ABSTRACT
Background Missouri is one of seven priority states identified by the Ending the HIV Epidemic Initiative, and St. Louis contains almost half of the people living with HIV (PLWH) in Missouri. As St. Louis has a marked history of structural racism and economic inequities, we utilized the Intersectionality Based Policy Analysis (IBPA) framework to guide a participatory needs assessment for planning and program development. Methods The planning team included researchers, the lead implementer from our community partner, and two community representatives, and had biweekly 60-90 minute meetings for 18 months. The planning team discussed and approved all research materials, reviewed and interpreted results, and made decisions about outreach, recruitment, conduct of the needs assessment and development of the planned intervention. The needs assessment integrated information from existing data, (1) interviews with (a) PLWH (n=12), (b) community leaders (n=5), (c) clinical leaders (n=4), and (d) community health workers (CHWs) (n=3) and (e) CHW supervisors (n=3) who participated in a Boston University-led demonstration project on CHWs in the context of HIV and (2) focus groups (2 FG, 12 participants) with front line health workers such as peer specialists, health coaches and outreach workers. A rapid qualitative analysis approach was used for all interviews and focus groups. Results The IBPA was used to guide team discussions of team values, definition and framing of the problem, questions and topics in the key informant interviews, and implementation strategies. Applying the IBPA framework contributed to a focus on intersectional drivers of inequities in HIV services. The effective management of HIV faces significant challenges from high provider turnover, insufficient integration of CHWs into care teams, and organizational limitations in tailoring treatment plans. Increasing use of CHWs for HIV treatment and prevention also faces challenges. People living with HIV (PLWH) encounter multiple barriers such as stigma, lack of social support, co-morbidities, medication side effects and difficulties in meeting basic needs. Conclusions Addressing intersectional drivers of health inequities may require multi-level, structural approaches. We see the IBPA as a valuable tool for participatory planning while integrating community engagement principles in program and implementation design for improving HIV outcomes.
ABSTRACT
Clinic appointment attendance is a significant determinant of improved HIV health outcomes. A retrospective longitudinal analysis from 2009 to 2015 examined the relationship of clinic policy attendance with and without medical case management (MCM) on HIV clinical outcomes. Clinical parameters were abstracted across the study years and latent growth models measured HIV clinical outcomes as a function of time. A total of 2773 patients were included in this study. More than the majority of individuals had 75% clinic policy attendance during each of the study years and the median number of MCM contact visits with the case manager was 4.0 visits per year (p < 0.01). While the overall trend identified improved HIV clinical outcomes across the clinic population over the study period, it also revealed individuals receiving MCM and with 75% clinic policy attendance had significantly faster improvement in HIV clinical outcomes compared to the individuals who did not receive MCM nor had 75% clinic policy attendance. This study identified how MCM, in combination with clinic policy attendance efforts, are useful in quickly improving HIV viral load and CD4 T-cell count. These findings support the continued need for funding of the Ryan White Care Act as it assists with the support of MCM and appointment attendance through the guidance of wrap-around services.
Subject(s)
Case Management , HIV Infections , HIV , HIV Infections/drug therapy , Humans , Longitudinal Studies , Retrospective Studies , Treatment OutcomeABSTRACT
Medical case management (MCM) is a core medical service in The Ryan White HIV/AIDS Program and aims to provide treatment and care for people living with HIV/AIDS by engaging, identifying and eliminating barriers to HIV care. Little research has examined the impact of this intervention; therefore, the purpose of this study was to examine the how MCM affects HIV clinical outcomes. The study took place at a midwestern, outpatient infectious diseases clinic. This study utilized a longitudinal, retrospective study design to analyze to the impact of MCM engagement on HIV clinical outcomes (viral loads, CD4 counts) from 2009 to 2015 as a time-varying predictor. A total of 2773 patients were included in this study, of which 975 patients (35.2%) engaged in MCM. Among those in MCM, approximately 90% of the population were between 25 and 64 years of age, more than three-quarters were African American men, mean time of HIV care engagement in at this clinic care was 3.2 (± 4.1), while mean years living with HIV was 10.5 (± 7.1). Throughout the study period, those engaged in MCM had a significantly faster improvement in their HIV clinical outcomes compared to the non-MCM group (p < 0.001). The study highlights the significant impact MCM services have on improving CD4 T cell counts and HIV viral loads. The successful care coordination that MCM offers clearly improves health outcomes while creating a network of patient care.
