Abstract
BackgroundMedical care re-engagement is critical to suppressing viral load and preventing HIV transmission, morbidity and mortality, yet few rigorous intervention studies address this outcome. We assessed the effectiveness of a Ryan White Part A-funded HIV Care Coordination Program relative to ‘usual care,’ for short-term care re-engagement and viral suppression among people without recent HIV medical care.MethodsThe Care Coordination Program was launched in 2009 at 28 hospitals, health centers, and community-based organizations in New York City. Designed for people with HIV (PWH) experiencing or at risk for poor HIV outcomes, the Care Coordination Program provides long-term, comprehensive medical case management utilizing interdisciplinary teams, structured health education and patient navigation. The intervention was implemented as a safety-net services program, without a designated comparison group. To evaluate it retrospectively, we created an observational, matched cohort of clients and controls. Using the HIV surveillance registry, we identified individuals meeting program eligibility criteria from December 1, 2009 to March 31, 2013 and excluded those dying prior to 12 months of follow-up. We then matched clients to controls on baseline status (lacking evidence of viral suppression, consistently suppressed, inconsistently suppressed, or newly diagnosed in the past 12 months), start of follow-up and propensity score. For this analysis, we limited to those out of care at baseline (defined as having no viral load test in the 12 months pre-enrollment) and still residing within jurisdiction (defined as having a viral load or CD4 test reported to local surveillance and dated within the 12-month follow-up period). Using a GEE model with binary error distribution and logit link, we compared odds of care re-engagement (defined as having ≥ 2 laboratory events ≥ 90 days apart) and viral suppression (defined as having HIV RNA ≤ 200 copies/mL on the most recent viral load test) at 12-month follow-up.ResultsAmong 326 individuals out of care at baseline, 87.2% of clients and 48.2% of controls achieved care re-engagement (Odds Ratio: 4.53; 95%CI 2.66, 7.71); 58.3% of clients and 49.3% of controls achieved viral suppression (Odds Ratio: 2.05; 95%CI 1.30, 3.23).ConclusionsHIV Care Coordination shows evidence of effectiveness for care and treatment re-engagement.
Highlights
The individual and population-level benefits of antiretroviral therapy (ART) for HIV depend upon consistent medical care to achieve and maintain viral suppression (VS) [1,2,3]
In December 2009, the New York City (NYC) Health Department launched a Ryan White Part A—funded comprehensive medical case management intervention known as the HIV Care Coordination Program (CCP)
We developed an a priori list of variables considered to be potential confounders of the relationship between enrollment in the CCP and the outcome of VS: sex, race/ethnicity, age at enrollment/pseudo-enrollment, country of birth, HIV transmission risk, year of diagnosis, baseline viral load (VL), baseline CD4, successful linkage to HIV care within three months of diagnosis, presence of an AIDS diagnosis within one year of HIV diagnosis, number of VL laboratory tests reported in the year prior to enrollment/pseudo-enrollment, residential Zone Improvement Plan (ZIP) code at enrollment/pseudo-enrollment, HIV prevalence and poverty level within ZIP code at enrollment/pseudoenrollment and interaction terms for baseline CD4 and baseline VL, baseline CD4 and race, sex and risk, and year of diagnosis and risk [23]
Summary
The individual and population-level benefits of antiretroviral therapy (ART) for HIV depend upon consistent medical care to achieve and maintain viral suppression (VS) [1,2,3]. The CCP has demonstrated effectiveness for VS and for durable VS (defined as regular monitoring and all viral loads ≤ 200 copies/mL in months 13–36 of follow-up) among previously unsuppressed individuals [16,17,18], but it has not been examined for its effect on CR. The objective of this analysis was to assess CCP versus usual-care effectiveness for CR and VS among people with HIV (PWH) lacking recent HIV medical care. We assessed the effectiveness of a Ryan White Part A-funded HIV Care Coordination Program relative to ‘usual care,’ for short-term care re-engagement and viral suppression among people without recent HIV medical care
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