN), a prevention case manager (masters prepared individual who provides supports in addressing specific barriers preventing retention and adherence), a patient navigator (formally trained), and a behaviorist (a license-eligible, masters prepared individual who performs short-term interventions focused on behavioral changes that a client has expressed a desire to change). The case managers, navigators, and behaviorists conduct either a short term or longer term intervention, depending on the issue, specifically targeting the client's substance use and/or mental health problem. The ultimate goal of this tailored intervention is to remove the barriers that impede client retention in HIV primary medical care.

Peer advocates also provide further support to these clients by:

     * Contacting the client to remind him/her of upcoming appointments

     * Conducting home visits

     * Providing peer support

     * Emphasizing the importance of consistent medical care and medication adherence.

The Division holds multidisciplinary case conferencing to review the records of those clients not retained in medical care. The discussion is led by the primary care provider (MD or NP) and includes the nurse case manager, prevention case managers, substance use workers, and a representative from the psychiatric team. For clients that are part of the Women's Center for Excellence, which includes HIV-positive female clients with substance use or mental health problems, the case conference occurs on a weekly basis. All other case conferences occur on a monthly basis. An action plan for finding clients that are not consistently retained in care is established at these meetings.

The combined efforts of data from HERO, case finding, and case conferencing help UCSF HIV/AIDS Division retain clients that are in danger of falling out of care, as well as re-engage patients previously lost to care.

Marks, G., Gardner, L.I., Craw, J., & Crepaz, N. (2010) Entry and retention in medical care among HIV-diagnosed persons: a meta-analysis. AIDS, 24, 2665-2678.

Marks, Gardner, Craw and Crepaz conducted basic meta-analyses of available literature to help determine if the 'test and treat' strategy has the ability to impact transmission of HIV.   'Test and treat' is the concept by which increasing the number of individuals that know their HIV status, bringing them into medical care, and initiating HAART at earlier stages of diseases will ultimately reduce the transmission of HIV. This idea is reliant on linking and retaining individuals in HIV medical care. The authors first identified that the percentage of those newly diagnosed individuals that enter care and the percentage of individuals living with HIV that regularly attend HIV medical visits must be known in order to evaluate the potential success of the 'test and treat' strategy. Retention in care for this meta-analysis was defined as those individuals living with HIV that kept three or more HIV medical visits in the prior 12 months or kept visits in consecutive quarters or consecutive 6-month periods through the measurement period. These assessment intervals represent the current standards of care.

Marks et al. searched three electronic databases (PUBMED, EMBASE, and CINAHL) for studies published between 1996 and 2009 that included information on HIV, linkage to care, retention and medical care and studies that were based in the United States. Separate meta-analyses were conducted for entry into care and retention in care. These studies were used to estimate a proportion of individuals in the U.S. that were linked to care and the proportion that were retained in medical care. The authors identified 26 U.S. studies that included a total of 53,323 persons living with HIV related to entry into care. For retention in care, 28 studies were identified with a total of 75,655 HIV-positive persons.

Meta-analysis findings for entry into care:

     1. 69% of diagnosed persons entered medical care

     2. 72% of diagnosed persons entered care within 4 months of diagnosis

     3. Among those diagnosed in emergency/care departments 76% entered care

     4. Among those diagnosed in community venues 67% entered care

Meta-analysis findings for retention in care:

     1. 59% of persons living with HIV had multiple HIV medical care visits in the measurement period

     2. 69% of HIV-positive persons had 2 or more medical visits during a 6-month interval

     3. 54% were retained, defined as 2 or more medical visits, during a 12-month interval

     4. Retention over extended periods of time for HIV-positive individuals with consecutive medical visits:

         a. 61% retained during 18-24 month period

         b. 26% retained during 3-5 year period

     5. Retention rates were higher among those with previously established HIV medical care

     6. No significant retention in care differences between high-risk populations (drug users, mental health problems, recently released from prison, or those unstably housed) as compared to the general HIV-positive population.

The meta-analyses performed by Marks et al. identified fairly high rates of both entry into care and retention in HIV medical care. The authors also suggest that entry and retention may be further improved by specific interventions including: linkage coordinators, utilizing a strengths-based approach when working with individuals living with HIV, addressing motivational and behavioral factors that impact a person's medical care attendance, and addressing unmet needs of clients related to mental health, substance abuse, housing and transportation. Additionally, the authors recommend working on clinic-level factors to improve retention.   Some of the key clinic-level factors are responsive and supportive providers that focus on positive relationships with clients, flexible hours, appointment reminder notices, and client-friendly administrative and medical systems. The authors did not mention whether mortality or out-migration had an effect on longer term retention and this data potentially identifies a major deficiency in the lifetime care of HIV-positive individuals that can be used to propel studies and quality improvement projects related to lifetime retention.