Integrated care for people living with HIV
Dr. Claire Kendall, of the University of Ottawa, talked about the opportunities for improving HIV care in Ontario and particularly about the potential for a more integrated model of community care.
We know that once people living with HIV are engaged in care they do pretty well. However, there are several models of HIV care delivery in Ontario: specialist care, family physician care, and a blend of the two. Dr. Kendall explained that each model has its strengths. Data shows that people with HIV receiving family physician care are most likely to receive services such as cancer screening, while those receiving mostly specialist care are more likely to be on ART. We also know that experience matters. People who receive care only from a family physician with fewer that 50 people living with HIV in their practice are half as likely to be on ART than those who see family physicians with more than 50 HIV patients in their practice. More than half of people living with HIV in Ontario receive all of their care from family physicians, and of these caregivers, 75% have low volume HIV practices (i.e., about 1% of all of their patients are HIV-positive).
Dr. Kendall suggested that we need a more integrated chronic care model for HIV care with care providers better connected to others. Using the framework of the recent Health Quality Ontario report, Measuring Up, she suggested several areas where improvement could be made:
- smooth out transitions
- improve access to care in the community
- reduce inequities.
Dr. Kendall also offered a fourth area for HIV care – enhance performance measurement.
Smoothing out transitions
Dr. Kendall talked about several areas where improved care transitions are needed:
- Initial linkage to care – Linkage to care plateaus at 90 days after diagnosis; those not linked by then are not likely to be. Where people are diagnosed matters: about 90% of people diagnosed in hospital are linked to care, compared to only 45% of those diagnosed in emergency departments. Models such as the RAPID program in San Francisco might contribute to improvement.
- End of life care – People living with HIV are more likely to die in hospital than those with other complex chronic conditions, and costs are much higher. We need to better ground HIV care in existing local community services to better address this problem.
- Specialist care within the HIV sector – There are clear gaps. For example, despite the high rates of depression amongst people living with HIV, recent research (Choi S, Rourke S, 2016) shows that only about 50% of people receive appropriate mental health care. In Ontario HIV care settings, only 17% of practices have access to a psychologist and only 41% have access to a psychiatrist; however, 75% have access to a pharmacist. This suggests that pharmacists may be an opportunity to provide an expert network, particularly important to the treatment of comorbidities, since in many speciality fields (i.e., cardiology) Ontario is unlikely to ever have the workforce to have HIV specialists in cardiology.
Improving access to care in the community
HIV care is not as well integrated into existing community services as other forms of chronic disease care. Only 87% of people with HIV have a family care doctor compared to 94% of all Ontarians, and people living with HIV are more likely to visit emergency departments. Primary care and integrated community services could provide more comprehensive care if we focus on how care providers communicate, and work to clearly define roles in a more integrated system.
Inequities, both geographic and socioeconomic, continue to impact HIV care – although such inequities have received more attention than in other areas of medicine. HIV could lead the way on addressing inequities within a model of integrated community care.
Enhancing performance measurement
Our system is missing measures that are important to patients themselves. PROMS (patient reported outcome measures) and PREMs (patient reported experience measures) could help better define care needs.
Our sector has an opportunity to use the knowledge and experience of people living with HIV and their care providers to integrate HIV care into existing community care frameworks. Improved inter-professional communication, better role definition, and listening to our patients will help narrow the gaps in HIV care.
RAPID ART initiation in San Francisco
Dr. Oliver Bacon is the chair of the RAPID (rapid antiretroviral [ART] program initiation for new diagnosis) committee of the San Francisco Getting to Zero initiative. He described the efforts underway to reduce the burden of HIV in San Francisco, and outcomes for the RAPID pilot.
The San Francisco Getting to Zero initiative aims to have 90% fewer new HIV infections by 2020, as well as 90% fewer HIV-associated deaths, and zero stigma and discrimination. This is a multi-sector effort of community members, academics, clinicians, and HIV service organizations organized through a central steering committee with four action committees focused on:
- retention and re-engagement
- city-wide PrEP (pre-exposure prophylaxis)
- ending stigma
- RAPID ART.
The latest epidemiological data reveals that new diagnoses have been dropping in San Francisco, with 255 new cases in 2015 (down from 309 in 2014 and roughly half of the total ten years before). There has been a concerted effort to address HIV in San Francisco recognizing that medicine is not enough. Key milestones have included:
- 2005 – FAST team piloted at General Hospital, a tailored retention and engagement program
- 2006 – requirement that all city agencies dealing with people with HIV offer HIV testing, leading to a dramatic increase in the availability of testing
- 2010 – universal ART initiative meant that therapy was available to all regardless of CD4 count
- 2011 – FAST program expands to a city-wide program called LINKS
- 2012 – PrEP took off with demonstration project and pioneering patients and clinicians.
The most rapid decline in new diagnoses began in 2012 with the widespread arrival of PrEP in an environment where universal ART and improved testing were already in place. Of those living with HIV, 76% have an undetectable viral load within one year of diagnosis; however serious disparities persist. Only 53% of African Americans and 53% of homeless people are undetectable at one year.
The rationale of the RAPID pilot is to deliver ART as early as possible. Prompt treatment improves mobility and morbidity, limits the reservoirs of virus in the body, and prevents new HIV transmission. The typical wait of weeks to months between diagnosis, ART, and viral suppression is a lost opportunity.
RAPID was piloted at the SF General HIV clinic, which by definition serves an uninsured or underinsured population. This population faces multiple challenges with a high rate of mental illness and substance use (33%), as well as co-infection with HCV (40%).
RAPID aims to provide ART on the day of diagnosis, and relies on the ability of team members (physicians, social workers, nurses) to be flexible. It uses preselected regimens for initial therapy. Intake once a person is diagnosed includes counselling around disclosure, registering for care, navigation of insurance coverage, initiation of supports for housing, substance use or other social issues, laboratory testing, counselling, medical evaluation, and a person’s first dose of therapy. Intake typically takes about 2 hours.
Despite the challenges facing the patient population, most people wanted rapid treatment. Fifty percent started on day one; 90% within 2 weeks. This has a profound impact on time to viral suppression which on average took 218 days from the time of diagnosis from 2006-2009 and dropped to 132 days in the era of universal ART access (2010-13). For those in the RAPID pilot, it took 56 days to viral suppression from the time of diagnosis and 90% of patients were engaged in care at six months.
Important lessons for a RAPID clinic:
- needs a single point of contact
- requires a committed team that will be flexible and can provide all services
- average RAPID intake 2 hours
- minimize handoffs and make every handoff a warm introduction (no sitting in waiting rooms)
- have a plan for medication access
- schedule follow-up in 5-7 days and check in with the patient 1-2 days after the appointment.
San Francisco is now aiming to take the program city-wide although they have had to lengthen the timeline to start therapy to five days. They have also had to map where and how people get care in order to target training. They have learned that provider acceptance is high and that clinical staff are willing to change behaviour; insurance remains the biggest barrier. They have also found that many new infections are “on PrEP”, although often they have not taken regular doses. Treatment can be initiated once the person has taken no PrEP drug in a week. In the first year of the city-wide program they are planning a boot camp for navigators and the further development of evaluation metrics.