Concept Clearance
January 14, 2011

Promoting Engagement in Care and Timely Antiretroviral Initiation Following HIV Diagnosis

NAMHC Concept Clearance

Presenter

Dianne Rausch, Ph.D.
Deputy Director, Center for Mental Health Research on AIDS
Division of AIDS Research (DAR)

Goal

The overarching aims of this initiative are to develop and test interventions to reduce the time between HIV diagnosis and achievement of first undetectable viral load among patients for whom antiretroviral therapy (ART) is indicated, as well as to reduce racial and ethnic disparities in HIV-treatment outcomes.

Rationale

The efficacy of combination ART for the treatment of HIV disease is firmly established. Sustained suppression of HIV replication through ART and attendant increases in CD4 T-cell count are strongly associated with improved patient outcomes. In treatment settings such as the U.S. where ART is broadly available, dramatic declines in HIV/AIDS-related mortality have been observed since the introduction of ART. Despite these advancements, many people living with HIV in the U.S. do not benefit from treatment because they are poorly engaged in medical care. It is estimated that one-third of persons in the U.S. with known HIV infection are not fully engaged in primary medical care.¹

HIV care represents a treatment cascade, where each step is contingent upon the achievement and maintenance of the prior one.² Persons diagnosed with HIV infection in the U.S. must first link to primary care in order to receive treatment. Regular medical appointment attendance is essential for clinical monitoring to determine when ART may be indicated. Those who initiate ART must subsequently maintain strong adherence and persistence to these regimens to optimize treatment outcomes. Challenges and disparities are evident at each of these steps in the treatment cascade, and few evidence-based interventions exist to address the following needs:

• Linkage to care
• Early retention in HIV care
• ART Readiness, Initiation, and Early Adherence.

This initiative seeks U.S. domestic research to improve medical care engagement and treatment adherence among HIV infected individuals in the first twelve months following HIV diagnosis, enrollment in HIV primary care, or initiation of ART. In targeting these junctures, this initiative seeks to address the need for efficacious interventions to promote rapid linkage to medical care following HIV diagnosis, to enhance retention early in the course of primary care, and to improve readiness to voluntarily initiate antiretroviral medications, timely antiretroviral initiation when indicated, and antiretroviral adherence—especially during the first year of ART.

This initiative encourages research including, but not limited to:

• Develop and test interventions for effectively linking individuals diagnosed with HIV to primary medical care, including interventions that can be directly integrated within post-test HIV counseling.
• Develop and test interventions and policies that improve enrollment in primary HIV medical care and reduce the time between HIV diagnosis and initial medical evaluation for recently diagnosed individuals.
• Develop and test interventions focused on enhancing and maintaining patient retention in primary medical care within the first year following initiation of HIV care.
• Develop and test the impact of interventions designed to enhance patient readiness for and voluntary initiation of antiretroviral medications, when indicated.
• Develop and test interventions to improve provider communication skills and messaging to patients (and patient-provider communication more generally) regarding ART initiation and adherence.
• Develop and test highly feasible and low-cost clinic-based interventions, practices, and policies to improve and sustain patient adherence to antiretroviral medications in the year following ART initiation.
• Develop and test interventions designed to reduce racial/ethnic, gender, and age-related disparities in HIV care utilization and treatment outcomes.
• Develop research partnerships between medical clinics, community organizations, public health departments, and/or related groups to integrate and strengthen patient-outreach efforts, peer-navigation programs, or other approaches designed to link the newly-diagnosed to care and improve patient retention in the first year of care.

This initiative corresponds to the priorities of the National HIV/AIDS Strategy for the United States, which establishes “increasing access to care and improving health outcomes for people living with HIV” and “reducing HIV-related disparities and health inequities” as central priorities. These priorities are further represented within the NIH Office of AIDS Research (NIH OAR) Trans-NIH Plan for HIV Research, which calls for research for “Improving Disease Outcomes for HIV-Infected Individuals” and “Reducing HIV-Related Disparities.”

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¹ Teshale, E., Kamimoto, L., Harris, N., L,i J., Wang, H., & McKenna, M. (February, 2005). Estimated number of HIV-infected persons eligible for and receiving HIV antiretroviral therapy, 2003 -- United States [abstract 167]. Paper presented at the 12th Conference on Retroviruses and Opportunistic Infections (CROI), Boston, MA.

² Giordano, T. P., Suarez-Almazor, M. E., & Grimes R. M. (2005). The population effectiveness of highly active antiretroviral therapy: Are good drugs good enough? Current HIV/AIDS Reports, 2, 177-183.