ECHPP Initiative

Amanda D. Castel, MD, MPH

August 09, 2012

The District of Columbia HIV/AIDS Hepatitis, STD, TB Administration (HAHSTA) is actively working to meet the goals of the National HIV/AIDS Strategy (NHAS) goals. An interim review found that as of 2010, HAHSTA was making substantial progress in achieving the NHAS goals; however, objectives that were more challenging to meet included reducing new infections and transmissions and retaining persons in continuous care.  In an attempt to address these gaps, HAHSTA is also focused on understanding the factors associated with maximizing outcomes at each point in the HIV continuum of care cascade. Thus far, the city has been able to successfully conduct case surveillance to identify the number of HIV positive persons in the city, to link the majority of those persons into care, and to measure rates of viral suppression. Our initial ECHPP supplement focused on routine testing and linkage to care. Secondary analysis of surveillance data found that linkage to care within three months of diagnosis differed depending on site type. A greater proportion of clients diagnosed in non-medical cases management sites were linked to care within three months of HIV diagnosis when compared with medical cases management sites. However, with regard to continuity of care, a greater proportion of clients receiving care at medical case management sites were in continuous, or regular care, during FY2010. HAHSTA has coordinated efforts among providers to attempt to re-engage persons who have been out of care; however, reasons for poor engagement in care have not been systematically elucidated among HIV infected individuals in the District of Columbia.

In 2008, HAHSTA conducted the “Recapture Blitz”, an effort to identify persons known to have previously been in care but who had since fallen out of care and re-engage them into care. Five HIV primary care sites participated by submitting to HAHSTA the names of persons who had received care at their site but who had not been seen in a two-year period. Based on surveillance and laboratory data, HAHSTA identified those persons as having died, receiving care at another site in the District or indicated that they had no evidence of being in care. The methods used by each site to re-engage persons were site dependent and sites did not systematically document the reasons that these people were not in care. HAHSTA is currently working with providers to conduct a second Recapture Blitz thus this ECHPP supplement provides a timely opportunity to assist in this effort to identify persons who are out of care, and to simultaneously collect data regarding reasons for being out of care in an attempt to identify predictors of retention in care.

In addition to HAHSTA’s re-engagement efforts, they are promoting the establishment of a patient-centered medical homes model. Core elements of this model will include availability of an HIV specialist, support services, and community outreach. HAHSTA leadership believes that this medical home model will assist in improving the continuity and provision of comprehensive care among HIV-infected persons in the District. However, in order to further define the necessary components for implementing this approach additional research is needed from both a patient and provider perspective, to identify the barriers and facilitators of engagement in care including an assessment of the quality of healthcare currently being provided. In keeping with these priorities, HAHSTA has identified several areas in which the expertise of researchers at the DC Developmental Center for AIDS Research (DC D-CFAR) can complement and support these activities. Therefore, using a mixed-methods approach, the DC D-CFAR aims to identify predictors of retention in HIV care through linkage of clinic-based and surveillance data, and patient-level surveys and identify individual and structural-level barriers and facilitators to engagement and retention in HIV care through the conduct of qualitative interviews with patients and providers.