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Getting in Care, Getting Treatment

“Retention in care is linked with better overall health and survival among people with HIV/AIDS [including treatment adherence]. Ryan White uses quality improvement measures, and system level measures such as the number of people with AIDS who get to their first and second appointments because the second visit has been shown to be an indicator of retention in care—the “no-show” rate drops dramatically among people who make it to their second medical visit.  Many Ryan White-funded programs now have concierge services. At their first visit, people are introduced to staff who will call them to follow-up. They can work with patient navigators and get  linked to care and a second appointment.”

—Laura Cheever,
Chief medical officer and deputy associate

Ryan White grantees continue to grow with the epidemic. Because the medical tools to treat HIV are available, it has become increasingly important to reach the people who need them, to get those people into care, and to make sure that they remain engaged. In fact, a key provision of the 2009 reauthorization involves bringing people, especially members of poor, minority, and underserved populations who are unaware of their status, into care and maintaining them in treatment.

The Special Projects of National Significance (SPNS) program looks at innovative ways to deliver HIV care and treatment where it matters most. SPNS models are designed and intended for implementation by Ryan White grantees. “SPNS can shift models of care . . . HIV is a chronic illness—we need to deal with the things that are killing people,” says Cheever.

Trio of SPNS

The Hepatitis C Treatment Expansion Initiative is looking at best practices for delivering HCV treatment to people coinfected with HIV. HCV is highly prevalent among people with HIV: In the United States, as many as 30 percent of PLWHA are coinfected.100 End-stage liver disease from HCV is now a leading cause of death among PLWHA. Several new HCV drugs are in development and are being or will be studied in HIV/HCV coinfected people, so it is more important than ever to optimize delivery of HCV treatment.101

SPNS focuses on where the need is greatest. From the beginning of the epidemic, HIV/AIDS has had a devastating and disproportionate impact on African-American and Hispanic/Latina women. In 2010, the CDC estimated that 1 in 30 African-American women and 1 in 106 Hispanic/Latina women will contract HIV.102,103 Minority women have traditionally been underrepresented in clinical trials; often suffer from comorbidities such as depression and substance use disorders; are often uninsured; and have worse outcomes across a range of conditions, including HIV/AIDS.104,105 The Enhancing Access to and Retention in Quality HIV/AIDS Care for Women of Color Initiative will identify innovative methods of reaching and continuing to deliver care to women of color and getting them into treatment.

HRSA has worked diligently to ensure that advances in HIV treatment will benefit people who need them most, not just those who are easiest to reach. Because HIV/AIDS is prevalent among current and former drug users, treatment for substance use disorders is one of the core medical services specified in the Ryan White HIV/AIDS Treatment Extension Act of 2009. According to the CDC, more than one-third of AIDS cases and 19 percent of HIV cases are attributed to injection drug use, and survival is poorer among PLWHA who are injection drug users, in part because of late initiation of ART.106,107,108,109

In late 2002, the approval of buprenorphine for treatment of opioid dependence marked a significant advance in the field. In 2004, HRSA launched the Buprenorphine Initiative: An Evaluation of Innovative Methods for Integrating Buprenorphine Opioid Abuse Treatment in HIV Primary Care. This initiative reflects the ongoing commitment of Ryan White staff and grantees to optimize delivery of care to PLWHA. The buprenorphine initiative evaluated feasibility and effectiveness of integrating medication-assisted treatment for opioid dependence into HIV primary care. For more information about HIV primary care and buprenorphine, see the HRSA CAREAction newsletter on medication-assisted treatment, available online (http://hab.hrsa.gov/newspublications/careactionnewsletter/may2011.pdf; and look for the forthcoming buprenorphine monograph.)

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