The Human Immunodeficiency Virus Workforce in Crisis: An Urgent Need to Build the Foundation Required to End the Epidemic

Do HIV Care Outcomes Differ by Provider Type?

BACKGROUND

We compared HIV care outcomes by HIV provider type to inform efforts to strengthen the HIV provider workforce.

SETTING

United States.

METHODS

We analyzed data from Center for Disease Control and Prevention's Medical Monitoring Project collected during June, 2019-May, 2021 from 6323 adults receiving HIV medical care. Provider types include infectious disease physicians only (ID physicians), non-ID physicians only, nurse practitioners only, physician assistants only, and ID physicians plus nurse practitioners and/or physician assistants (mixed providers). We measured patient characteristics, social determinants of health, and clinical outcomes, including retention in care; antiretroviral therapy prescription; antiretroviral therapy adherence; viral suppression; gonorrhea, chlamydia, and syphilis testing; satisfaction with HIV care; and HIV provider trust.

RESULTS

Compared with patients of ID physicians, higher percentages of patients of other provider types had characteristics and social determinants of health associated with poor health outcomes and received HIV care at Ryan White HIV/AIDS Program-funded facilities. After accounting for these differences, most outcomes were not meaningfully different; however, higher percentages of patients of non-ID physicians, nurse practitioners, and mixed providers were retained in care (6.5, 5.6, and 12.7 percentage points, respectively) and had sexually transmitted infection testing in the past 12 months, if sexually active (6.9, 7.4, and 13.5 percentage points, respectively).

CONCLUSION

Most HIV outcomes were equivalent across provider types. However, patients of non-ID physicians, nurse practitioners, and mixed providers were more likely to be retained in care and have recommended sexually transmitted infection testing. Increasing delivery of comprehensive primary care by ID physicians and including primary care providers in ID practices could improve HIV primary care outcomes.

Effects of telehealth-assisted interventions among people living with HIV/AIDS: A systematic review and meta-analysis of randomized controlled studies

INTRODUCTION

Taking antiretroviral therapy (ART) is a daily necessity for people living with HIV but these individuals experience multiple barriers and challenges to medication adherence. Interventions to support medication adherence have yielded effects in the expected direction, but the extent to which telehealth or virtually delivered interventions to promote adherence are effective among people living with HIV/AIDS remains unknown. We aimed to address this knowledge gap and inform future research and practice that promotes the well-being of people living with HIV/AIDs through telehealth interventions addressing medication use.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted using the following databases: Academic Search Complete, Cochrane library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, MEDLINE, PubMed, OVID (UpToDate), and the Web of Science. Relevant full-text articles published through September 2021 were retrieved. The revised Cochrane risk of bias tool for randomized trials was used to assess the methodological quality of the included studies. A meta-analysis was performed using a random-effects model to calculate the pooled effects of telehealth-assisted interventions for people living with HIV/AIDS. Stata 16.0 was used for statistical analysis.

RESULTS

A total of 12 studies (N = 3557 participants) that used telehealth-assisted interventions for people living with HIV/AIDS were included. Telehealth interventions were found to increase the adherence to treatment (standardized mean difference [SMD]: 0.21; 95% confidence interval (CI): 0.03 to 0.40), to reduce depressive symptoms (SMD: -2,74; 95% CI: -3.39 to -2.09), and to improve perceived quality of life (SMD: 0.74; 95% CI: 0.37 to 1.10).

DISCUSSION

The meta-effects of telehealth-assisted interventions include significantly enhanced adherence to treatment, improved quality of life, and reduced depressive symptoms among people living with HIV/AIDS. These findings suggesting that delivering health management interventions remotely through telehealth-assisted modalities was both feasible and effective in yielding health benefits for people living with HIV/AIDS. Integrating telehealth-assisted interventions as a modality in HIV/AIDS care might support continuity of care and sustained well-being. Future research should evaluate telehealth intervention outcomes and examine mediating, moderating, or other tailorable variables affecting intervention effectiveness.

The impact of the COVID-19 pandemic on healthcare services utilization among people living with HIV in Catalonia, Spain: A population-based cohort study

BACKGROUND

The COVID-19 pandemic disrupted healthcare services usage. We estimated the impact of the COVID-19 pandemic on healthcare services utilization among people living with HIV (PLWH) in Catalonia, Spain.

METHODS

We accessed public healthcare usage in HIV units, primary care, hospitals, and emergency departments among 17,738 PLWH in the PISCIS cohort from January 1, 2017, to December 31, 2020. We performed an interrupted time series analysis using the autoregressive integrated moving average to estimate the effect of COVID-19 on medical visits and HIV monitoring among PLWH.

RESULTS

A non-significant decrease of 17.1% (95% CI: [-29.4, 0.4]) in overall medical visits was observed during the lockdown, followed by a steady resumption until the end of 2020. Three health facilities presented statistically significant declines in visits during the lockdown: HIV units (-44.8% [-56.7, -23.6]), hospitals (-40.4% [-52.8, -18.1]), and emergency departments (-36.9% [-47.0, -21.9]); thereafter, the visits have begun to increase steadily but not to previous levels as of December 2020. In contrast, primary care visits remained unchanged during the lockdown by 1.9% (95% CI: -13.5, 23.9). CD4 cell (54.2% [95% CI: -64.4, -36.0]) and HIV RNA viral load (53.1% [95% CI: -62.9, -36.1]) laboratory monitoring reduced significantly during the lockdown.

CONCLUSION

COVID-19 lockdowns significantly disrupted in-person healthcare services usage among PLWH. The reduction in healthcare utilization however did not affect primary care services. Despite services gradually rebounding to pre-pandemic levels, it is imperative to effectively prepare for future pandemics and implement measures to ensure continuous provision of care to PLWH during pandemic lockdowns.

A National HIV Provider Survey of Antiretroviral Therapy Preferences for Management of Treatment-Naive and Experienced Individuals With Drug Resistance

Background

HIV clinical practice guidelines outline broad treatment principles but offer less explicit recommendations by permutations of encountered viral resistance. We hypothesize that there is variability in antiretroviral (ARV) regimen decision making among providers when considering HIV drug resistance (HIVDR).

Methods

US HIV providers provided ARV regimen recommendations for case vignettes in a series of electronic surveys encompassing variations of HIVDR. Responses were characterized by drugs and classes selected and anticipated activity based on genotypic susceptibility. Heterogeneity was defined as the proportion of unique ARV regimens from total responses.

Results

An overall 119 providers from the United States participated. Among case vignettes with isolated M184V and viremia, 85.9% selected a regimen with 2 nucleoside reverse transcriptase inhibitors (NRTIs) + integrase strand transfer inhibitor (INSTI); 9.9% selected regimens with >3 ARVs. Alternatively, in scenarios of viremia with moderate to high-level NRTI resistance, >50% of providers selected an NRTI-sparing regimen, while a minority recommended 2 NRTIs + INSTI (21/123, 17%). In moderate to high-level INSTI resistance, there was response heterogeneity, with no common unifying approach to management (127 unique regimens/181 responses, 70% heterogeneity). Providers used cabotegravir/rilpivirine for treatment simplification in suppressed cases, despite a history of treatment failure (37/205, 36%).

Conclusions

Our national survey of US HIV providers revealed a consensus to management of HIV resistance with potential alternative options in cases with low heterogeneity. Providers selected cabotegravir/rilpivirine as a viable treatment simplification strategy in suppressed cases with a history of treatment failure. The responses to the case vignettes could be used an education tool for ARV decision making in HIVDR.

Mitigating the HIV and Viral Hepatitis Workforce Crisis Through Development of an HIV/Hepatitis C Coinfection Mobile Application

A decline in the HIV workforce has led to a crisis of insufficient expertise to manage people with HIV (PWH), roughly a quarter of whom are coinfected with hepatitis C. Task shifting to nonspecialist providers can contribute to solving the HIV workforce shortage problem, but nonspecialist providers require sufficient training and support to acquire and retain the necessary knowledge and skills. Digital tools including mobile applications (apps) and telementoring which utilizes telecommunication technology for education and skill acquisition can be used for professional development. Described is the development and dissemination of a mobile app specifically for providers managing HIV/HCV coinfection in the United States. The app, through provider professional development, facilitates access to curative HCV treatment in PWH, encourages integration of HCV care into primary care and contributes to national goals to eliminate HIV and viral hepatitis by 2030.

Efficacy of a Telehealth Delivered Couples' HIV Counseling and Testing (CHTC) Intervention to Improve Formation and Adherence to Safer Sexual Agreements Among Male Couples in the US: Results from a Randomized Control Trial

This paper reports the results of a randomized controlled trial (RCT) to assess the efficacy of Nexus, a telehealth delivered intervention that combines Couples' HIV counseling and testing (CHTC) with home-based HIV-testing, examining the impact of the intervention on the couples' formation and adherence to safer sexual agreements. Between 2016 and 2018, 424 couples were recruited online from the U.S and randomized to the intervention arm (a telehealth delivered CHTC session with two home HIV-testing kits) or a control arm (two home HIV-testing kits), with study assessments at baseline, 3 and 6 months. Outcomes were the formation and adherence to safer sexual agreements, dyadic discordance in sexual agreements, breakage of sexual agreements, and perceptions of PrEP. Couples in the intervention arm had significantly greater odds of reporting a safer sexual agreement (3 months OR 1.87, p-value 0.005, and 6 months OR 1.84, p-value 0.007), lower odds of reporting discordant sexual agreements at 6 months (OR 0.62, p-value 0.048), and a significantly lower odds of reporting breaking their sexual agreement (3 months OR 0.51, p-value 0.035, and 6 months OR 0.23, p-value 0.000). By 6 months, couples in the intervention arm were less likely to say PrEP was beneficial to one (RRR 0.33, P = 0.000) or both of them (RRR 0.29, P = 0.000) than being beneficial to neither of the partners. The high levels of acceptability and efficacy of the intervention demonstrate strong potential for the scale-up of this efficacious intervention that is delivered through a low-cost telehealth platform.

Comprehensive Process Mapping and Qualitative Interviews to Inform Implementation of Rapid Linkage to HIV Care Programs in a Mid-Sized Urban Setting in the Southern United States

BACKGROUND

Rapid antiretroviral therapy (ART) initiation, in which people living with HIV start ART within days of diagnosis, is a key component of the US Ending the HIV Epidemic initiative.

SETTING

The Memphis Metropolitan Statistical Area ranked fourth in the United States for the highest HIV incidence per 100,000 population in 2018. Rapid ART programs are limited in the Memphis Metropolitan Statistical Area, and our objective was to identify local implementation barriers.

METHODS

We conducted participatory process mapping and in-depth interviews to detail steps between HIV testing at the municipal health department's Sexually Transmitted Infections Clinic and ART prescription from a nearby high-volume Ryan White-funded HIV Clinic.

RESULTS

Process mapping identified 4 modifiable, rate-limiting rapid ART barriers: (1) requiring laboratory-based confirmatory HIV results, (2) eligibility documentation requirements for Ryan White-funded services, (3) insufficient HIV Clinic medical provider availability, and (4) variability in ART initiation timing among HIV Clinic providers. Staff at both sites highlighted suboptimal communication and sense of shared management between facilities, limited resources to address important social determinants of health, and lack of Medicaid expansion in Tennessee as key barriers. In-depth interview themes negatively affecting rapid ART initiation included clinic burden; provider knowledge, attitudes, and beliefs; and client psychosocial needs.

CONCLUSIONS

Our preimplementation work identified modifiable and systemic barriers to systems flow and patient-level outcomes. This work will inform the design and implementation of a locally relevant rapid ART program in Memphis, a community disproportionately affected by the HIV epidemic.

Patient Experiences with Telemedicine for HIV Care During the First COVID-19 Wave in Atlanta, Georgia

We explored experiences with telemedicine among persons with HIV (PWH) during the first wave of the coronavirus disease 2019 (COVID-19) pandemic. A convenience sample of adults (>18 years) receiving care in an urban clinic in Atlanta were invited to participate. Patients completed a structured survey that assessed the usefulness, quality, satisfaction, and concerns with telemedicine services (telephone calls) received during the first wave of the COVID-19 pandemic (March-May 2020). Demographic, plasma HIV-1 RNA, and CD4⁺ T cell count data were obtained through medical chart abstraction. Bootstrapped t-tests and chi-square tests were used to examine differences in patient experiences by age, sex, and race. Of 406 PWH contacted, 101 completed the survey (median age 55 years, 84% men, 77% Black, 98% virally suppressed, median CD4 count 572 cells/μL). The main HIV care disruptions experienced were delays in follow-up visits (40%), difficulty getting viral load measured (35%), and difficulty accessing antiretroviral therapy (21%). Participant ratings for quality (median score 6.5/7), usefulness (median score 6.0/7), and satisfaction (median score 6.3/7) with telemedicine were high. However, 28% of patients expressed concerns about providers' ability to examine them and about the lack of laboratory tests. More women had concerns about providers' ability to examine them (92% vs. 50%, p = .005) and about the safety of their personal information (69% vs. 23%, p = .002) compared with men. No age or race differences were observed. Although PWH are generally satisfied with telephone-based telemedicine, concerns with its use were notable, particularly among women. Future HIV telemedicine models should address these.

The Value of a Longitudinal HIV Track for Medical Students: Ten-Year Program Evaluation

We surveyed graduates of a longitudinal medical school human immunodeficiency virus curriculum to evaluate its impact. Respondents felt comfortable caring for people with human immunodeficiency virus (PWH) and found value from the curriculum regardless of ultimate career path. Programs like this contribute to the development of culturally sensitive clinicians comfortable caring for PWH.

The shifting age distribution of people with HIV using antiretroviral therapy in the United States

OBJECTIVE

To project the future age distribution of people with HIV using antiretroviral therapy (ART) in the United States, under expected trends in HIV diagnosis and survival (baseline scenario) and achieving the ending the HIV epidemic (EHE) goals of a 75% reduction in HIV diagnoses from 2020 to 2025 and sustaining levels to 2030 (EHE75% scenario).

DESIGN

An agent-based simulation model with mathematical functions estimated from North American AIDS Cohort Collaboration on Research and Design data and parameters from the US Centers for Disease Control and Prevention's annual HIV surveillance reports.

METHODS

The PEARL (ProjEcting Age, MultimoRbidity, and PoLypharmacy in adults with HIV) model simulated individuals in 15 subgroups of sex-and-HIV acquisition risk and race/ethnicity. Simulation outcomes from the baseline scenario are compared with outcomes from the EHE75% scenario.

RESULTS

Under the baseline scenario, PEARL projects a substantial increase in number of ART-users over time, reaching a population of 909 638 [95% uncertainty range (UR): 878 449-946 513] by 2030. The overall median age increased from 50 years in 2020 to 52 years in 2030, with 23% of ART-users age ≥65 years in 2030. Under the EHE75% scenario, the projected number of ART-users was 718 348 [703 044-737 817] (median age = 56 years) in 2030, with a 70% relative reduction in ART-users <30 years and a 4% relative reduction in ART-users age ≥65 years compared to baseline, and persistent heterogeneities in projected numbers by sex-and-HIV acquisition risk group and race/ethnicity.

CONCLUSIONS

It is critical to prepare healthcare systems to meet the impending demand of the US population aging with HIV.

An HIV Primary Care Rotation Improved HIV and STI Knowledge, Enhanced Sexual History-Taking Skills, and Increased Interest in a Career in Infectious Diseases Among Medical Students and Residents

Rotations in HIV primary care clinics have the potential to teach trainees core competencies and influence their career pathway. We found that fund of knowledge, confidence in obtaining a sexual history, and interest in an Infectious Diseases career all increased following an HIV clinic rotation.