REACH: a mixed-methods study to investigate the measurement, prediction and improvement of retention and engagement in outpatient HIV care

Abstract

BackgroundAntiretroviral therapy (ART) benefits individuals living with human immunodeficiency virus (HIV) through reduced morbidity and mortality, and brings public health gains through a reduction in HIV transmission. People living with human immunodeficiency virus (PLWH) need to know their HIV status and engage in HIV care in order for these individual and public health benefits to be realised.ObjectiveTo explore, describe and understand HIV outpatient attendance in PLWH, in order to develop cost-effective interventions to optimise engagement in care.DesignA mixed-methods study incorporating secondary analysis of data from the UK Collaborative HIV Cohort (UK CHIC) study and primary data collection.MethodsPhase 1 – an engagement-in-care (EIC) algorithm was developed to categorise patients as in care or out of care for each month of follow-up. The algorithm was used in group-based trajectory analysis to examine patterns of attendance over time and of the association between the proportion of months in care before ART initiation and post-ART mortality and laboratory test costs. Phase 2 – a cross-sectional survey was conducted among patients attending seven London HIV clinics. Regular attenders (all appointments attended in past year), irregular attenders (one or more appointments missed in past year) and non-attenders (recent absence of ≥ 1 year) were recruited. A ‘retention risk tool’ was developed to identify those at risk of disengaging from care. Individual in-depth interviews and focus groups were conducted with PLWH. Phase 3 – key informant interviews were conducted with HIV service providers. Interventions were developed from the findings of phases 2 and 3.ResultsPlots from group-based trajectory analysis indicated that four trajectories best fitted the data. Higher EIC is associated with reduced mortality but the association between EIC before starting ART, and post-ART mortality [relative hazard (RH) per 10% increase in EIC 0.29, 95% confidence interval (CI) 0.18 to 0.47] was attenuated after adjustment for fixed covariates and post-ART cluster of differentiation 4 counts and viral loads (RH 0.74, 95% CI 0.42 to 1.30). Small differences were found in pre-ART EIC and the costs of post-ART lab tests. The final model for the retention risk tool included age at diagnosis, having children, recreational drug use, drug/alcohol dependency, insufficient money for basic needs and use of public transport to get to the clinic. Quantitative and qualitative data showed that a range of psychological, social and economic issues were associated with disengagement from care. The negative impact of stigma on attendance was highlighted. Interventions were proposed that support a holistic approach to care including peer support, address stigma by holding clinics in alternative locations and involve training staff to encourage attendance.ConclusionsThe study shows the adverse health impacts of disengaging from HIV care and demonstrates the importance of the wider health and social context in managing HIV effectively. Although phase 1 analysis was based on UK data, phases 2 and 3 were limited to London. The interventions proposed are supported by the data but their cost-effectiveness requires testing. Future research is needed to evaluate the interventions, to validate our retention risk tool across populations and settings, and to fully analyse the economic costs of disengaging from HIV care.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The UK CHIC study is funded by the Medical Research Council UK (grant numbers G0000199, G0600337, G0900274 and M004236).

Incidence rate, predictors and outcomes of interruption of HIV care: nationwide results from the Belgian HIV cohort

“…Other demographic predictors of HCI identified in this analysis were male gender and foreign nationality; those who were male or of foreign nationality were less likely to return to HIV care in Belgium as a consequence of higher permanent out-migration during HCI. MSM were less likely to experience HCI compared to heterosexuals, as reported in the literature [10,11,[25][26][27].…”

Cause of death among HIV patients in London in 2016

“…However, a substantial number died from AIDS‐related illnesses, which are potentially preventable through earlier HIV diagnosis and/or support for those not engaged in care and/or not adherent to treatment . Innovative strategies to further expand HIV testing outside of sexual health services should be complemented by strategies to reduce stigma and promote long‐term integration into care in order to realize the benefits of wider testing and treatment for reducing mortality among people with HIV infection .…”

HIV testing history and access to treatment among migrants living with HIV in Europe

“…Poverty was especially prevalent among heterosexual men with over 20% reporting moderate or severe household hunger in the past four weeks. Poverty is well recognized as being associated with poorer engagement in care . While tackling the overall problem of economic inequality is beyond the capacity of service providers, these impediments to care need to be recognized and where possible support offered to help mitigate this barrier.…”