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  • April 15, 2013

    Retention and Re-Engagement in Care

    Mike Saag

                                                

    Mugavero

    MICHAEL S. SAAG, MD
    Jim Straley Chair in AIDS Research
    Director, Center for AIDS Research
    University of Alabama at Birmingham
    Birmingham, AL

     

      MICHAEL J. MUGAVERO, MD
    Associate Professor of Medicine
    University of Alabama at Birmingham
    Birmingham, AL

    Successful HIV management requires timely linkage to care, early initiation of ART, adherence to treatment, and retention in care.(1) Retention in care is essential to providing ongoing treatment to all HIV-infected persons, including those not yet receiving ART. A precise method for measuring retention in care has not yet been defined, although a number of options have been proposed including quantitating gaps in care and measuring visit consistency.(2,3) It should be noted, however, that retention in care is not necessarily "all or nothing" and some patients may exhibit a cyclical in-and-out pattern of care (re-engagement).(4) An estimated 49% of Americans diagnosed with HIV are not linked or retained in care,(5) representing the most important group for prevention with positive initiatives. Retention in care is associated with improved clinical variables and health outcomes, including higher CD4 counts, more patients with undetectable HIV RNA values, and lower HIV plasma viral loads, which in turn may reduce community-level viral burden.(6-8) Many studies describe the adverse impact of poor retention in care on patient outcomes.(6) In particular, poor retention in care is associated with decreased likelihood of receiving ART, higher rates of ART failure, increased risky behaviors that promote HIV transmission, increased rates of hospitalization, and decreased survival. In a study of more than 100,000 persons living with HIV in the United States, less than half had laboratory evidence of ongoing clinical care and only two thirds established care after diagnosis.(9) 

    Improving Retention in Care
    Clinical guidelines for improving retention in care for persons with HIV recommend systematic monitoring of retention for all patients by applying retention measures in accordance with local resources and standards of care.(10) Retention in care generally can be increased by improving patient information, motivation, and skills that enable navigation of the health care system.(4) In addition, HIV providers can utilize a number of specific methods to improve retention in care. The first step is to measure retention in care by determining retention rates and rates of patients lost to follow-up such as  tracking “no-show” rates and rates of patients “lost-to-care.” Other steps to improve retention include: 

    1) contacting patients who miss appointments; 2) improving patients’ healthcare experience, which typically leads to an increase in return visits; 3) assessing patients’ psychosocial needs and providing referrals to address substance-use, mental health, case management, and social issues such as housing; 4) maintaining accurate patient contact information; 5) conducting a pilot trial of increased appointment availability and considering open appointment access if suitable; and  6) extending office or clinic hours to include evenings and weekends.

    HIV treaters must remember that most patients already know they should be in care and that reminders - with or without encouragement or admonition - while often helpful, alone are usually inadequate to improve retention. Retention in care, however, can be improved when providers and patients problem solve collaboratively, and simple affirmative statements acknowledging the importance of retention such as “I'm really glad you are here today” can be impactful. A recent study demonstrated that a low-cost intervention to incorporate retention in care into the clinic culture, and including such brief messages, proved effective in improving visit adherence, particularly among new patients and those with detectable viral loads.(11) Respectful and nonjudgmental prevention messages can increase the likelihood that a patient will remain in treatment.(12) 

    Conclusions
    Regular, ongoing care is necessary for optimal treatment for all HIV-infected patients, including those not yet on ART, and can increase the success of HIV management strategies. Retention in care in HIV practice settings is associated with better outcomes, including lower rates of ART failure, reduced HIV transmission risk behaviors, and improved survival.

    References
    1. Ulett KB, Willig JH, Lin H-Y, et al. The therapeutic implications of timely linkage and early retention in HIV care. AIDS Patient Care STDS. 2009;23:41-49.

    2. Yehia BR, Fleishman JA, Metlay JP, et al. Comparing different measures of retention in outpatient HIV care. AIDS. 2012;26:1131-1139.

    3. Mugavero MJ, Westfall AO, Zinski A, et al. Measuring retention in HIV care: the elusive gold standard. J Acquir Immune Defic Syndr. 2012;61:574-580.

    4. Christopoulos KA, Das M, Colfax GN. Linkage and retention in HIV care among men who have sex with men in the United States. Clin Infect Dis. 2011;52(Suppl 2):S214-S222.

    5. Cohen MS, Van Handel MM, Branson BM, et al. Vital signs: HIV prevention through care and treatment-United States. MMWR Morb Mortal Wkly Rep. 2011;60:1618-1623.

    6. Giordano TP. Retention in HIV care: what the clinician needs to know. Top Antivir Med. 2011;19:12-16.

    7. Naar-King S, Bradford J, Coleman S, et al. Retention in care of persons newly diagnosed with HIV: outcomes of the Outreach Initiative. AIDS Patient Care STDS. 2007;21(Suppl 1):S40-48.

    8. Tripathi A, Youmans E, Gibson JJ, Duffus WA. The impact of retention in early HIV medical care on viro-immunological parameters and survival: a statewide study. AIDS Res Hum Retroviruses. 2011;27:751-758.

    9. Hall HI, Gray KM, Tang T, et al. Retention in care of adults and adolescents living with HIV in 13 US areas. J Acquir Immune Defic Syndr. 2012;60:77-82.

    10. Thompson MA, Mugavero MJ, Amico KR, et al. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel. Ann Intern Med. 2012;156:817-833.

    11. Gardner L, Marks G, Craw J, et al. A low-effort clinic-wide intervention improves attendance for HIV primary care. Clin Infect Dis. 2012;55:1124-1134.

    12. Gardner L, Marks G, Craw J, et al. A low-effort clinic-wide intervention improves attendance for HIV primary care. Clin Infect Dis. 2012;55:1124-1134.

  • This article was developed as part of the Prevention IS Care Campaign of the Centers for Disease Control and Prevention (CDC).

    Additional articles and resources are available here and on CDC’s website.

     

     

  • Practice Tips

    • Measuring retention in HIV care is recommended for all HIV service providers, and can be assessed in practice settings by quantitating gaps in care, measuring visit consistency, or assessing visit adherence, among other measures.
    • Retention in care is associated with improved clinical variables and individual health outcomes for patients, including higher CD4 cell counts, lower HIV plasma viral loads, and a higher proportion of patients with undetectable HIV RNA, which in turn may reduce community-level viral burden.
    • Poor retention in care is associated with decreased likelihood of receiving antiretroviral therapy, higher rates of antiretroviral therapy failure, increased risky behavior promoting HIV transmission, increased rates of hospitalization, and decreased survival.
    • Retention in care can be increased generally by improving patient information, motivation, and skills that enable navigation of the health care system.
    • Incorporating retention in care into clinic culture can be done at low-cost, including brief, respectful and non-judgmental messages from all staff, with modest improvements in retention rates.

 

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