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in+care Newsletter

Issue 17 


National Campaign to Improve Retention in HIV Care
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In This Issue
Integration of Retention Efforts
Provider Spotlight
Featured Article

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Data - National Averages*

(as of 04/30/13)

Gap Measure
(n = 141 sites, 99,572 patients)


Visit Frequency Measure
(n = 134 sites, 79,523 patients)


New Patient Measure
(n = 138 sites, 5,367 patients)


Viral Load Suppression
(n = 142 sites, 115,920 patients)


*data not unduplicated
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


Website Updated!

 The in+care Campaign has recently updated its website to make searching for Retention Strategies and Tools easier for you! Visit the website today to explore the new area!

Retention in Care and Viral Suppression


Spring is here and the in+care Campaign continues to bring you information and activities related to HIV patient retention in+care. The month of April was dedicated to the goal of viral load suppression for people living with HIV. There is a great deal of working going on across the U.S. in this area and as a whole, participants in the in+care Campaign are making incremental progress in increasing the proportion of HIV patients who achieve this goal. Keep up the good work and remember to tell us what strategies you are putting in place to improve patient retention by visiting this link and completing four simple questions. Please take a few moments to fill out this form.
Upcoming Events
+ Partners in+care Webinar | What is Viral Suppression?
May 21, 2013 at 12pm ET
Agenda: Dr. Moupali Das of the San Francisco Department of Public Health will describe viral suppression for a non-clinical audience. The presentation will include a discussion of why viral load suppression is the ultimate goal of the in+care Campaign and will drill down to what that means to individuals living with HIV. Treatment as prevention, community viral load and other topic areas will also be covered. As always, there will be a panel discussion including people with HIV, NQC quality coaches and Campaign staff to provide additional context related to our important work with in+care.
If you have any specific questions you would like to have addressed, please mail them in advance of the webinar to Michael@NationalQualityCenter.org. No pre-registration is needed, just enter the room as a guest at the time of this webinar.
Dial-in#: 866.394.2346
Participant Code: 397 154 6368 #
+ in+care Campaign Webinar | Care Transitions, Adolescent to Adult Care
May 22, 2013 at 3pm ET
Agenda: Dr. Rana Chakraborty, Dr. Andres Camacho-Gonzalez and nurse practitioner Ashley Boylan of Grady Infectious Disease Program in Atlanta, GA, will present on their adolescent care program and the steps they have put in place to ensure smooth transitions to adult care that retain these patients in care. In addition, the team will review findings from recently conducted research in this area and policy recommendations that flow from their research. Finally, Campaign staff will review recent Campaign data submissions and retention improvement strategies submitted by Campaign participants that relate to adolescent care and transitioning to adult care.
If you have any specific questions you would like to have addressed, please mail them in advance of the webinar to Michael@NationalQualityCenter.org. No pre-registration is needed, just enter the room as a guest at the time of this webinar.
Dial-in#: 866.394.2346
Participant Code: 397 154 6368 #



+ Partners in+care Webinar | Mental Health and Medical Services Linkages
May 29, 2013 at 12pm ET
Agenda: In this Campaign we have explored how to retain patients in care. In this presentation, David Thompson of the Substance Abuse and Mental Health Services Administration will discuss how federally funded mental health programs are actively working to ensure people with HIV are linked to HIV medical care. Examples from the field will be shared by AIDS Alabama and the New Orleans AIDS Clinic.
If you have any specific questions you would like to have addressed, please mail them in advance of the webinar to Michael@NationalQualityCenter.org. No pre-registration is needed, just enter the room as a guest at the time of this webinar.
Dial-in#: 866.394.2346
Participant Code: 397 154 6368 #



+ Journal Club Webinar | Timothy Minniear, MD
May 30 at 2pm ET
Agenda: Dr. Timothy Minniear of St. Jude's Chilren's Research Hospital in Memphis, TN, discusses his recent peer reviewed study "Delayed Entry Into and Failure to Remain in HIV Care Among HIV-Infected Adolescents." Participants will have the opportunity to ask Dr. Minniear questions regarding his work. You can find the abstract and full text for this work using the following citation: Minniear, T. et al. "Delayed Entry Into and Failure to Remain in HIV Care Among HIV-Infected Adolescents". AIDS Res Hum Retroviruses. 2013 Jan;29(1):99-104.

If you have any specific questions you would like to have addressed, please mail them in advance of the webinar to Michael@NationalQualityCenter.org. No pre-registration is needed, just enter the room as a guest at the time of this webinar.

Dial-in#: 866.394.2346
Participant Code: 397 154 6368 #
+ Next Campaign Performance Data Submission

June 3, 2013



+ Next Improvement Update Form Submission
June 15, 2013
Keep up-to-date with the latest in+care events through our webpage: http://incarecampaign.org/index.cfm/75283


Continuum of HIV Care among Ryan White HIV/AIDS Program Clients

New data show that the majority of patients receiving medical care funded by the Ryan White (RW) HIV/AIDS Program are virally suppressed. Study data are from the 2010 RW HIV/AIDS Services Report, a client-level data system. Results were presented in March at the Conference on Retroviruses and Opportunistic Infections (CROI) by HRSA/HAB's Drs. Laura Cheever and Rupali Doshi.


Beginning in 2009, RW grantees began annual reporting of demographic, service, and clinical data into the Ryan White Services Report (RSR) using encrypted unique client identifiers. The RSR 2010 data set was cleaned, de-duplicated using probabilistic records linkage techniques, and merged to create a single record for each client. Using these data, HAB calculated the total number of RW clients served, and the numbers of clients who were HIV-infected and received RW-funded medical care or case management, received medical care and had visit dates available, were retained in medical care (≥2 visits ≥90 days apart), were prescribed antiretroviral therapy (ART), and had their viral load suppressed (HIV RNA <200 copies/ml) at the most recent test.


Findings include:

* An estimated 546,156 individual clients received RW services in 2010.
* Of these, 429,881 (79%) received any RW-funded outpatient ambulatory medical care or case

* 307,562 (56% of RW clients) received RW-funded medical care.
* Of the 291,449 individuals who received RW-funded medical care and had visit dates available,

  220,645 were retained in medical care (76%).
* Among subpopulations, retention was highest in those <13 years, ≥65 years, individuals with

  multiple forms of health insurance, and females.
* Of the 261,865 individuals who received RW-funded medical care and had ART data and visit

  date available, 208,808 (80%) were prescribed ART.
* Of the 250,344 individuals who received RW-funded medical care and had viral load data

  available, 174,114 (70%) had viral load suppressed (see chart below).
* Viral load suppression was higher in retained patients (75%) compared with patients who were

  not retained (50%).



These rates of retention, ART prescription, and viral load suppression among RW clients are high compared to CDC's nationwide estimates of the continuum of care for all people living with HIV.


To see the full study:

Working Toward Viral Load Suppression

As Campaign participants know, one of the in+care performance measures focuses on viral load suppression-the percentage of patients, over the age of 24 months, with a diagnosis of HIV/AIDS with a viral load less than 200 copies/mL at last viral load test during the measurement year. Ryan White grantees are taking a variety of approaches to promote viral suppression.  Here are three examples.


Los Angeles County Department of Public Health (Part A)
For several years, the Los Angeles County Department of Public Health (LACDPH) has implemented various programs aimed at identifying, engaging, and retaining HIV-infected individuals in medical care to achieve viral load suppression and prevent transmission of HIV.  In 2006, LACDPH began implementing rapid HIV testing (2-test) algorithm and later restructured its HIV Testing Services (HTS) programs to create a strong incentive structure tied to specific performance measures including HIV positivity rate, linkage to medical care, referral to partner services, and HIV testing episodes. As a result, many HTS programs developed more intensive client-centered approaches to better link clients into medical care. 

For individuals who were not ready to link to care, LACDPH implemented Antiretroviral Treatment Access Study Linkage Case Management (ARTAS LCM) protocol, which deploys public health investigators to locate clients who tested positive for HIV to offer education and partner elicitation services and use case management techniques to support initial linkage and engagement in medical care.  Additionally, youth linkage specialists worked with children or adolescents newly diagnosed with HIV through public testing programs to facilitate their timely entry into HIV medical care.  In 2008, LACDPH obtained NIH funding to support the use of peer navigation in improving linkage to care (LTC) for two specific populations with historically poor LTC in the EMA-HIV-infected individuals released from jail and MSM of color.

While LTC is a critical first step, ongoing engagement and retention in care are equally important to achieve viral load suppression and improved health outcomes.  A concurrent core set of Ryan White services supports ongoing engagement and retention in care that includes early intervention programs (EIP) with outreach bridge workers, case management, substance abuse, mental health, transportation, and other wrap around services. Two complementary outreach-focused interventions were implemented in 2009 to enhance efforts. The first intervention, Project Engage, taps into the social networks of in-care HIV-infected patients to identify other people living with HIV/AIDS.  The second intervention is a navigation program that is anchored to HIV medical homes and aims to identify patients who have fallen out of care at their medical clinics. HIV Surveillance and Ryan White Program data are cross referenced to determine whether these patients are receiving HIV medical services elsewhere in the EMA. Navigators reach out to those patients who are out-of-care to address barriers and re-engage them in HIV medical care.  An HIV non-occupational post-exposure prophylaxis (nPEP) demonstration project was implemented to deliver intensive biomedical prevention and risk reduction counseling to individuals following very high-risk non-occupational exposure to HIV. In 2012, the pilot was turned into a successful nPEP program serving clients in two of the EMA's most affected areas, West Hollywood and South Los Angeles.

Once patients are successfully linked to medical care, ongoing engagement and retention in care are top priorities.  In late 2012, LACDPH implemented Medical Care Coordination (MCC), a Ryan White system-wide program within Los Angeles County designed to streamline and improve HIV-infected patients' access, retention, and adherence to medical care and treatment. The MCC model employs a multi-disciplinary team approach that integrates both medical and non-medical case management by coordinating behavioral interventions and support services with medical care to promote improved health outcomes.  The core team-made up of a registered nurse, social worker, and case worker-are co-located at the patient's medical home. LACDPH developed an MCC protocol and assessment tool used to deliver the intervention and LACDPH staff provide ongoing training to accommodate current and new MCC core team members and staff.

Over the last three years, LACDPH became an active participant in the regional quality group and thereafter, joined the in+care Campaign.  As a result of the above efforts and participation in the in+care Campaign, LACDPH formalized its process of collecting data on viral load suppression.  LACDPH is using this in+care performance measure to track viral load suppression to evaluate the effectiveness of linkage and retention activities.


Learn more at http://publichealth.lacounty.gov/aids/index.htm


Virginia Department of Health (Part B)
Two years ago, the Virginia Department of Health (VDH) received a SPNS grant focused on system linkages and access to care. As part of the SPNS intervention, VDH implemented a patient navigator model. The model was pilot tested during the first two years of the grant and has recently been rolled out by Part B-supported providers in two additional regions of the state. The navigators serve as a link between HIV testing sites and medical care and then work to support retention in care. Mental health service networks are also being developed in these health regions to assist with retention.

An important tool that has been developed is the coordination of care form. HIV testing sites requested that VDH develop a feedback loop to inform them that a patient has entered medical care. Patient navigators use the form to document when a medical appointment is scheduled.

Implementing a new model across multiple providers presents some challenges. Providers that had existing programs experienced some infrastructure and staffing challenges. In addition, there was some resistance to change, especially by those providers that thought they already had a successful model in place. VDH has provided extensive training in the new model with an emphasis on the components focused on mental health, such as motivational interviewing. A fidelity monitoring program has been initiated, which will provide feedback to providers on how effectively they are implementing the model.

In conjunction with implementing the patient navigator model, VDH has worked to combine HIV-related data systems in the state. Previously, HIV prevention and care data were maintained in separate systems. The new database will be used for a variety of purposes, including tracking patients that are lost to care."

In the new database, viral load data are collected and viral suppression is tracked at the provider, regional, and state level by gender and race. Patient navigators use the data to track viral suppression, which will be one of the ways VDH measures the effectiveness of the patient navigator model.

Learn more at http://www.vdh.virginia.gov/epidemiology/DiseasePrevention/HCS/.



University of Kansas Medical Center (Part C and D)
As a provider of direct services, KU Medical Center has taken a "hands on" approach to tracking viral suppression. An important part of this process was "going electronic." A key step was implementing electronic laboratory reporting and linking the results to the electronic health record. This greatly reduced the level of effort required to manually enter data and also reduced the possibility of error. Now that the data are readily available, staff are using the data to provide retention support.


These efforts are paying off. At the beginning of 2012, 600 of 1,100 HIV patients (55%) had a viral load below 200. By the end of the year, that number had increased to 800 of 1,100 HIV patients (73%) patients (an increase of .

This year, KU will be collecting retention and adherence best practices from consumers-after all, they are the experts on what works. 


* Patients with a viral load over 100,000 are automatically identified.
* Patients with high viral load are contacted by case managers outside of medical visits to
  provide additional support.
* Team clinical conferences are held twice a year to review each patient and consider the need
  for addition interventions to support retention. 
Disparities in engagement in care and viral suppression among persons with HIV
Muthulingam, D., Chin, J., Hsu, L., Scheer, S., Schwarcz, S.

Researchers from the University of California, San Francisco and the San Francisco Department of Public Health used HIV surveillance data to measure the relation between socio-demographic and risk disparities and the timely linkage to care, retention in care, and viral suppression among persons newly diagnosed with HIV in San Francisco. Surveillance data were used because the data are population-based, systematically and routinely collected, and evaluated annually.


According to the research, only an estimated 19-35 percent of people living with HIV achieve successful viral suppression. Disparities occur in certain populations across the HIV testing and care continuum.


Reducing such disparities is a goal of the National HIV/AIDS Strategy.


Below are the subpopulations with disparties for each aspect of the continuum found in the San Francisco data


* Delays in diagnosis (people of color, heterosexuals, those with unknown risk, those without
  insurance, immigrants)

* Linkage to care (immigrants, younger persons, African Americans, uninsured, testing in
  publicly funded sites)
* Retention in care (African Americans, Latinos, heterosexual men, injection drug users,
  unstably housed, unmet social needs, adolescents)
* Interruptions in therapy/failed viral suppression (women, Latinos, African Americans, younger
  persons, substance users, unstably housed)

The study sample consisted of 862 San Francisco residents who were diagnosed with HIV between 2009 and 2010. The researchers measured the characteristics and proportion of persons linked to medical care within six months of diagnosis, retained in medical care for second and third visits, and virally suppressed within 12 months of diagnosis.

According to the study findings, 750 (87%) of those diagnosed entered medical care within six months of diagnosis. Of these, 72 percent had a second medical visit in the following 3-6 months; and of these, 80 percent had a third medical visit in the following 3-6 months. Viral suppression was achieved in 50 percent of the total study population and in 76 percent of those retained for three medical visits.

Factors associated with not entering care were a lack of health insurance and homelessness. Unknown insurance status was associated with a failure to return for a second medical visit and those less than 30 years old were less likely to be retained for a third medical visit. Independent predictors of failed viral suppression included age <40 years, homelessness, unknown housing status, and having fewer than three medical visits. The researchers will use the study findings as a baseline to monitor engagement in care and the achievement of viral suppression.

The researchers noted that although current standardized methods of HIV surveillance provide consistent data with which to monitor diagnosis and care indicators, they do not provide data on care utilization. The researchers echoed the recommendation of the Institute of Medicine for the use of multiple data sources to evaluate successes, failures, and factors associated with HIV diagnosis and care. 

Connect. With patients.
Collaborate. With a community of learners.
Change. The course of HIV. 

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