HIV care using differentiated service delivery during the COVID-19 pandemic: a nationwide cohort study in the US Department of Veterans Affairs.

Kathleen A Mcginnis,Evelyn Hsieh,Roozbeh Yousefzadeh,Amy C Justice,Kathleen M Akgün,Melissa Skanderson,Christopher T Rentsch,Lesley S Park,Vincent C Marconi,Joseph T King,Janet P Tate,Farah Kidwai‐Khan,Joseph Erdos,Christopher Ruser

doi:10.1002/jia2.25810

Abstract

IntroductionThe Department of Veterans Affairs (VA) is the largest provider of HIV care in the United States. Changes in healthcare delivery became necessary with the COVID‐19 pandemic. We compared HIV healthcare delivery during the first year of the COVID‐19 pandemic to a prior similar calendar period.MethodsWe included 27,674 people with HIV (PWH) enrolled in the Veterans Aging Cohort Study prior to 1 March 2019, with ≥1 healthcare encounter from 1 March 2019 to 29 February 2020 (2019) and/or 1 March 2020 to 28 February 2021 (2020). We counted monthly general medicine/infectious disease (GM/ID) clinic visits and HIV‐1 RNA viral load (VL) tests. We determined the percentage with ≥1 clinic visit (in‐person vs. telephone/video [virtual]) and ≥1 VL test (detectable vs. suppressed) for 2019 and 2020. Using pharmacy records, we summarized antiretroviral (ARV) medication refill length (<90 vs. ≥90 days) and monthly ARV coverage.ResultsMost patients had ≥1 GM/ID visit in 2019 (96%) and 2020 (95%). For 2019, 27% of visits were virtual compared to 64% in 2020. In 2019, 82% had VL measured compared to 74% in 2020. Of those with VL measured, 92% and 91% had suppressed VL in 2019 and 2020. ARV refills for ≥90 days increased from 39% in 2019 to 51% in 2020. ARV coverage was similar for all months of 2019 and 2020 ranging from 76% to 80% except for March 2019 (72%). Women were less likely than men to be on ARVs or to have a VL test in both years.ConclusionsDuring the COVID‐19 pandemic, the VA increased the use of virtual visits and longer ARV refills, while maintaining a high percentage of patients with suppressed VL among those with VL measured. Despite decreased in‐person services during the pandemic, access to ARVs was not disrupted. More follow‐up time is needed to determine whether overall health was impacted by the use of differentiated service delivery and to evaluate whether a long‐term shift to increased virtual healthcare could be beneficial, particularly for PWH in rural areas or with transportation barriers. Programmes to increase ARV use and VL testing for women are needed.

Highlights

The Department of Veterans Affairs (VA) is the largest provider of HIV care in the United States
In this study of people with HIV (PWH) receiving care in the VA, we found that HIV care during and prior to the COVID-19 pandemic was similar by race/ethnicity except for those of unknown race/ethnicity and this is consistent with a previous study that reported that HIV clinical management and adherence in the VA was similar by race/ethnicity [31]
More observation time is needed to determine whether the health of PWH, measured by viral load (VL) suppression, CD4 cell count, comorbidity diagnoses and other long-term outcomes, was impacted by the differentiated service delivery and to evaluate whether a long-term shift to increased use of virtual healthcare could be beneficial, for those in rural areas or with transportation barriers

Summary

Introduction

Changes in healthcare delivery became necessary with the COVID-19 pandemic. We compared HIV healthcare delivery during the first year of the COVID-19 pandemic to a prior similar calendar period. We determined the percentage with ≥1 clinic visit (in-person vs telephone/video [virtual]) and ≥1 VL test (detectable vs suppressed) for 2019 and 2020. Conclusions: During the COVID-19 pandemic, the VA increased the use of virtual visits and longer ARV refills, while maintaining a high percentage of patients with suppressed VL among those with VL measured. More follow-up time is needed to determine whether overall health was impacted by the use of differentiated service delivery and to evaluate whether a long-term shift to increased virtual healthcare could be beneficial, for PWH in rural areas or with transportation barriers. With the emergence of the COVID-19 pandemic, changes in healthcare delivery became immediately necessary [4,5], and the VA responded quickly by expanding virtual care [2,6–10]. By June 2020, 58% of VA visits were virtual compared to 14% prior to March 2020 [12]

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Discussion

Conclusion