The COVID-19 pandemic as a catalyst for differentiated care models to end the HIV epidemic in the United States: applying lessons from high-burden settings.

Abstract

The COVID-19 pandemic has exposed longstanding vulnerabilities in our healthcare system, and has laid bare the individuals and communities most threatened by insufficient public health support. In the United States, persons with HIV (PWH) represent a heterogenous population with complex medical and sociobehavioral needs currently unmet by systemically flawed care models [1,2]. Thriving on health disparity, COVID-19 devastates the same communities where HIV prevalence is highest [3], illuminating the catastrophic synergy of poverty, policies, and structural racism [4]. This unprecedented time demands reexamination of HIV care delivery, paving the way for a revitalized healthcare infrastructure tailored to the needs of PWH and those at-risk of HIV to realize the goals of the ending the HIV epidemic (EHE) initiative [5]. The EHE initiative aims to reduce new HIV infections in the United States by 90% by 2030 through focusing resources on hardest hit communities. A vital component of this strategy is to treat HIV infection rapidly and effectively so PWH achieve and maintain viral suppression. Prior to COVID-19, HIV care in the United States was frequently delivered by facility-based, provider-led visits occurring at 3–6-month intervals, with antiretroviral therapy (ART) dispensed in 30-day increments for the majority of patients. This ‘one-size-fits-all’ model inadequately considers the varied needs of an estimated 1.1 million PWH residing in diverse local contexts across the United States [6]. The consequence is substantial drop-offs at each step in the HIV care continuum; in 2016, only 49% of PWH were retained in care and 53% had viral suppression, the current marker of successful HIV treatment [6]. In February 2020, COVID-19 arrived to the Southern United States, the national epicenter of the HIV/AIDS epidemic and a region crippled by limited healthcare infrastructure and widespread health disparities [1,7]. As the pandemic rapidly expanded, clinic operations pivoted to minimize in-person visits while ensuring patients had an uninterrupted ART supply. COVID-19 forced health systems to urgently implement mechanisms to reach patients and keep essential medications accessible through telehealth, medication delivery programs, mobile health units, and home visits. For implementers of HIV care, the pandemic provides a long-overdue impetus to build innovative, more patient-centered healthcare delivery models. Differentiated service delivery (DSD) is an HIV care model that combines aspects of facility-based and community-based care and healthcare worker-led or peer-led care processes [8] (Fig. 1). Fundamentally, DSD is an adaptive approach that aims to efficiently use limited resources by tailoring health services to local context, and patients’ clinical status and preferences. This care model originated in sub-Saharan Africa after global HIV care shifted to a ‘treat all’ strategy in 2016. Existing healthcare infrastructure became severely overwhelmed by the marked expansion of PWH requiring care [9]. To expand access, healthcare providers, pharmacies, and communities collaborated on remodeling ART delivery, adherence support, and retention tracking by leveraging local resources including personnel and alternative care sites. Employing a more client-centered approach than standard ambulatory-based visits, DSD empowers the primary stakeholder (patient) to find a mode of care conducive to their lifestyle while simultaneously decongesting the traditional healthcare system [8,9].Fig. 1: Current care delivery for persons with HIV in the United States comprises in-facility, provider-led visits every 3–6 months with antiretroviral therapy dispensed in 30-day supplies (a). Differentiated service delivery provides a more patient-centered approach adapted to local preference and context, allowing for innovative care platforms via telehealth, mobile units or home visits, and antiretroviral therapy delivery by mail order, community distribution points, or in-facility ‘fast-track’ pick-up supported by adherence clubs (b).DSD has been most widely adopted in high-burden settings, where heterogeneity in HIV microepidemics (ranging from stable patients requiring fewer system touches to ill patients requiring intensive medical services) [10,11] drives the need for a personalized public health approach [12]. In the United States, populations of PWH, barriers to care, and care continuum outcomes differ regionally, with the Deep South falling behind [1,13]. Implementation of locally tailored DSD across the country could offer access to care and ART in diverse settings such as clinics, communities and homes, with varying frequency of clinical assessment based on need [14]. The Ebola crisis in 2014–2015 accelerated use of DSD models in African countries to safeguard continuous ART through 6-month refills and community distribution [15]. COVID-19 likewise catalyzed adoption of HIV care models in the United States that are more accessible, differentiated, and patient-centered, and progress should be sustained beyond the current crisis. While DSD has thus far been most commonly implemented for PWH with stable viral suppression, similar strategies may be useful for populations with retention and adherence challenges, especially if difficulty attending in-person provider of pharmacy appointments leads to ART disruptions. Rather than dispensing 1-month ART refills by pharmacy pick-up, DSD models encourage 3-month or 6-month ART supplies obtained via ‘fast-track’ intrafacility retrieval or community distribution points [16]. Models are individualized based on community context and patient status (i.e. newly initiating ART, unstable or stable on treatment) [17,18]. Task-shifting has been widely used in South Africa since 2012 when the STRETCH trial demonstrated nurse-initiated and monitored ART improved mortality for PWH with CD4+ cell counts more than 200 cells/μl and overall quality of care [19]. Another South African study found that when compared with usual care, participation in client-led ‘adherence clubs’ improved retention in care (81.6 vs. 89.5%) and had comparable viral suppression (79.6 vs. 80.0%) [20]. While ‘fast-track’ models were cost-saving in Malawi (10% reduction in annual unit cost of providing care to stable patients) [18], it will be important to evaluate cost-effectiveness in US settings and among patients of varying clinical stability. Reduced frequency of in-person visits and ramping-up telehealth has potential to further decongest clinics, reduce patient inconvenience and improve outcomes. In 2015, the Veterans Affairs healthcare system offered telehealth in HIV specialty clinics given the large proportion (21%) of PWH who must travel at least 1 h for care. A cluster-randomized trial of 1670 veterans found telehealth uptake increased as the time saved from travel increased; viral suppression was higher among telehealth users than controls (91.5 vs. 80.0%) [21]. Telehealth is generally acceptable and multibeneficial [22]; however, the availability of and proficiency with technology varies among patients, presenting challenges to effective patient–provider communication. Ideally programs should offer flexibility in format (video, telephonic, face-to-face, coprovider) to accommodate patient–provider preferences and also guide implementation science to determine which approaches are most effective. COVID-19 has starkly exposed gaps in our healthcare infrastructure beyond service delivery, namely social determinants of health that are exacerbated by the current crisis. Without addressing the intersectionality of structural racism, food insecurity, housing instability, stigma, mental health, and substance use disorders – synergized by the COVID-19 and HIV epidemics – we will not be successful at EHE in the United States [1]. DSD offers a strategic platform to confront social determinants of health that obstruct HIV treatment outcomes (i.e. retention and viral suppression) and deliver on the other EHE pillars: diagnosis, prevention, outbreak response [5]. Critical to this mission is building a robust public health workforce trained in testing, counseling, and triaging community referrals [23]. Community health worker and patient navigator interventions among PWH in the United States and high-burden settings have been shown to promote psychosocial outcomes and housing security, respectively, and ultimately improve success across the care continuum [24,25]. Investing in community-based public health personnel equipped with multifaceted skills and resources allows for bundling of health promotion activities [26]. For example, performing culturally competent COVID-19 contact tracing could double as an opportunity to conduct HIV testing and provide preexposure prophylaxis for HIV prevention [27]. Such integrated service delivery has the potential to destigmatize and scale-up testing (for COVID-19, HIV, other sexually transmitted infections, and noncommunicable diseases, such as hypertension and diabetes), build trust among communities, and restore public health infrastructure for long-lasting impacts on individual and community health [23,26,28]. The current era prompts reevaluation of the standard metrics used to evaluate the quality of HIV care and to inform programming. Current measures are imperfect; they require several visits per year, involve longitudinal measurement, are not immediately actionable, and do not consider the patient's psychosocial health and overall wellbeing. Among the six core HIV/AIDS Bureau clinical care performance measures, three require a visit in the last 6 months (HIV medical visit frequency, gap in HIV medical visits, annual retention in care) [29]. Using current definitions, if a patient stably suppressed was seen annually, this would result in misclassification as ‘not retained’. Moving forward, patients with stable viral suppression should be allowed annual HIV-1 RNA measurements – instead of biannual – without forfeiting ART coverage or retention status. Acceptable clinical encounters should include telehealth, in addition to face-to-face visits. Lastly, the pandemic has accentuated the psychologic toll of health, economic, and social stressors on overall wellbeing [30]. Validated tools exist to measure quality of life (QOL) among PWH [31] and should be the final step in the care continuum, beyond viral suppression. For example, the WHOQOL-HIV BREF is a cross-culturally validated scale assessing six QOL domains, can be self-administered in 10 min or less, and has been used in Ethiopia and Nigeria among PWH to guide targeted interventions [32,33]. This scale could be integrated into US DSD models once adapted to local context. Differentiated care models have been needed for decades, but the COVID-19 pandemic has served as a catalyst to harness tragedy for change [16,34]. In refocusing our health systems to become patient-centered and community-invested, we have an unparalleled opportunity to use this crisis to restructure HIV care delivery permanently. Not only will these changes lead to progress toward EHE in the United States, but may improve health disparities and clinical outcomes for PWH and all people in vulnerable populations. The HIV/COVID-19 syndemic makes it apparent that we must prioritize robust and sustained investment in addressing social determinants of health and in rebuilding our public health infrastructure to provide destigmatized and accessible care for all. Acknowledgements This work was supported by the Emory Center for AIDS Research (award number P30-AI-050409). L.F.C. is also supported by the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH) (award numbers UL1TR002378 and TL1TR002382). C.A.M. is also supported by the National Heart, Lung, and Blood Institute of the NIH (award number K23-HL152903). C.D.L. is also supported by the National Institute of Allergy and Infectious Diseases (NIAID) of the NIH (award number K23-AI124913). V.C.M. is also supported by the NIAID of the NIH (award numbers 5U01AI069918-14, MH121424-01A1, R01AI15124718). Conflicts of interest There are no conflicts of interest.