Human Immunodeficiency Virus Care Delivery Research Articles

Impact of the COVID-19 Pandemic on HIV Services in Korea: Results from a Cross-Sectional Online Survey.

BackgroundGlobally, the coronavirus disease 2019 (COVID-19) pandemic has compromised human immunodeficiency virus (HIV) services. The study aimed to assess the impact of COVID-19 on the access and delivery of HIV care in Korea.Materials and MethodsPeople living with HIV (PLHIV), people at risk of HIV (PAR) and prescribers of HIV care were recruited through a patient advocacy group, online communities for men who have sex with men (MSM) and a HIV care center for a web-based survey between October 22 and November 26, 2020. The survey compared the frequency of hospital/clinic visits, HIV-related testing, access to antiretroviral therapy (ART) or preventive medications, and experience with telehealth services by PLHIV and PAR between the pre-pandemic and pandemic eras.ResultsOne hundred and twelve PLHIV (mean age: 38.5 ± 10.2 years), 174 PAR (mean age: 33.5 ± 8.0 years) and 9 prescribers participated the survey; ≥97% of the PLHIV and PAR were male. A greater proportion of PAR than PLHIV reported a decrease in the frequency of hospital/clinical visits (59.2% vs. 17.0%) and HIV-related testing (50.6% vs. 6.3%) since COVID-19. Among PAR, not engaging or engaging less in high-risk behaviors was the most frequently cited reason (51.1%) for decreased frequency of HIV-related tests. A substantial proportion of PLHIV (12.5%) and PAR (50.0%) experienced interrupted use of ART and HIV preventive medications, respectively. A substantial proportion of PLHIV (35.7%) and PAR (62.5%) were concerned about the long-term accessibility of HIV care, however, >90% had not used any types of telehealth services during the pandemic.ConclusionOverall, COVID-19 has negatively impacted the access and delivery of HIV services in Korea, especially HIV-related testing for PAR. Our findings highlight the need to develop strategies to mitigate the interrupted HIV care.

The Impact of Human Immunodeficiency Virus and Menopause on Bone Mineral Density: A Longitudinal Study of Urban-Dwelling South African Women.

An estimated 25% of South African women live with human immunodeficiency virus (HIV). Antiretroviral therapy roll-out has improved life expectancy, so many more women now reach menopause. We aimed to quantify changes in bone mineral density (BMD) during the menopausal transition in urban-dwelling South African women with and without HIV and determine whether HIV infection modified the effect of menopause on BMD changes. A 5-year population-based longitudinal study recruited women aged 40-60 years residing in Soweto and collected demographic and clinical data, including HIV status, anthropometry, and BMD, at baseline and at 5-year follow-up. All women were staged as pre-, peri-, or postmenopausal at both time points. Multivariable linear regression assessed relationships and interactions between HIV infection, menopause, and change in BMD. At baseline, 450 women had mean age 49.5 (SD 5.7) years, 65 (14.4%) had HIV, and 140 (31.1%), 119 (26.4%), and 191 (42.4%) were pre-, peri-, and postmenopausal, respectively; 34/205 (13.6%) women ≥50 years had a total hip (TH) or lumbar spine (LS) T-score ≤ -2.5. At follow-up 38 (8.4%), 84 (18.7%), and 328 (72.9%) were pre-, peri-, and postmenopausal. Those with HIV at baseline lost more total body (TB) BMD (mean difference -0.013 [95% confidence interval -0.026, -0.001] g/cm2 , p=0.040) and gained more weight 1.96 [0.32, 3.60] kg; p=0.019 than HIV-uninfected women. After adjusting for age, baseline weight, weight change, and follow-up time, the transition from pre- to postmenopause was associated with greater TB BMD losses in women with HIV (-0.092 [-0.042, -0.142] g/cm2 ; p=0.001) than without HIV (-0.038 [-0.016, -0.060] g/cm2 , p=0.001; interaction p=0.034). Similarly, in women who were postmenopausal at both time points, those with HIV lost more TB BMD (-0.070 [-0.031, -0.108], p=0.001) than women without HIV (-0.036 [-0.015, -0.057], p=0.001, interaction p=0.049). Findings were consistent but weaker at the LS and TH. Menopause-related bone loss is greater in women with HIV, suggesting women with HIV may be at greater risk of osteoporotic fractures. HIV services should consider routine bone health assessment in midlife women as part of long-term HIV care delivery. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

COVID-19 Pandemic as "Curate's Egg" on Human Immunodeficiency Virus Infection: A Commentary.

It is a high time not to sideline human immunodeficiency virus (HIV) response during the 2019 coronavirus disease (COVID-19) crisis. COVID-19 will affect the decade’s hard-earned gains from HIV care delivery and response. At the same time, it could be an important time for the COVID-19 containment response to help minimize the occurrence of a new infection. Sexual contact is the main transmission ways in HIV dynamics. However, COVID-19 prevention and control strategies such as movement restrictions, physical and social distancing will reduce exposure to such kinds of risk behaviors. Those containment strategies, including stringent infection prevention and control at health facilities, may minimize transmission of HIV infection and will reduce the incidence of new HIV infection. While recognizing the immense challenges of the COVID-19 pandemic, efforts should be made by governments and international organizations to maintain the response to HIV and to ensure that the progress made against HIV is not lost. In addition, it is very crucial to undertake further researches on the status of new HIV infection during the COVID-19.

A Survey of Patients' Perspectives on Outpatient HIV Care in the Netherlands.

IntroductionResponding to patients’ needs and preferences is important in the delivery of outpatient care. Recent and systematically collected data reflecting human immunodeficiency virus (HIV)-infected patients’ opinions on how their outpatient care should be delivered are lacking. Our aim was to identify aspects of care that people with HIV in outpatient care in The Netherlands consider important and to evaluate the extent to which the received care meets their expectations.MethodsWe measured patient preferences and experiences in a nationwide sample of HIV-infected patients using a modified, previously validated questionnaire (QUOTE-HIV).ResultsThe aspects of care that were considered most important were specific expertise of the care provider in HIV medicine, the care provider taking the patient seriously and receiving adequate information about treatment options. In addition, confidentiality of HIV status at the outpatient clinic was a major concern. Patient experiences were positive, with the majority of the respondents indicating that they always or usually received care in accordance with their preferences.ConclusionHIV-infected patients greatly value having care providers with HIV-specific expertise. Safeguarding the privacy of HIV status and the provision of information about treatment options are matters that deserve continuous attention in the delivery of outpatient HIV care.Electronic supplementary materialThe online version of this article (doi:10.1007/s40121-017-0164-z) contains supplementary material, which is available to authorized users.

Patient Centered Care for Persons with HIV Disease: Protocol Review for CASA Study (Care and Support Access) Early in Chronic Disease Management

Background: In the US, more than 1.2 million adults are living with human immunodeficiency virus (HIV); gay and bisexual men account for 82% of new diagnoses annually. Young men of color account for 67% of this total. Despite advances in disease control, lack of retention in care itself remains a barrier and how outpatient staff members impact this has not been investigated. The palliative approach is patient-centered care targeting relief of suffering and quality of life. This paper describes the original protocol for the Care and Support Access Study (CASA) where outpatient HIV staff members are challenged to improve outcomes for young men who have sex with men (yMSM) by integrating the palliative approach early (ePA) with HIV care delivery. Methods: The hypothesis is that ePA can favorably impact outcomes for yMSM in one HIV clinic compared with treatment as usual (TAU) at a second clinic. In the era of HIVdisease control, we use a quasi-experimental design with mixed methods to compare patient-level outcomes at 2 HIV clinics. The intervention fosters incorporation of the ePA with care provision using didactic and iterative education. We survey HIV staff members with regard to stress of care-giving. Qualitative interviews will highlight impact of the experience. Objectives: This paper reviews the aims of the study including: 1) compare outcomes of yMSM receiving care from staff using the ePA to those receiving TAU; 2) compare work-related staff stress at a clinic receiving the ePA with staff providing standard HIV outpatient care; and 3) refine, deliver and determine the acceptability and applicability of interdisciplinary professional education to deliver the ePA in HIV management. Discussion: We will measure the impact of the ePA on care delivery relative to patientcentered benefits. Lessons learned can contribute to a model for working with diverse patients facing challenging life transitions.

Human Immunodeficiency Virus (HIV) Quality Indicators Are Similar Across HIV Care Delivery Models.

There are limited data on human immunodeficiency virus (HIV) quality indicators according to model of HIV care delivery. Comparing HIV quality indicators by HIV care model could help inform best practices because patients achieving higher levels of quality indicators may have a mortality benefit. Using the Partners HIV Cohort, we categorized 1565 patients into 3 HIV care models: infectious disease provider only (ID), generalist only (generalist), or infectious disease provider and generalist (ID plus generalist). We examined 12 HIV quality indicators used by 5 major medical and quality associations and grouped them into 4 domains: process, screening, immunization, and HIV management. We used generalized estimating equations to account for most common provider and multivariable analyses adjusted for prespecified covariates to compare composite rates of HIV quality indicator completion. We found significant differences between HIV care models, with the ID plus generalists group achieving significantly higher quality measures than the ID group in HIV management (94.4% vs 91.7%, P = .03) and higher quality measures than generalists in immunization (87.8% vs 80.6%, P = .03) in multivariable adjusted analyses. All models achieved rates that equaled or surpassed previously reported quality indicator rates. The absolute differences between groups were small and ranged from 2% to 7%. Our results suggest that multiple HIV care models are effective with respect to HIV quality metrics. Factors to consider when determining HIV care model include healthcare setting, feasibility, and physician and patient preference.

The influence of integrated tuberculosis and human immunodeficiency virus service delivery on patient outcomes

Public health clinics in Cape Town, South Africa. To examine the influence of integrated tuberculosis (TB) and human immunodeficiency virus (HIV) service delivery on mortality, TB cure and successful treatment completion and loss to follow-up of TB-HIV co-infected patients on concurrent anti-tuberculosis and antiretroviral treatment (ART). A survey instrument was used to measure the degree to which TB and HIV services were jointly delivered, and patient data were collected retrospectively from clinic sites and the Department of Health. Six domains measuring integrated TB and HIV service delivery were modelled to assess their relationship with patient outcomes. Two domains, integrated TB and ART service delivery and the delivery of TB and HIV care by one clinical team, were associated with lowered odds of death. Care by the same clinical team was also associated with reduced loss to follow-up. Overall, these findings show that the organization and delivery of health services are important factors that influence health outcomes. These findings strongly support efforts by local governments to integrate TB and ART services, and may help to alleviate concerns that restructuring of TB programs could have a negative impact on long-standing gains.

"Know your CD4 campaign": 6-year outcomes from a quality improvement initiative to promote earlier initiation of antiretroviral therapy in Tanzania

Background: Late initiation of treatment for illness secondary to the human immunodeficiency virus (HIV) remains a major challenge in developing countries. Despite the World Health Organization (WHO) recommendation that treatment be initiated early in disease management, health providers conducting quality improvement monitoring in one region of Tanzania noted that common management practice relies upon clinical signs of advanced disease alone for initiation of combination antiretroviral therapy (ART). Although Tanzanian National Treatment Guidelines followed standard WHO recommendations, few patients initiated ART based on laboratory parameters. As a potential barrier to optimal patient outcomes, further investigation of this inconsistency led to recognition of challenges reflecting patient, healthcare staff, and laboratory levels that might inhibit the use of CD4 cell counts as the entryway to care. Materials and Methods: Using a quality improvement approach, investigations were pursued for six discrete activities of HIV care delivery with before and after measures of selected indicators. With respect to patient engagement, meetings and informal educational sessions were held to promote understanding of the meaning of and need for CD4 testing. For clinic staff: (1) Qualitative interviews were conducted with providers to understand why laboratory data was not being used and (2) on-site interviews were conducted with laboratory personnel to review beliefs, methods, and practices related to measurement of CD4 cells testing. A large scale local campaign was mounted to (1) educate and empower patients to recognize a need for CD4 information in management of their own care; (2) re-educate and encourage providers to use measured, rather than clinical observation alone to initiate ART; and (3) understand and resolve clinical and laboratory challenges. Based upon findings from the interviews: (1) Meetings with hospital administrations were effected to resolve institutional barriers to using CD4 cell testing. Specific on-site training was initiated for both providers, with regard to use of CD4 cell counts, and nurses, with advanced training to initiate routine CD4 testing. These activities were well received because all staff were able to review unlinked, site-based clinical data to appreciate gaps in a local care. Results: The number of CD4 samples obtained and recorded increased by 114% between May and October 2007 at targeted health facilities. ART enrollment increased by 62% between June and September 2007 without other significant change in care delivery. The median baseline CD4 at enrollment increased from 110 cells/mm 3 in June to 150 cells/mm 3 in September. Overall retention rate was 77% for 13,333 HIV patients enrolled in seven facilities. In September 2013, the cumulative 6-year overall retention rates are 77% for 53,040 patients enrolled in 42 health facilities in the region. Obstacles were addressed and community empowerment techniques used to stimulate change in established clinical behaviors. Conclusion: This Know your CD4 campaign initiative resulted in increased uptake of CD4 testing, treatment initiation and an unanticipated improvement in patient retention. With attention to patient, staff, and laboratory elements in resource-poor settings, decline in immune function and morbidity may be reduced and viral suppression prolonged. Empowering patients to be involved in their own care resulted in better overall adherence with HIV management. Local use of reviewed data can impact overall effectiveness of HIV care delivery. Simple quality improvement approaches impact sustainable change.

The Vermont Model for Rural HIV Care Delivery: Eleven Years of Outcome Data Comparing Urban and Rural Clinics

Provision of human immunodeficiency virus (HIV) care in rural areas has encountered unique barriers. To compare medical outcomes of care provided at 3 HIV specialty clinics in rural Vermont with that provided at an urban HIV specialty clinic. This was a retrospective cohort study. Over an 11-year period 363 new patients received care, including 223 in the urban clinic and 140 in the rural clinics. Patients in the 2 cohorts were demographically similar and had similar initial CD4 counts and viral loads. There was no difference between the urban and rural clinic patients receiving Pneumocystis carinii prophylaxis (83.5% vs 86%, P= .38) or antiretroviral therapy (96.8% vs 97.5%, P= .79). Both rural and urban cohorts had similar decreases in median viral load from 1996 to 2006 (3,876 copies/mL to <50 copies/mL vs 8,331 copies/mL to <50 copies/mL) and change in percent of patients suppressed to <400 copies/mL (21.4%-69.3% vs 16%-71.4%, P= .11). Rural and urban cohorts had similar increases in median CD4 counts (275/mm(3)-350/mm(3) vs 182 cells/mm(3)-379/mm(3)). A repeated measures regression analysis showed that neither fall in viral load (P= .91) nor rise in CD4 count (P= .64) were associated with urban versus rural site of care. Survival times, using a Cox proportional hazards model, were similar for urban and rural patients (hazard ratio for urban = 0.80 [95% CI, 0.39-1.61; P= .53]). This urban outreach model provides similar quality of care to persons receiving care in rural areas of Vermont as compared to those receiving care in the urban center.

Challenges to the Success of HIV and Tuberculosis Care and Treatment in the Public Health Sector in South Africa

The escalating human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics have had a significant impact on public health services in resource-limited settings. The province of KwaZulu-Natal in South Africa is estimated to have one of the greatest TB/HIV coinfection burdens on the African continent, coupled with historically low TB treatment success rates. In May 2004, the South African government began providing antiretroviral therapy (ART) for HIV-infected individuals within the public sector. As in many counties, this HIV treatment program was established in parallel with an existing TB treatment service. In 2005, the Integration of TB in Education and Care for HIV/AIDS (iTEACH) Program was launched in KwaZulu-Natal at Edendale Hospital. The goal of iTEACH was to identify barriers to effective treatment and develop support interventions to enable rapid expansion of access to ART and improve ART and TB treatment outcomes within the district served by this facility. In the present article, we discuss challenges to the delivery of TB and HIV care by these separate treatment programs, as well as opportunities to improve both TB treatment and ART outcomes through lessons learned during ART scale-up in the context of the HIV and TB coepidemics.

Guidelines for Effective Integration of Information Technology in the Care of HIV-infected Populations

Although information technology (IT) plays an increasingly important role in the delivery of healthcare, specific guidelines to assist human immunodeficiency virus (HIV) care settings in adopting IT are lacking. Through the experiences of six Special Projects of National Significance - (SPNS) funded HIV-specific IT interventions, key considerations prior to adoption and evaluation of IT are presented. The purpose of this article is to provide guidelines to consider prior to adoption and evaluation of IT in HIV care settings. Six sites conducted comprehensive evaluations of IT interventions between 2002 and 2005, encompassing care delivered to 24,232 clients by 700 providers. Six key considerations prior to adoption of IT in HIV care delivery were identified, including IT and programmatic capacity, expectations, participation, organizational models, end-user types, and challenges. Specific evaluation techniques included implementation assessment, formative evaluation, cost studies, outcomes evaluation, and performance indicators. Grantee experiences are used to illustrate key considerations. With proper preparation, even resource-poor HIV care delivery programs can successfully adopt IT.

HIV/AIDS challenges the normative model of healthcare delivery in Canada

With advances in therapeutics, effective therapy for human immunodeficiency virus (HIV) has shifted the focus of HIV care from an acute illness to a chronic disease requiring the services of several disciplines in a primary care setting. This article describes a collaborative model in the delivery of HIV care for HIV-infected individuals who remain fragile, both physically and psychosocially.

HIV/AIDS challenges the normative model of healthcare delivery in Canada.

With advances in therapeutics, effective therapy for human immunodeficiency virus (HIV) has shifted the focus of HIV care from an acute illness to a chronic disease requiring the services of several disciplines in a primary care setting. This article describes a collaborative model in the delivery of HIV care for HIV-infected individuals who remain fragile, both physically and psychosocially.