EPIDEMIOLOGY
AND
PREVENTION
HIV Care Continuum Applied to the US Department of Veterans Affairs: HIV Virologic Outcomes in an Integrated Health Care System Lisa Backus, MD, PhD,*†‡ Maggie Czarnogorski, MD, MPH,*§ Gale Yip, BA,† Brittani P. Thomas, MPH,k Marisa Torres, MPH,k Tierney Bell, MPH,k and David Ross, MD, PhD*k
Background: The Department of Veterans Affairs (VA), the largest integrated HIV care provider in the United States (US), used the HIV Care Continuum to compare clinical care within the VA HIV population with the general US HIV population and to identify areas for improvement.
comes along the HIV Care Continuum can be achieved in a comprehensive integrated health care system. Key Words: HIV care continuum, Department of Veteran Affairs, engagement in care, HIV, integrated health care system (J Acquir Immune Defic Syndr 2015;69:474–480)
Methods: National data from the VA’s HIV Clinical Case Registry were used to construct measures along the Continuum for Veterans in VA care diagnosed with HIV by June 2013 and alive by December 31, 2013. Comparisons were made to recent estimates for the same measures for the US HIV population. Additional comparisons were performed for demographic subgroups of sex, race/ethnicity, and age.
Results: Of 25,480 Veterans diagnosed with HIV, 77.4% were engaged in care compared with 46.3% in the US population diagnosed with HIV (P , 0.001). Seventy-three percent of Veterans diagnosed with HIV received antiretroviral therapy compared with 43% of the US population diagnosed with HIV (P , 0.001). Nearly two-thirds (65.3%) of HIV-diagnosed Veterans had suppressed HIV viral loads compared with 35.0% of the US population diagnosed with HIV (P , 0.001). Conclusions: The VA health care system performed better at every stage of the HIV Care Continuum compared with the general US estimates. Comparable high rates with some variation were noted among the demographic groups in the VA cohort. The high viral suppression rate in VA, which was almost double the estimate for the HIV-diagnosed US population, demonstrates that improved outReceived for publication March 5, 2014; accepted February 2, 2015. From the *Department of Veterans Affairs; †Office of Public Health/ Population Health, Veterans Health Administration, Palo Alto, CA; ‡Department of Medicine, VA Palo Alto Health Care System, Veterans Health Administration, Palo Alto, CA; §Patient Care Services/Women’s Health Services, Veterans Health Administration, Washington, DC; and kOffice of Public Health/Clinical Public Health, Veterans Health Administration, Washington, DC. The authors have no conflicts of interest to disclose. L.B., M.C., and G.Y. had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: L.B. and M.C. Acquisition of data: L.B. and G.Y. Analysis and interpretation of data: L.B. and M.C. Drafting of the manuscript: L.B., M.C., B.T., M.T., and T.B. Critical revision of the manuscript for important intellectual content: D.R. Statistical analysis: L.B. Administrative, technical, and material support: D.R. Study supervision: M.C. and D.R. Correspondence to: Maggie Czarnogorski, MD, Department of Veteran Affairs, 810 Vermont Avenue, NW 10P4W, Washington, DC 20420 (e-mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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BACKGROUND The Department of Veterans Affairs (VA) is the largest provider of HIV care in the United States (US).1 The VA health care system is an expansive organization composed of 151 medical centers and over 820 outpatient clinics with points of care in all states across the nation.2 Every medical center in VA has HIV-positive Veterans enrolled in care.3 Most importantly, the VA system can provide integrated coordinated health and social care to Veterans with HIV. Primary care, mental health care, substance abuse treatment, specialty care, and social services such as housing services and job opportunities are available to Veterans within the VA health care system.4–6 Additionally, in the VA health care system, access to care is equitable across all demographics.6 The HIV Care Continuum is an initiative proposed by researchers and policy leaders that serves as a population health approach based on scientific advances in HIV care and management to identify critical foci for improvement in HIV care.7–12 Rapid HIV testing methods have made HIV testing more convenient, faster, and more accurate than ever before.13–17 HIVinfected individuals who are receiving and adherent to antiretroviral treatment (ART) can achieve undetectable viral loads and thereby avoid or delay progression to AIDS18–22 and other longterm complications23,24 as well as decrease the potential for transmission of the virus to others. By promoting HIV testing, improving engagement in care, and supporting efforts for universal treatment, the HIV Care Continuum permits a health care system to assess and monitor over time the quality of its HIV care provision and to identify targeted performance metrics to improve health outcomes and curb the spread of the epidemic.20,25–28 VA, an integrated health care system, may be a model for how HIV care could be monitored and delivered in the US VA is able to capture patient-level data regarding the HIV Care Continuum using elements from the VA’s electronic medical record.29,30 VA is able to provide testing services and coordinated health care delivery in the same system. Additionally, social services and mental health care are readily available and often
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integrated within HIV clinics to provide a seamless collaborative approach at all stages of the HIV Care Continuum.31 Integrated health care systems can potentially weave together the health and social aspects of HIV care that are needed to ensure optimal outcomes of the Care Continuum. VA sought to measure and then compare performance along the HIV Care Continuum with estimates for the general US HIV population, and to potentially demonstrate the success, an integrated health care system can achieve in this framework. Mangal et al have documented that the Atlanta VA Medical Center Infectious Disease Clinic, 1 of the 151 VA medical centers, outperformed the comparable US standards in every step along the HIV Care Continuum. This present analysis sought to assess performance on the HIV Care Continuum for the entire national VA HIV population. In addition, this analysis examined performance along the HIV Care Continuum stratified by sex, race/ethnicity, and age.
METHODS Using the VA’s HIV Clinical Case Registry (CCR)— a database compiled from the VA’s electronic medical record— all HIV-infected patients in VA care in 2013 with laboratorydiagnosed HIV by June 30, 2013, and alive through December 31, 2013, were identified and included in the analysis. The CCR contains information from all VA facilities nationwide on demographics, laboratory tests, outpatient visits, and prescriptions for Veterans in VA care. Measures for the HIV Care Continuum were based on the Centers for Disease Control and Prevention (CDC), HIV Diagnosis, Care, and Treatment Among Persons Living with HIV—United States, 2011, and included HIV diagnosed, engaged in care, on ART, and suppressed viral load.32 HIVdiagnosed Veterans were identified as having a positive laboratory diagnosis of HIV by June 30, 2013. A Veteran was defined as engaged in care based on having at least 2 outpatient visits at the same facility to a primary care or infectious disease clinic with HIV coded as a primary or secondary diagnosis for the visits, with at least 1 visit in each 6-month period of the year with a minimum of 60 days between visits. To be classified as being on ART required outpatient prescription fills in the year from at least 2 ART drug classes. A Veteran was considered to be virologically suppressed if he or she had HIV RNA less than 200 copies per milliliter on the most recent HIV RNA test in the year. Population-level data from the VA were compared with the US HIV Care Continuum rates as reported by the CDC for HIV Care Continuum Estimates in 2011. HIV Care Continuum measures were also calculated for subgroups based on sex, race/ethnicity, and age. Patients with a reported ethnicity of Hispanic were considered Hispanic in the combined variable of race/ethnicity regardless of the reported race. The race/ethnicity category of “other” includes American Indian/Alaska Native, Asian, Native Hawaiian/other Pacific Islander, multiple races, and declined to answer. Age was calculated as of the end of the calendar year. To provide crude estimates of overall prevalence in the VA population, the total number of Veterans in VA care in 2013—defined as having at least 1 outpatient visit in the year— was determined from the VA’s Corporate Data Warehouse. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
HIV Care Continuum Applied to US Department of VA
Estimates of the total number of Veterans in VA care in 2013 by sex, race/ethnicity, and age as of the end of the calendar year were also generated from the Corporate Data Warehouse. Percentages were calculated as a proportion of the total sample in each subgroup along the HIV Care Continuum. VA and US HIV Care Continuum measures were compared with Chisquare tests with Yates correction. P values of less than 0.05 were accepted as significant. Analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC).
RESULTS Nationally, 25,480 Veterans in VA care in 2013 were diagnosed with HIV compared with an estimated 1,032,800 people in the general US population. There were 5,596,178 Veterans with at least 1 VA outpatient visit in 2013 so the cohort of HIV-diagnosed Veterans in VA represents a diagnosed HIV prevalence of 0.46%. In comparison, the prevalence of diagnosed HIV infection in the general US population has been estimated to be approximately 0.3%–0.4%.33 With regard to the HIV Care Continuum, 77.4% of HIVdiagnosed Veterans were engaged in care, which was significantly greater than the linkage to care rate in the US population diagnosed with HIV (46.3%, P , 0.001) (Table 1 and Fig. 1). Of the HIV-diagnosed Veterans in VA care, 72.6% were on ART compared with 42.8% in the general US population diagnosed with HIV (P , 0.001). Nearly two-thirds (65.3%) of all HIV-diagnosed Veterans had suppressed viral loads in comparison with the general population estimated rate of 35.0% among those diagnosed with HIV (P , 0.001). When assessed with regard to the preceding step in the HIV Care Continuum, of those engaged in care, 93.7% of HIVdiagnosed Veterans received ART compared with 92.3% of the US population. Of those on ART, 90.0% of Veterans had suppressed viral loads compared with the US estimate of 81.9%.
Sex Veterans diagnosed with HIV infection in VA care are predominantly men, who comprise 24,679 (96.9%) of the VA HIV-diagnosed population. Women and men were similar in their engagement in care rates (75.9% vs. 77.5%, respectively, P = 0.29) (Fig. 2A). The percentage of women on ART was statistically lower than the percentage of men (68.2% vs. 72.7%, respectively, P = 0.005), although the absolute difference (4.5%) was numerically quite small. When limited to those who were engaged in care, the rates of being on ART were extremely high for both women and men (89.8% and 93.8%, respectively), although statistically slightly lower for women (P , 0.001). Women were also less likely to have suppressed viral loads (59.9% vs. 65.9%, respectively, P = 0.002). When limited to those on ART, the rates of suppressed viral loads were extremely high and did not differ between women and men (87.9% vs. 90.1%, respectively, P = 0.10).
Race/Ethnicity A higher prevalence of diagnosed HIV infection was seen among blacks (1.47%) than Hispanics (0.56%), whites (0.26%), or other (0.21%). On each stage of the Care www.jaids.com |
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TABLE 1. Veteran (2013) and US population (2011) estimates at Each Stage of the HIV Care Continuum Stage
VA
HIV diagnosed Sex Female Male Race/ethnicity Black Hispanic White Other Age group (yrs) 18–24 25–34 35–44 45–54 55–64 $65 Engaged in care Sex Female Male Race/ethnicity Black Hispanic White Other Age group (yrs) 18–24 25–34 35–44 45–54 55–64 $65 On ART Sex Female Male Race/ethnicity Black Hispanic White Other Age group (yrs) 18–24 25–34 35–44 45–54 55–64 $65 Suppressed Sex Female Male
476
25,480
Percent of Total Diagnosed 100
Percent of Preceding Stage
US
—
1,032,800
Percent of Total Diagnosed
Percent of Preceding Stage
100
801 24,679
247,900 784,900
12,696 1856 9426 1502
417,500 205,600 362,100 47,600
66 1198 2420 7513 9406 4877 19,732
77.4*
30,400 122,500 246,200 390,900 192,700 49,900 478,433
46.3
608 19,124
75.9 77.5
125,691 352,523
50.7 44.9
9715 1502 7424 1091
76.5 80.9 78.8 72.6
195,159 97,169 160,777 25,328
46.7 47.3 44.4 53.2
42 794 1649 5587 7527 4133 18,490
63.6 66.3 68.1 74.4 80.0 84.7 72.6*
93.7*
13,976 55,934 108,247 185,376 91,483 23,416 441,661
46.0 45.7 44.0 47.4 47.5 46.9 42.8
92.3
546 17,944
68.2 72.7
89.8 93.8
115,381 326,061
46.5 41.5
91.8 92.5
8978 1398 7087 1027
70.7 75.3 75.2 68.4
92.4 93.1 95.5 94.1
178,237 90,132 150,675 22,617
42.7 43.8 41.6 47.5
91.3 92.8 93.7 89.3
35 714 1543 5242 7043 3913 16,641
53.0 59.6 63.8 69.8 74.9 80.2 65.3*
83.3 89.9 93.6 93.8 93.6 94.7 90.0*
11,338 49,105 98,754 173,350 86,274 22,840 361,764
37.3 40.1 40.1 44.3 44.8 45.8 35.0
81.1 87.8 91.2 93.5 94.3 97.5 81.9
480 16,160
59.9 65.5
87.9 90.1
90,188 271,358
36.4 34.6
78.2 83.2
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J Acquir Immune Defic Syndr Volume 69, Number 4, August 1, 2015
HIV Care Continuum Applied to US Department of VA
TABLE 1. (Continued ) Veteran (2013) and US population (2011) estimates at Each Stage of the HIV Care Continuum Stage Race/ethnicity Black Hispanic White Other Age group (yrs) 18–24 25–34 35–44 45–54 55–64 $65
Percent of Total Diagnosed
Percent of Preceding Stage
7846 1288 6558 949
61.8 69.4 69.6 63.2
87.4 92.1 92.5 92.4
33 625 1353 4663 6328 3639
50.0 52.2 55.9 62.1 67.3 74.6
94.3 87.5 87.7 89.0 89.8 93.0
VA
Percent of Total Diagnosed
Percent of Preceding Stage
137,740 74,734 129,891 19,399
33.0 36.3 35.9 40.8
77.3 82.9 86.2 85.8
7834 37,667 78,271 144,004 74,565 19,423
25.8 30.7 31.8 36.8 38.7 38.9
69.1 76.7 79.3 83.1 86.4 85.0
US
US population estimates obtained from MMWR 2014, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a5.htm. *P , 0.001 for comparison with the US population estimate.
Continuum, blacks and other had comparable and slightly lower rates whereas whites and Hispanics had virtually identical and slightly higher rates. Nearly three quarters of all Veterans diagnosed with HIV were engaged in care, although the rates varied slightly across race/ethnicity groups ranging from 72.6% other, 76.5% black, 78.8%
white, and 80.9% for Hispanics (Fig. 2B). Rates for other and black were both statistically lower than the rates for whites. The engagement in care rate for Hispanics was actually statistically higher when compared with whites. Rates of being on ART also varied ranged from 68.4% for other, 70.7% for blacks, 75.2% for whites, and 75.3% for
FIGURE 1. A, VA HIV Care Continuum, 2013. B, US HIV Care Continuum (adapted), 2011. Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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FIGURE 2. VA HIV Care Continuum stratified by (A) gender, (B) Race/ Ethnicity, and (C) Age, 2013.
Hispanics. Of those engaged in care, over 90% were on ART regardless of the race/ethnicity: blacks 92.4%, Hispanics 93.1%, other 94.1%, and whites 95.5%. Rates of viral suppression ranged from 61.8% for blacks, 63.2% for others, 69.4% for Hispanics, and 69.6% for whites. When limited to those on ART, blacks had the lowest rates of suppressed HIV viral loads
(87.4%), with rates for Hispanics, other, and whites virtually identical at 92.1%, 92.4%, and 92.5%, respectively.
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Age As of 2013, the age group with the largest cohort of HIV-diagnosed Veterans in VA was the 55–64 age category
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J Acquir Immune Defic Syndr Volume 69, Number 4, August 1, 2015
(9406/36.9%) followed by Veterans 45–54 years of age (7513/ 29.5%) and Veterans 65 years of age or older (4877, 19.1%). On all measures in the Care Continuum, the youngest/not, Veterans had the lowest rates, and rates progressively increased with each increase in age group. Veterans age 65 years and older had the highest rates on all stages of the Care Continuum. Engagement in care rates increased from 63.6% for Veterans 18–24 years of age to 84.7% for Veterans age 65 years or older. Among all HIV-diagnosed Veterans, the percentage on ART increased across the age groups from 53.0% for Veterans 18–24 years of age to 80.2% of those 65 years and older. In terms of virologic response, 50.0% of those aged 18–24 years had suppressed viral loads, which increased to a high of 74.6% among those 65 years or older (Fig. 2C).
DISCUSSION Current analysis of the HIV Care Continuum in the US primarily relies on estimates from data collected from the CDC’s Medical Monitoring Project.34 These national estimates concluded that approximately 35% of patients diagnosed with HIV had suppressed HIV viral loads largely because of deficits in engagement in care. The present analysis from the national VA health care system uses clinical data from the entire population of Veterans in VA care. Our results document better performance at every stage of the HIV Care Continuum than seen in the general US population. In particular, we found that 77.4% of HIVdiagnosed Veterans were engaged in care compared with the general US population, where less than half of those diagnosed with HIV are engaged in care. As a result of the extremely high engagement in care rates, nearly two-thirds of all diagnosed HIV patients and 90% of HIV patients on ART had suppressed HIV viral loads, indicating that extremely high rates of HIV viral control can be achieved in a comprehensive integrated health care system. The notable difference between VA’s engagement in care rate and the estimates for the general US population warrants broader review, analysis, and intervention. In the VA cohort, at each stage of the HIV Care Continuum, there were some differences in rates based on sex, race/ethnicity, and age, with the most striking differences by age group. Given the large sample size, many statistically significant differences may not reflect clinically significant differences. For example, women had numerically lower rates for each stage of the HIV Care Continuum than men, but the differences at any stage were less than 6% points, which likely limits the utility as a target for quality improvement. Hispanics and whites had comparably high rates for each stage of the Care Continuum. Blacks, however, had lower rates for each stage of the HIV Care Continuum compared with whites with the largest difference of 7.8% points when comparing the rates of suppressed viral loads among those HIV diagnosed (61.8% vs. 69.6%). Because over 92% of all patients engaged in care received ART regardless of the race/ethnicity, the lower rates of suppressed viral loads for blacks are not primarily accounted for by lower rates of ART prescription. Of those on ART, the rates of viral suppression were over 92% and virtually identical for Hispanics, other, and whites but only 87% for blacks on ART. Given the extreme importance of virologic control, this difference may warrant additional investigation to better understand why blacks Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
HIV Care Continuum Applied to US Department of VA
seemingly do not achieve similar virologic suppression despite similar access to ART. More efforts may be needed in targeted adherence or persistence programs among blacks to improve virologic suppression rates, given that the apparent difference in virologic outcomes does not appear to arise from differences in access to ART. The most striking differences in the HIV Care Continuum are across age groups with the lowest rates for the youngest patients then the progressive increase across age groups with the highest rates for each stage among those 65 years and older. Taking into account the preceding stage, the largest drop-off along the Care Continuum for the youngest patients compared with the oldest patients occurs in engagement in care, suggesting that greater efforts are necessary to engage younger Veterans in VA HIV Care. Nevertheless, rates of suppressed viral loads among all sexes, races/ethnicities, and age groups were generally high and relatively similar (above 87% for those on ART) and higher than among those in the US population, which suggests that in an integrated health care system, where access to care and medications is equivalent and simple for patients, health disparities can be narrowed among different demographic groups. Although there is no direct method to show that an integrated health care system is superior to fragmented care, these findings from the VA document that improved outcomes along the HIV Care Continuum are seen in an integrated system. VA is known to serve a marginalized population that is afflicted with high rates of mental health comorbidities, substance abuse, homelessness, and poverty.35–37 Based on other US studies, HIV-infected individuals with such mental health and social struggles tend to perform poorly along the HIV Care Continuum.38–41 However, the VA system outperforms other reports that describe the HIV Care Continuum among all demographics when analyzed by gender, race/ethnicity, and age. One limitation in calculating the HIV Care Continuum in the VA cohort is the uncertainty of how many Veterans in VA care have undiagnosed HIV. Of course, the true prevalence in the general US population is similarly unknown. As of 2013, over 32% of the VA population had been tested for HIV.42 The seroprevalence among those tested for HIV in VA care in 2013 was 0.21. The seroprevalence among those tested has dropped annually since the implementation of the routine HIV testing policy, suggesting that seroprevalence among those still untested is even lower. Further modeling studies that extrapolate and model the HIV testing data to predict the number of undiagnosed Veterans in the VA health care system may be warranted. VA’s integrated health care system is able to provide easy access to care, a relatively seamless continuum of health care services, and uncomplicated linkage to specialists and subspecialists, which puts the health care system at an advantage when using the HIV Care Continuum framework. VA patients also have access to integrated mental health services, housing assistance programs, job training, transportation assistance, and other social services that address many of the social determinants of health that many believe impact outcomes along the HIV Care Continuum. The VA may be a model for how HIV care should be delivered in the US to optimize outcomes. An integrated health care system allows for providers to implement the best practices to optimize outcomes, especially viral suppression. www.jaids.com |
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The high performance along the HIV Care Continuum in the VA health care system compared with the general US HIV population is remarkable. Nevertheless, VA continues to strive to identify targets for improvement along the HIV care continuum and implement innovative best practices to achieve higher rates of viral load suppression among Veterans. In the future, the metrics of HIV care in VA may serve as a benchmark and/or the system may serve as a model for the best approaches improving outcomes along the HIV Care Continuum.
1. Backus LI, Boothroyd DB, Phillips BR, et al. National quality forum performance measures for HIV/AIDS care: the Department of Veterans Affairs’ experience. Arch Intern Med. 2010;170:1239–1246. 2. Department of Veterans Affairs, Department of Veterans Affairs. FY 2014-2020 Strategic Plan. Available at: http://www.va.gov/op3/docs/ StrategicPlanning/VA2014-2020strategicPlan.PDF. Accessed January 3, 2015. 3. Czarnogorski M, Halloran Cns J, Pedati C, Dursa EK, Durfee J, Martinello R, Ross D. Expanded HIV testing in the US Department of Veterans Affairs, 2009–2011. Am J Public Health. 2013;103:e40–e45. 4. Zeiss AM, Karlin BE. Integrating mental health and primary care services in the Department of Veterans Affairs health care system. J Clin Psychol Med Settings. 2008;15:73–78. 5. Perlin JB, Kolodner RM, Roswell RH. The Veterans Health Administration: quality, value, accountability, and information as transforming strategies for patient-centered care. Am J Manag Care. 2004;10:828–836. 6. Kizer KW, Fonseca ML, Long LM. The veterans healthcare system: preparing for the twenty-first century. Hosp Health Serv Adm. 1996;42:283–298. 7. Gardner EM, McLees MP, Steiner JF, et al. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52:793–800. 8. The White House Office of National AIDS Policy. Executive Order: White House Care Continuum Initiative. 2013. Available at: http://www. whitehouse.gov/the-press-office/2013/07/15/executive-order-hiv-carecontinuum-initiative. Accessed December 20, 2013. 9. Mugavero MJ, Amico KR, Westfall AO, et al. Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention. J Acquir Immune Defic Syndr. 2012;59:86. 10. 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 and STDS. 2007;21:40–48. 11. Dombrowski JC, Kent JB, Buskin SE, et al. Population-based metrics for the timing of HIV diagnosis, engagement in HIV care, and virologic suppression. AIDS. 2012;26:77. 12. Das M, Chu PL, Santos GM, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS One. 2010;5:e11068. 13. Kassler WJ, Dillon BA, Haley C, et al. On-site, rapid HIV testing with same-day results and counseling. AIDS. 1997;11:1045–1051. 14. Fernández-Balbuena S, de la Fuente L, Hoyos J, et al. Highly visible street-based HIV rapid testing: is it an attractive option for a previously untested population? A cross-sectional study. Sex Transm Infect. 2014; 90:112–118. 15. Hennessey Z, Osorio G, Pati R, et al. A quality framework to improve routine rapid HIV screening, diagnosis, and linkage to care at a highvolume, urban emergency department in New York City. Lancet. 2013; 382:S14. 16. Liang TS, Erbelding E, Jacob CA, et al. Rapid HIV testing of clients of a mobile STD/HIV clinic. AIDS Patient Care STDS. 2005;19:253–257. 17. da Motta LR, Vanni AC, et al. Evaluation of five simple rapid HIV assays for potential use in the Brazilian national HIV testing algorithm. J Virol Methods. 2013;194:132–137.
18. Bauman LJ, Braunstein S, Calderon Y, et al. Barriers and facilitators of linkage to HIV primary care in New York City. J Acquir Immune Defic Syndr. 2013;64:S20–S26. 19. Gruber D, Campos P, Dutcher M, et al. Linking recently diagnosed HIVpositive persons to medical care: perspectives of referring providers. AIDS Care. 2011;23:16–24. 20. Ulett KB, Willig JH, Lin HY, et al. The therapeutic implications of timely linkage and early retention in HIV care. AIDS Patient Care STDS. 2007;370(9590):859–877. 21. Holtgrave DR, Maulsby C, Wehrmeyer L, Hall HI Behavioral factors in assessing impact of HIV treatment as prevention. AIDS Behav. 2012;1–7. 22. Marks G, Gardner LI, Craw J, et al. Entry and retention in medical care among HIV-diagnosed persons: a meta-analysis. AIDS. 2010;24:2665–2678. 23. Kitahata M, Gange S, Abraham A. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med. 2009;360: 1815–1826. 24. The Strategies for Management of Antiretroviral Therapy (SMART) Study Group. CD4+ count-guided interruption of antiretroviral treatment. N Engl J Med. 2006;355:2283–2296. 25. Giordano TP, Gifford AL, White AC Jr, et al. Retention in care: a challenge to to survival with HIV infection. Clin Infect Dis. 2007;44: 1493–1499. 26. Mugavero MJ, Lin HY, Willig JH, et al. Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis. 2009;48:248–256. 27. Giordano TP, White AC Jr, Sajja P, et al. Factors associated with the use of highly active antiretroviral therapy in patients newly entering care in an urban clinic. J Acquir Immune Defic Syndr. 2003;32:399–405. 28. Byrne CM, Mercincavage LM, Pan EC, et al. The value from investments in health information technology at the U.S. Department of Veterans Affairs. Health Aff (Millwood). 2010;29:629–638. 29. Brown SH, Lincoln MJ, Groen PJ, Kolodner RM. VistA—US Department of Veterans Affairs national-scale HIS. Int J Med Inform. 2003;69:135–156. 30. Mangal JP, Rimland D, Marconi VC. The continuum of HIV care in a Veterans’ Affairs clinic. AIDS Res Hum Retroviruses. 2014;30:409–415. 31. Gregory H, Orden O, Jordan L, et al. New directions in capacity building: incorporating cultural competence into the interactive systems framework. Am J Community Psychol. 2012;50:321–333. 32. Morbidity and Mortality Weekly Report: HIV diagnosis, care, and treatment among persons living with HIV—United states, 2011. 2014;63: 1113–1117. 33. Chen M, Rhodes PH, Hall IH, Kilmarx PH, Branson BM, Valleroy LA. Prevalence of undiagnosed HIV infection among persons aged $ 13 years–National HIV Surveillance System, United States, 2005–2008. MMWR Morb Mortal Wkly Rep. 2012;61:57–64. 34. CDC. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data, United States and 6 Dependent Areas, 2012. HIV Surveillance Supplemental Report. 2014:19. 35. O’Toole TP, Conde-Martel A, Gibbon JL, Hanusa, BH, Fine MJ. Health care of homeless veterans. Journal of General Internal Medicine. 2003; 18:929–933. 36. Tessler R, Rosenheck R, Gamache G. Comparison of homeless veterans with other homeless men in a large clinical outreach program. Psychiatr Q. 2002;73:109–119. 37. Wenzel SL, Bakhtiar L, Caskey NH, et al. Homeless veterans’ utilization of medical, psychiatric, and substance abuse services. Med Care. 1995; 1132–1144. 38. Prince M, Patel V, Saxena S, et al. No health without mental health. The Lancet. 2007;370:859–877. 39. Royal SW, Kidder DP, Patrabansh S, et al. Factors associated with adherence to highly active antiretroviral therapy in homeless or unstably housed adults living with HIV. AIDS Care. 2009;21:448–455. 40. Smith MY, Rapkin BD, Winkel G, et al. Housing status and health care service utilization among low-income persons with HIV/AIDS. J Gen Intern Med. 2000;15:731–738. 41. Knowlton AR, Hoover DR, Chung SE, et al. Access to medical care and service utilization among injection drug users with HIV/AIDS. Drug Alcohol Depend. 2001;64:55–62. 42. Department of Veterans Affairs, Office of Public Health. HIV, hepatitis, and public health pathogens communication. Available at: https://vaww. vha.vaco.portal.va.gov/sites/PublicHealth/pophealth/hiv-testing/default. aspx. Accessed January 26, 2015.
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ACKNOWLEDGMENTS The authors thank the local CCR coordinators who make this information possible. REFERENCES
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AND
PREVENTION
HIV Care Continuum Applied to the US Department of Veterans Affairs: HIV Virologic Outcomes in an Integrated Health Care System Lisa Backus, MD, PhD,*†‡ Maggie Czarnogorski, MD, MPH,*§ Gale Yip, BA,† Brittani P. Thomas, MPH,k Marisa Torres, MPH,k Tierney Bell, MPH,k and David Ross, MD, PhD*k
Background: The Department of Veterans Affairs (VA), the largest integrated HIV care provider in the United States (US), used the HIV Care Continuum to compare clinical care within the VA HIV population with the general US HIV population and to identify areas for improvement.
comes along the HIV Care Continuum can be achieved in a comprehensive integrated health care system. Key Words: HIV care continuum, Department of Veteran Affairs, engagement in care, HIV, integrated health care system (J Acquir Immune Defic Syndr 2015;69:474–480)
Methods: National data from the VA’s HIV Clinical Case Registry were used to construct measures along the Continuum for Veterans in VA care diagnosed with HIV by June 2013 and alive by December 31, 2013. Comparisons were made to recent estimates for the same measures for the US HIV population. Additional comparisons were performed for demographic subgroups of sex, race/ethnicity, and age.
Results: Of 25,480 Veterans diagnosed with HIV, 77.4% were engaged in care compared with 46.3% in the US population diagnosed with HIV (P , 0.001). Seventy-three percent of Veterans diagnosed with HIV received antiretroviral therapy compared with 43% of the US population diagnosed with HIV (P , 0.001). Nearly two-thirds (65.3%) of HIV-diagnosed Veterans had suppressed HIV viral loads compared with 35.0% of the US population diagnosed with HIV (P , 0.001). Conclusions: The VA health care system performed better at every stage of the HIV Care Continuum compared with the general US estimates. Comparable high rates with some variation were noted among the demographic groups in the VA cohort. The high viral suppression rate in VA, which was almost double the estimate for the HIV-diagnosed US population, demonstrates that improved outReceived for publication March 5, 2014; accepted February 2, 2015. From the *Department of Veterans Affairs; †Office of Public Health/ Population Health, Veterans Health Administration, Palo Alto, CA; ‡Department of Medicine, VA Palo Alto Health Care System, Veterans Health Administration, Palo Alto, CA; §Patient Care Services/Women’s Health Services, Veterans Health Administration, Washington, DC; and kOffice of Public Health/Clinical Public Health, Veterans Health Administration, Washington, DC. The authors have no conflicts of interest to disclose. L.B., M.C., and G.Y. had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: L.B. and M.C. Acquisition of data: L.B. and G.Y. Analysis and interpretation of data: L.B. and M.C. Drafting of the manuscript: L.B., M.C., B.T., M.T., and T.B. Critical revision of the manuscript for important intellectual content: D.R. Statistical analysis: L.B. Administrative, technical, and material support: D.R. Study supervision: M.C. and D.R. Correspondence to: Maggie Czarnogorski, MD, Department of Veteran Affairs, 810 Vermont Avenue, NW 10P4W, Washington, DC 20420 (e-mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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BACKGROUND The Department of Veterans Affairs (VA) is the largest provider of HIV care in the United States (US).1 The VA health care system is an expansive organization composed of 151 medical centers and over 820 outpatient clinics with points of care in all states across the nation.2 Every medical center in VA has HIV-positive Veterans enrolled in care.3 Most importantly, the VA system can provide integrated coordinated health and social care to Veterans with HIV. Primary care, mental health care, substance abuse treatment, specialty care, and social services such as housing services and job opportunities are available to Veterans within the VA health care system.4–6 Additionally, in the VA health care system, access to care is equitable across all demographics.6 The HIV Care Continuum is an initiative proposed by researchers and policy leaders that serves as a population health approach based on scientific advances in HIV care and management to identify critical foci for improvement in HIV care.7–12 Rapid HIV testing methods have made HIV testing more convenient, faster, and more accurate than ever before.13–17 HIVinfected individuals who are receiving and adherent to antiretroviral treatment (ART) can achieve undetectable viral loads and thereby avoid or delay progression to AIDS18–22 and other longterm complications23,24 as well as decrease the potential for transmission of the virus to others. By promoting HIV testing, improving engagement in care, and supporting efforts for universal treatment, the HIV Care Continuum permits a health care system to assess and monitor over time the quality of its HIV care provision and to identify targeted performance metrics to improve health outcomes and curb the spread of the epidemic.20,25–28 VA, an integrated health care system, may be a model for how HIV care could be monitored and delivered in the US VA is able to capture patient-level data regarding the HIV Care Continuum using elements from the VA’s electronic medical record.29,30 VA is able to provide testing services and coordinated health care delivery in the same system. Additionally, social services and mental health care are readily available and often
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integrated within HIV clinics to provide a seamless collaborative approach at all stages of the HIV Care Continuum.31 Integrated health care systems can potentially weave together the health and social aspects of HIV care that are needed to ensure optimal outcomes of the Care Continuum. VA sought to measure and then compare performance along the HIV Care Continuum with estimates for the general US HIV population, and to potentially demonstrate the success, an integrated health care system can achieve in this framework. Mangal et al have documented that the Atlanta VA Medical Center Infectious Disease Clinic, 1 of the 151 VA medical centers, outperformed the comparable US standards in every step along the HIV Care Continuum. This present analysis sought to assess performance on the HIV Care Continuum for the entire national VA HIV population. In addition, this analysis examined performance along the HIV Care Continuum stratified by sex, race/ethnicity, and age.
METHODS Using the VA’s HIV Clinical Case Registry (CCR)— a database compiled from the VA’s electronic medical record— all HIV-infected patients in VA care in 2013 with laboratorydiagnosed HIV by June 30, 2013, and alive through December 31, 2013, were identified and included in the analysis. The CCR contains information from all VA facilities nationwide on demographics, laboratory tests, outpatient visits, and prescriptions for Veterans in VA care. Measures for the HIV Care Continuum were based on the Centers for Disease Control and Prevention (CDC), HIV Diagnosis, Care, and Treatment Among Persons Living with HIV—United States, 2011, and included HIV diagnosed, engaged in care, on ART, and suppressed viral load.32 HIVdiagnosed Veterans were identified as having a positive laboratory diagnosis of HIV by June 30, 2013. A Veteran was defined as engaged in care based on having at least 2 outpatient visits at the same facility to a primary care or infectious disease clinic with HIV coded as a primary or secondary diagnosis for the visits, with at least 1 visit in each 6-month period of the year with a minimum of 60 days between visits. To be classified as being on ART required outpatient prescription fills in the year from at least 2 ART drug classes. A Veteran was considered to be virologically suppressed if he or she had HIV RNA less than 200 copies per milliliter on the most recent HIV RNA test in the year. Population-level data from the VA were compared with the US HIV Care Continuum rates as reported by the CDC for HIV Care Continuum Estimates in 2011. HIV Care Continuum measures were also calculated for subgroups based on sex, race/ethnicity, and age. Patients with a reported ethnicity of Hispanic were considered Hispanic in the combined variable of race/ethnicity regardless of the reported race. The race/ethnicity category of “other” includes American Indian/Alaska Native, Asian, Native Hawaiian/other Pacific Islander, multiple races, and declined to answer. Age was calculated as of the end of the calendar year. To provide crude estimates of overall prevalence in the VA population, the total number of Veterans in VA care in 2013—defined as having at least 1 outpatient visit in the year— was determined from the VA’s Corporate Data Warehouse. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
HIV Care Continuum Applied to US Department of VA
Estimates of the total number of Veterans in VA care in 2013 by sex, race/ethnicity, and age as of the end of the calendar year were also generated from the Corporate Data Warehouse. Percentages were calculated as a proportion of the total sample in each subgroup along the HIV Care Continuum. VA and US HIV Care Continuum measures were compared with Chisquare tests with Yates correction. P values of less than 0.05 were accepted as significant. Analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC).
RESULTS Nationally, 25,480 Veterans in VA care in 2013 were diagnosed with HIV compared with an estimated 1,032,800 people in the general US population. There were 5,596,178 Veterans with at least 1 VA outpatient visit in 2013 so the cohort of HIV-diagnosed Veterans in VA represents a diagnosed HIV prevalence of 0.46%. In comparison, the prevalence of diagnosed HIV infection in the general US population has been estimated to be approximately 0.3%–0.4%.33 With regard to the HIV Care Continuum, 77.4% of HIVdiagnosed Veterans were engaged in care, which was significantly greater than the linkage to care rate in the US population diagnosed with HIV (46.3%, P , 0.001) (Table 1 and Fig. 1). Of the HIV-diagnosed Veterans in VA care, 72.6% were on ART compared with 42.8% in the general US population diagnosed with HIV (P , 0.001). Nearly two-thirds (65.3%) of all HIV-diagnosed Veterans had suppressed viral loads in comparison with the general population estimated rate of 35.0% among those diagnosed with HIV (P , 0.001). When assessed with regard to the preceding step in the HIV Care Continuum, of those engaged in care, 93.7% of HIVdiagnosed Veterans received ART compared with 92.3% of the US population. Of those on ART, 90.0% of Veterans had suppressed viral loads compared with the US estimate of 81.9%.
Sex Veterans diagnosed with HIV infection in VA care are predominantly men, who comprise 24,679 (96.9%) of the VA HIV-diagnosed population. Women and men were similar in their engagement in care rates (75.9% vs. 77.5%, respectively, P = 0.29) (Fig. 2A). The percentage of women on ART was statistically lower than the percentage of men (68.2% vs. 72.7%, respectively, P = 0.005), although the absolute difference (4.5%) was numerically quite small. When limited to those who were engaged in care, the rates of being on ART were extremely high for both women and men (89.8% and 93.8%, respectively), although statistically slightly lower for women (P , 0.001). Women were also less likely to have suppressed viral loads (59.9% vs. 65.9%, respectively, P = 0.002). When limited to those on ART, the rates of suppressed viral loads were extremely high and did not differ between women and men (87.9% vs. 90.1%, respectively, P = 0.10).
Race/Ethnicity A higher prevalence of diagnosed HIV infection was seen among blacks (1.47%) than Hispanics (0.56%), whites (0.26%), or other (0.21%). On each stage of the Care www.jaids.com |
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Backus et al
TABLE 1. Veteran (2013) and US population (2011) estimates at Each Stage of the HIV Care Continuum Stage
VA
HIV diagnosed Sex Female Male Race/ethnicity Black Hispanic White Other Age group (yrs) 18–24 25–34 35–44 45–54 55–64 $65 Engaged in care Sex Female Male Race/ethnicity Black Hispanic White Other Age group (yrs) 18–24 25–34 35–44 45–54 55–64 $65 On ART Sex Female Male Race/ethnicity Black Hispanic White Other Age group (yrs) 18–24 25–34 35–44 45–54 55–64 $65 Suppressed Sex Female Male
476
25,480
Percent of Total Diagnosed 100
Percent of Preceding Stage
US
—
1,032,800
Percent of Total Diagnosed
Percent of Preceding Stage
100
801 24,679
247,900 784,900
12,696 1856 9426 1502
417,500 205,600 362,100 47,600
66 1198 2420 7513 9406 4877 19,732
77.4*
30,400 122,500 246,200 390,900 192,700 49,900 478,433
46.3
608 19,124
75.9 77.5
125,691 352,523
50.7 44.9
9715 1502 7424 1091
76.5 80.9 78.8 72.6
195,159 97,169 160,777 25,328
46.7 47.3 44.4 53.2
42 794 1649 5587 7527 4133 18,490
63.6 66.3 68.1 74.4 80.0 84.7 72.6*
93.7*
13,976 55,934 108,247 185,376 91,483 23,416 441,661
46.0 45.7 44.0 47.4 47.5 46.9 42.8
92.3
546 17,944
68.2 72.7
89.8 93.8
115,381 326,061
46.5 41.5
91.8 92.5
8978 1398 7087 1027
70.7 75.3 75.2 68.4
92.4 93.1 95.5 94.1
178,237 90,132 150,675 22,617
42.7 43.8 41.6 47.5
91.3 92.8 93.7 89.3
35 714 1543 5242 7043 3913 16,641
53.0 59.6 63.8 69.8 74.9 80.2 65.3*
83.3 89.9 93.6 93.8 93.6 94.7 90.0*
11,338 49,105 98,754 173,350 86,274 22,840 361,764
37.3 40.1 40.1 44.3 44.8 45.8 35.0
81.1 87.8 91.2 93.5 94.3 97.5 81.9
480 16,160
59.9 65.5
87.9 90.1
90,188 271,358
36.4 34.6
78.2 83.2
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HIV Care Continuum Applied to US Department of VA
TABLE 1. (Continued ) Veteran (2013) and US population (2011) estimates at Each Stage of the HIV Care Continuum Stage Race/ethnicity Black Hispanic White Other Age group (yrs) 18–24 25–34 35–44 45–54 55–64 $65
Percent of Total Diagnosed
Percent of Preceding Stage
7846 1288 6558 949
61.8 69.4 69.6 63.2
87.4 92.1 92.5 92.4
33 625 1353 4663 6328 3639
50.0 52.2 55.9 62.1 67.3 74.6
94.3 87.5 87.7 89.0 89.8 93.0
VA
Percent of Total Diagnosed
Percent of Preceding Stage
137,740 74,734 129,891 19,399
33.0 36.3 35.9 40.8
77.3 82.9 86.2 85.8
7834 37,667 78,271 144,004 74,565 19,423
25.8 30.7 31.8 36.8 38.7 38.9
69.1 76.7 79.3 83.1 86.4 85.0
US
US population estimates obtained from MMWR 2014, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a5.htm. *P , 0.001 for comparison with the US population estimate.
Continuum, blacks and other had comparable and slightly lower rates whereas whites and Hispanics had virtually identical and slightly higher rates. Nearly three quarters of all Veterans diagnosed with HIV were engaged in care, although the rates varied slightly across race/ethnicity groups ranging from 72.6% other, 76.5% black, 78.8%
white, and 80.9% for Hispanics (Fig. 2B). Rates for other and black were both statistically lower than the rates for whites. The engagement in care rate for Hispanics was actually statistically higher when compared with whites. Rates of being on ART also varied ranged from 68.4% for other, 70.7% for blacks, 75.2% for whites, and 75.3% for
FIGURE 1. A, VA HIV Care Continuum, 2013. B, US HIV Care Continuum (adapted), 2011. Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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FIGURE 2. VA HIV Care Continuum stratified by (A) gender, (B) Race/ Ethnicity, and (C) Age, 2013.
Hispanics. Of those engaged in care, over 90% were on ART regardless of the race/ethnicity: blacks 92.4%, Hispanics 93.1%, other 94.1%, and whites 95.5%. Rates of viral suppression ranged from 61.8% for blacks, 63.2% for others, 69.4% for Hispanics, and 69.6% for whites. When limited to those on ART, blacks had the lowest rates of suppressed HIV viral loads
(87.4%), with rates for Hispanics, other, and whites virtually identical at 92.1%, 92.4%, and 92.5%, respectively.
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Age As of 2013, the age group with the largest cohort of HIV-diagnosed Veterans in VA was the 55–64 age category
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J Acquir Immune Defic Syndr Volume 69, Number 4, August 1, 2015
(9406/36.9%) followed by Veterans 45–54 years of age (7513/ 29.5%) and Veterans 65 years of age or older (4877, 19.1%). On all measures in the Care Continuum, the youngest/not, Veterans had the lowest rates, and rates progressively increased with each increase in age group. Veterans age 65 years and older had the highest rates on all stages of the Care Continuum. Engagement in care rates increased from 63.6% for Veterans 18–24 years of age to 84.7% for Veterans age 65 years or older. Among all HIV-diagnosed Veterans, the percentage on ART increased across the age groups from 53.0% for Veterans 18–24 years of age to 80.2% of those 65 years and older. In terms of virologic response, 50.0% of those aged 18–24 years had suppressed viral loads, which increased to a high of 74.6% among those 65 years or older (Fig. 2C).
DISCUSSION Current analysis of the HIV Care Continuum in the US primarily relies on estimates from data collected from the CDC’s Medical Monitoring Project.34 These national estimates concluded that approximately 35% of patients diagnosed with HIV had suppressed HIV viral loads largely because of deficits in engagement in care. The present analysis from the national VA health care system uses clinical data from the entire population of Veterans in VA care. Our results document better performance at every stage of the HIV Care Continuum than seen in the general US population. In particular, we found that 77.4% of HIVdiagnosed Veterans were engaged in care compared with the general US population, where less than half of those diagnosed with HIV are engaged in care. As a result of the extremely high engagement in care rates, nearly two-thirds of all diagnosed HIV patients and 90% of HIV patients on ART had suppressed HIV viral loads, indicating that extremely high rates of HIV viral control can be achieved in a comprehensive integrated health care system. The notable difference between VA’s engagement in care rate and the estimates for the general US population warrants broader review, analysis, and intervention. In the VA cohort, at each stage of the HIV Care Continuum, there were some differences in rates based on sex, race/ethnicity, and age, with the most striking differences by age group. Given the large sample size, many statistically significant differences may not reflect clinically significant differences. For example, women had numerically lower rates for each stage of the HIV Care Continuum than men, but the differences at any stage were less than 6% points, which likely limits the utility as a target for quality improvement. Hispanics and whites had comparably high rates for each stage of the Care Continuum. Blacks, however, had lower rates for each stage of the HIV Care Continuum compared with whites with the largest difference of 7.8% points when comparing the rates of suppressed viral loads among those HIV diagnosed (61.8% vs. 69.6%). Because over 92% of all patients engaged in care received ART regardless of the race/ethnicity, the lower rates of suppressed viral loads for blacks are not primarily accounted for by lower rates of ART prescription. Of those on ART, the rates of viral suppression were over 92% and virtually identical for Hispanics, other, and whites but only 87% for blacks on ART. Given the extreme importance of virologic control, this difference may warrant additional investigation to better understand why blacks Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
HIV Care Continuum Applied to US Department of VA
seemingly do not achieve similar virologic suppression despite similar access to ART. More efforts may be needed in targeted adherence or persistence programs among blacks to improve virologic suppression rates, given that the apparent difference in virologic outcomes does not appear to arise from differences in access to ART. The most striking differences in the HIV Care Continuum are across age groups with the lowest rates for the youngest patients then the progressive increase across age groups with the highest rates for each stage among those 65 years and older. Taking into account the preceding stage, the largest drop-off along the Care Continuum for the youngest patients compared with the oldest patients occurs in engagement in care, suggesting that greater efforts are necessary to engage younger Veterans in VA HIV Care. Nevertheless, rates of suppressed viral loads among all sexes, races/ethnicities, and age groups were generally high and relatively similar (above 87% for those on ART) and higher than among those in the US population, which suggests that in an integrated health care system, where access to care and medications is equivalent and simple for patients, health disparities can be narrowed among different demographic groups. Although there is no direct method to show that an integrated health care system is superior to fragmented care, these findings from the VA document that improved outcomes along the HIV Care Continuum are seen in an integrated system. VA is known to serve a marginalized population that is afflicted with high rates of mental health comorbidities, substance abuse, homelessness, and poverty.35–37 Based on other US studies, HIV-infected individuals with such mental health and social struggles tend to perform poorly along the HIV Care Continuum.38–41 However, the VA system outperforms other reports that describe the HIV Care Continuum among all demographics when analyzed by gender, race/ethnicity, and age. One limitation in calculating the HIV Care Continuum in the VA cohort is the uncertainty of how many Veterans in VA care have undiagnosed HIV. Of course, the true prevalence in the general US population is similarly unknown. As of 2013, over 32% of the VA population had been tested for HIV.42 The seroprevalence among those tested for HIV in VA care in 2013 was 0.21. The seroprevalence among those tested has dropped annually since the implementation of the routine HIV testing policy, suggesting that seroprevalence among those still untested is even lower. Further modeling studies that extrapolate and model the HIV testing data to predict the number of undiagnosed Veterans in the VA health care system may be warranted. VA’s integrated health care system is able to provide easy access to care, a relatively seamless continuum of health care services, and uncomplicated linkage to specialists and subspecialists, which puts the health care system at an advantage when using the HIV Care Continuum framework. VA patients also have access to integrated mental health services, housing assistance programs, job training, transportation assistance, and other social services that address many of the social determinants of health that many believe impact outcomes along the HIV Care Continuum. The VA may be a model for how HIV care should be delivered in the US to optimize outcomes. An integrated health care system allows for providers to implement the best practices to optimize outcomes, especially viral suppression. www.jaids.com |
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J Acquir Immune Defic Syndr Volume 69, Number 4, August 1, 2015
Backus et al
The high performance along the HIV Care Continuum in the VA health care system compared with the general US HIV population is remarkable. Nevertheless, VA continues to strive to identify targets for improvement along the HIV care continuum and implement innovative best practices to achieve higher rates of viral load suppression among Veterans. In the future, the metrics of HIV care in VA may serve as a benchmark and/or the system may serve as a model for the best approaches improving outcomes along the HIV Care Continuum.
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ACKNOWLEDGMENTS The authors thank the local CCR coordinators who make this information possible. REFERENCES
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