Engaging HIV Patients ... ... And Keeping Them Engaged BY DAVID C. HOLZMAN
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ost people living with HIV today—as much as 90%—are involved in care and doing very well, but it’s the remaining 10% that is the real concern. “People who are engaged in care and take their medications do really well,” said Daniel A. Solomon, MD, an internist in the Division of Infectious Disease, Brigham and Women’s Hospital, and an Instructor of medicine at Harvard Medical School, both in Boston. “They have high rates of viral suppression, and HIV becomes a chronic disease that is easily managed, often more so than diabetes and high blood pressure.” However, “those who are homeless or unstably housed, have substance use disorders [SUDs], or have psychiatric disorders are particularly vulnerable to disengaging from HIV care and may need options that differ from the conventional clinical approach,” said Julie C. Dombrowski, MD, MPH, an associate professor in the Department of Medicine, Division of Allergy and Infectious Diseases, and the deputy director of the HIV/STD Program, Public Health Seattle and King County. Not surprisingly, studies are examining the effectiveness of different strategies to get people with HIV back into care. A recent metaanalysis examined 14 interventions (AIDS 2022 Jan 12. doi: 10.1097/ QAD.0000000000003172). The investigators reported that there are several effective strategies for improving the outcomes for people with HIV who are not receiving care, including re-engaging and retaining them by data-to-care, which looks to multiple data points to identify people not receiving care, helping them navigate the health system, offering transportation, accompanying patients to appointments and providing psychosocial support. “Papers like this are laudable efforts to summarize the literature, but a lot of amazing stuff doesn’t make it into peer review,” said Dr. Dombrowski, who was the principal investigator on an earlier paper on the topic (AIDS Patient Care STDS 2020;34[6]:267-274). Many interventions designed to re-engage people in healthcare focus on changing the patient’s care-seeking behavior or helping them navigate the HIV healthcare system, instead of changing the healthcare system to meet the needs of those who are disengaged.
Striving for the ‘Max’
Figure. The HIV care continuum outlines the steps that people with HIV take from diagnosis to achieving and maintaining viral suppression. Source: HIV.gov
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A handful of clinics across the United States are working on meeting the needs of those 10% to 15% of patients with HIV who have trouble remaining in care and maintaining viral suppression. Seattle’s Max (short for Maximum Assistance) Clinic, which provides both primary care and HIV care, is taking this new approach. The Max provides “intensive case management support,” Dr. Dombrowski explained. “We do that with both medical and nonmedical continued on page 41
