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HIV Treatment and Care: Information for Health Care Providers

Antiretroviral therapy (ART) reduces HIV-related morbidity and mortality at all stages of HIV infection and reduces HIV transmission.1-8 When taken consistently as prescribed, ART can suppress viral load, maintain high CD4 cell counts, prevent AIDS, prolong survival, and reduce risk of transmitting HIV to others, all of which are important treatment goals.9,10 Current treatment guidelines recommend ART for all people with HIV, regardless of CD4 cell count. ART should be started as soon as possible after diagnosis and should be accompanied by patient education regarding the benefits and risks of ART and the importance of adherence.

ART Initiation

Clinical providers play a crucial role in describing the benefits of early initiation of ART, offering and prescribing ART, managing long-term ART use, and providing information on other interventions that can reduce the risk of HIV transmission.

By using open communication, providers can emphasize the benefits of consistent, long-term adherence to the prescribed ART regimen and the potential negative consequences of nonadherence. One way health care providers can enhance communication is to ask open-ended questions. These can help the medical provider better understand the patient’s views, barriers, and ability to adhere to their treatment regimen.

Here are some examples of questions around initiating ART:

  • “What have you heard about HIV medicines?”
  • “What are the most important results you hope to get from treatment?”
  • “What are your concerns about HIV medicines?”

ART Adherence and Viral Suppression

There are many benefits to ART, including improved health and reduced risk of transmission, but adherence is key. The success of ART is contingent on adherence to achieve and maintain viral suppression. Data show, however, that not all HIV-positive individuals on ART are virally suppressed, while even fewer maintain viral suppression over time. CDC’s national surveillance data estimate that 58% of persons diagnosed with HIV in the United States in 2014 were virally suppressed.11 In addition, while most (about 80%) HIV-positive persons in the United States engaged in HIV clinical care (defined as either receiving HIV medical care or having a viral load test) were virally suppressed at their last test, almost 20% were not.11-13 Also, about two-thirds achieved and maintained viral suppression over twelve months, which means about one-third (or about 33%) did not maintain viral suppression over that time period.12,13

Studies have shown that health care providers can positively impact adherence among people with HIV by engaging in regular, ongoing discussions at every office visit that describe the benefits of ART adherence; identifying barriers to adherence; offering adherence support services; and providing information on other interventions that can improve adherence and reduce the risk of HIV transmission to others.14,15

Here are some examples of questions to ask about ongoing adherence:

  • “How has it been going taking your HIV medicines?”
  • “What seems to get in the way of taking your medicines?”
  • “Have you missed any doses of your medication and if so, what was going on at that time?”

 

Once the conversation has started, health care providers may find that patients are encountering barriers to adherence. Below is a list of common barriers and ways to address them through routine conversations during patient visits. Note that some of these evidence-based approaches move beyond conversations and may include referral to patient navigators or case managers as appropriate:

Barrier(s) Approach to Address the Barrier(s)
Patient beliefs and behaviors, such as not taking their medications when they “feel well.”
  • Explain the importance of consistent ART adherence even when they feel well or their viral load is already undetectable, and the decrease in transmission risk when viral suppression is achieved.
Cognitive or organizational barriers, such as lack of logistic skills and comprehension level.
  • Offer advice about and tools for adherence, such as weekly pill boxes, dose reminder alarms, and linking dosing to daily events/activities. Consider the free smartphone app, Every Dose, Every Day™ (Archived) .
  • Use a feedback strategy (such as “tell me what you just heard”) to help patients avoid confusion about new medicines, dosing schedule, and/or changed regimen.
Treatment competence or the overall ability to adhere to a potentially complicated and long-term regimen.
  • Involve patients in decision making, including selection of the ART regimen, if options exist.
  • Ensure patients understand the treatment plan, including drug regimen, dosing schedule, and dietary restrictions.
  • Prepare patients for situations or changes in routine that could trigger nonadherence or short-term interruption, such as side effects, illicit drug use, or running out of HIV medication.
  • Encourage patients to keep one or two days worth of medication on hand in case of emergency to avoid missed doses.
  • Encourage patients to recruit friends and/or family members to help with adherence.
Comorbid conditions – such as diabetes, dyslipidemia, hypertension, and viral hepatitis – that may further complicate the treatment plan design and the ability of the patient to adhere to the plan.
  • Regularly review the total treatment plan, and simplify regiment if possible with consideration for patients’ lifestyles and comorbidities.
  • Anticipate (and plan to manage) possible drug-drug interactions.
Regimen-related barriers, including fear of treatment, fear of treatment-related side effects, and confusion about doses.
  • Offer ART regimens that are highly effective and simple to take (e.g., once daily single-tablet dosing, few if any dietary restrictions).
  • Explain that treatment has improved and is easier to take and better tolerated today than ever before.
  • Encourage patients to recruit friends and/or family members to help with adherence.
Short-term side effects that can occur when patients start or change ART regimens, such as nausea, fatigue, disturbed sleep or dreaming.
  • Alert patients that some people have side effects but that they are usually mild, short-lived, and can be managed.
  • Explain which side effects may occur with the ART they are taking.
  • Anticipate (and plan to manage) these side effects.
  • Instruct patients that if they experience these or other side effects, they should seek help before stopping their ART regimen.
Psychosocial barriers, such as mental health issues (e.g., depression, perceived low quality of live), drug or alcohol abuse, negative attitudes or beliefs about HIV, and lack of social support.
  • When possible, refer patients to patient navigators for help with receiving essential support services related to mental health, substance use, and other support resources (e.g., psychologists, addiction specialists, support groups, adherence counselors, case managers)
  • Remind patients not to share their ART with anyone.
  • Encourage patients to recruit friends and/or family members to help with adherence.
Structural barriers, such as lack of transportation, housing, childcare, or insurance covering ART and long-term HIV care.
  • When possible, refer patients to patient navigators for help with issues such as lack of transportation, housing, childcare, and access to insurance.

Viral Load Monitoring

Plasma HIV RNA viral load should be measured regularly to confirm initial and sustained response to ART. Most patients taking ART as prescribed achieve viral suppression within six months.

The frequency of viral load testing depends on several factors. Current guidelines recommend viral load monitoring as follows:16

  • With initiation of ART (before initiation and within 2 to 4 weeks after treatment initiation, followed by 4 to 8 week intervals until the levels become undetectable)
  • After ART modification due to suboptimal response (within 2 to 4 weeks after treatment modification, followed by 4 to 8 week intervals until the levels become undetectable)
  • After ART modification due to toxicity or need for regiment simplification (within 4 to 8 weeks after changing therapy)
  • In patients on a stable, suppressive ART regimen (every 3 to 4 months, or every 6 months if virally suppressed for more than 2 years, to confirm durable viral suppression)
  • In patients with suboptimal response (frequency depends on clinical circumstances)

 

Patients may experience a temporary increase or “blip” in their viral load, defined as viral loads transiently detectable at low levels. These blips usually go back down by the next viral load test. Patients who are using viral suppression as their primary prevention method and experience a blip may benefit from using other prevention strategies until their viral load is undetectable again.

Regular, Ongoing Care

Keeping patients in regular, ongoing care improves their health and reduces their risk of HIV transmission. The benefits of on-going care can include addressing and supporting ART adherence, maintaining decreased viral load and increased CD4 count, lower rates of progression to AIDS, decreased rates of hospitalization, and improved overall health.17-19 Poor retention is more common in people who have substance use disorders, serious mental health problems, unmet socioeconomic needs (e.g., housing, food, or transportation), limited financial resources or health insurance, or schedules that complicate adherence.

There are several effective approaches to help patients stay in HIV care, improve medication adherence, achieve viral suppression, and improve health outcomes. Science-based approaches include the following:

  • Clinic-wide marketing (e.g., posters, brochures) and support (e.g., customer service training of patient-facing staff) to promote attending scheduled visits and provide patients a welcoming and courteous experience.20,21
  • A designated staff person, often referred to as a patient navigator, to focus on retention, adherence, and re-engagement efforts. This person can help with appointments, referrals, system navigation, service coordination, and transportation.21
  • “Data to Care” approaches which use clinic and public health data to identify patients in need of retention, reengagement, or adherence support services to improve patient’s health outcomes, including achieving viral suppression (Note – the effectiveness of data to care strategies is variable and privacy concerns must be adequately addressed).22-24
  • Providing medication adherence support for patients in care, either starting HIV treatment or struggling with adherence
    • Every Dose Every Day™ has an online toolkit for providers and other support staff to help patients improve their adherence. It provides a mobile app to help with appointment and medication reminders and other evidence-based strategies.
  • Providing retention and reengagement support for out-of-care persons or patients at risk of falling out of care (e.g., missed a care visit, experiencing barriers to care engagement)
    • STEPS to Care is an online toolkit to help agencies implement three integrated care coordination strategies – Patient navigation, Care team coordination, and HIV self-management.25
  • Local or state health department or local community-based organizations can help providers and HIV medical clinics by integrating their existing prevention services within the HIV care clinic to provide the support services patients need to improve engagement and adherence in HIV care.

Patient-Provider Relationship

Studies have found that low trust in providers and poor patient-provider relationships have been associated with lower retention in care and lower satisfaction with the clinic experience.26-28 These findings underscore the need to build supportive relationships with patients that improve their health outcomes. Here are some ways health care providers and their practices can achieve this:

Help patients modify behaviors that lead to poor retention in HIV care.
  • Communicate with the patient nonjudgmentally to learn what they know about the importance of retention.
  • Identify skills that the patient might lack to remain in care, such as problem-solving skills.
  • Guide the patient to identify possible changes that would eliminate or reduce barriers they face; congratulate patient when they are able lessen the barriers.
  • Strategize with the patient to identify new goals and healthy behaviors.
  • Actively refer patients to relevant clinic support services as needed to provide additional support for retention.
Foster patient trust
  • Be direct, nonjudgmental, and supportive.
  • Use open-ended questions to involve the patient in decision making regarding their HIV treatment and overall care.
  • Include simple, basic actions during patient encounters to foster communication, such as asking how a patient prefers to be addressed.
Allow open communication and collaborative decision making
  • Educate patients about their options and ask what questions come to mind when considering those options to encourage informed conversation as part of the decision making process.
  • Encourage discussions on subjects about substance use, sexual behavior, and mental health.
  • Provide referrals when appropriate, and assess patient willingness to complete the referral.*
Demonstrate interest in addressing barriers to care, including structural barriers, from the first interaction
  • When possible, extend office hours or offer more flexible appointment times one or more days per week (e.g., offer some walk-in or same-day appointments).
  • Maintain accurate patient contact information and update it at every visit.
  • Use patient-tracking systems to determine whether a patient has dropped out of care; contact patients promptly to reschedule missed appointments.
  • Help patients find resources to address unmet needs and barriers to care. When possible, connect patients with childcare, transportation, or other services and offer collocation of primary care and social services.*
  • When warranted, encourage patients to access substance use or mental health services.
  • Encourage patients to identify friends and family who can help with encouragement, support, and attend medical appointments with them.
* Patient navigators, case managers, peer counselors, social workers, and treatment advocates can also assist with referrals and resources.

 

Talking with patients at each visit allows health care providers to reinforce positive behaviors, uncover barriers to successful long-term treatment, and facilitate access to services and resources as needs change over time. Below are some suggestions to help start the conversation:

  • “I know it can be difficult to keep all your appointments, but it’s very important. What can we do to make sure you keep your next appointment?”
  • “People with HIV do better overall when they come to their appointments on a regular basis. How can we work together to help you stay as healthy as possible?”
  • “It’s been a while since you last came in. Let’s talk about what has been keeping you from coming to see me.”

Coinfections

Patients with HIV are at an increased risk of acquiring STDs, viral hepatitis, and opportunistic infections such as tuberculosis (TB). Coinfections can have a negative impact on their health and HIV treatment. Viral suppression can reduce the risk of coinfection, but regular screening and prevention measures should be discussed with patients.

STD preventive services are an essential component of HIV prevention and care. Regular conversations about STDs, including review of sexual history and STD symptoms, should be held at every visit. Patients with HIV should be screened for STDs at least annually, and more frequently if they or their sexual partners have multiple or anonymous sex partners. Certain STDs can increase HIV viral load and genital HIV shedding, which may increase the risk of sexual and perinatal HIV transmission. Correct and consistent condom use should be advised to prevent STDs and can reduce HIV transmission risk in those with an STD or unsuppressed viral load. Learn more about STD treatment and care with the STD Treatment Guidelines and Updates.

Because of shared modes of transmission, a high proportion of adults with HIV are also at risk for coinfection with hepatitis B virus, or more commonly, hepatitis C virus. People who have these coinfections are at increased risk for serious, life-threatening complications. Anyone with HIV should be tested for hepatitis B and hepatitis C and treatment or vaccinations, when appropriate, should be considered. Learn more on the HIV/AIDS and Viral Hepatitis page.

People with HIV are also at risk for a variety of opportunistic infections such as TB. These risks can be reduced by viral suppression and a number of other prevention behaviors. Learn more about opportunistic infection prevention and treatment by referring to Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. The guidelines were developed by CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Disease Society of America (HIVMA/IDSA), and other experts in infectious disease.

Conclusion

Staying in care can be challenging, even for the most motivated patients, and their needs may change over time. Positive reinforcement can help patients maintain high levels of adherence to care appointments and HIV treatment. This technique to foster adherence includes informing patients of their low or suppressed viral load and increases in CD4 count. Use repeated brief discussions to help patients identify and deal with potential adherence problems that will support engagement in care and viral suppression and establish a trusting patient-provider relationship.

Resources

Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention

Effective Interventions – High Impact Prevention Interventions

Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living with HIV

Recommendations for HIV prevention with adults and adolescents with HIV in the United States, 2014: Summary for clinical providers (amended Dec. 30, 2016)

References

    1. INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med. Jul 20 2015;373(9):795-807. PubMed abstract.
    2. TEMPRANO ANRS Study Group, Danel C, Moh R, et al. A trial of early antiretrovirals and isoniazid preventive therapy in africa. N Engl J Med. Aug 27 2015;373(9):808-822. PubMed abstract.
    3. Kitahata MM, Gange SJ, Abraham AG, et al. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med. Apr 30 2009;360(18):1815-1826. PubMed abstract.
    4. Mofenson LM, Lambert JS, Stiehm ER, et al. Risk factors for perinatal transmission of human immunodeficiency virus type 1 in women treated with zidovudine. Pediatric AIDS Clinical Trials Group Study 185 Team. N Engl J Med. Aug 5 1999;341(6):385-393. PubMed abstract.
    5. Wood E, Kerr T, Marshall BD, et al. Longitudinal community plasma HIV-1 RNA concentrations and incidence of HIV-1 among injecting drug users: prospective cohort study. BMJ. 2009;338:b1649. PubMed abstract.
    6. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. Aug 11 2011;365(6):493-505. PubMed abstract.
    7. Reynolds SJ, Makumbi F, Nakigozi G, et al. HIV-1 transmission among HIV-1 discordant couples before and after the introduction of antiretroviral therapy. AIDS. Feb 20 2011;25(4):473-477. PubMed abstract.
    8. O’Brien WA, Hartigan PM, Martin D, et al. Changes in plasma HIV-1 RNA and CD4+ lymphocyte counts and the risk of progression to AIDS. Veterans Affairs Cooperative Study Group on AIDS. N Engl J Med. Feb 15 1996;334(7):426-431. PubMed abstract.
    9. Garcia F, de Lazzari E, Plana M, et al. Long-term CD4+ T-cell response to highly active antiretroviral therapy according to baseline CD4+ T-cell count. J Acquir Immune Defic Syndr. Jun 1 2004;36(2):702-713. PubMed abstract.
    10. Cohen MS, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011;365(6):493-505. PubMed abstract.
    11. CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 dependent areas, 2015. HIV Surveillance Supplemental Report 2017;22(No. 2).
    12. CDC. Behavioral and clinical characteristics of persons receiving medical care for HIV infection—Medical Monitoring Project, United States, 2014 Cycle (June 2014–May 2015). HIV Surveillance Special Report 17.
    13. Marks G, Patel U, Stirratt MJ, et al. Single viral load measurements overestimate stable viral suppression among HIV patients in care: Clinical and public health implications. J Acquir Immune Defic Syndr 2016;73:205-12. PubMed abstract.
    14. Parsons JT, Golub SA, Rosof E, Holder C. Motivational interviewing and cognitive-behavioral intervention to improve HIV Medication adherence among hazardous drinkers: a randomized controlled trial. J Acquir Immune Defic Syndr. Dec 01 2007;46(4):443-450. PubMed abstract.
    15. Bogart LM, Mutchler MG, McDavitt B, et al. A randomized controlled trial of rise, a community-based culturally congruent adherence intervention for black Americans living with HIV. Ann Behav Med. Apr 21 2017. PubMed abstract.
    16. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agends in HIV-1-Infected Adults and Adolescents (section C-7). DHHS.
    17. Avnish Tripathi, Eren Youmans, James J. Gibson, and Wayne A. Duffus. AIDS Res Hum Retroviruses. June 2011, 27(7): 751-758. PubMed abstract.
    18. Giordano TP. Retention in HIV care: what the clinician needs to know. Top Antivir Med. 2011;19(1):12-16. PubMed abstract.
    19. Mizuno Y, Zhu J, Crepaz N, Beer L, et al. Receipt of HIV/STD prevention counseling by HIV-infected adults receiving medical care in the United States. AIDS. 2014;28(3):407-415. PubMed abstract.
    20. Gardner LI, Marks G, Craw JA, et al. A low-effort, clinic-wide intervention improves attendance for HIV primary care. Clin Infect Dis. Oct 2012;55(8):1124-1134. PubMed abstract.
    21. Higa, D. H., Crepaz, N., Mullins, M. M., & the Prevention Research Synthesis Project. (2016). Identifying best practices for increasing linkage to, retention, and re-engagement in HIV medical care: Findings from a systematic review, 1996-2014. AIDS and Behavior, 20(5), 951-966. PubMed abstract.
    22. Bove JM, Golden MR, Dhanireddy S, Harrington RD, Dombrowski JC. Outcomes of a clinic-based surveillance-informed intervention to relink patients to HIV care. J Acquir Immune Defic Syndr. Nov 01 2015;70(3):262-268. PubMed abstract.
    23. Sena AC, Donovan J, Swygard H, et al. The North Carolina HIV Bridge Counselor Program: outcomes from a statewide level intervention to link and reengage HIV-infected persons in care in the South. J Acquir Immune Defic Syndr. Sep 01 2017;76(1):e7-e14. PubMed abstract.
    24. Udeagu CC, Webster TR, Bocour A, Michel P, Shepard CW. Lost or just not following up: public health effort to re-engage HIV-infected persons lost to follow-up into HIV medical care. AIDS. Sep 10 2013;27(14):2271-2279. PubMed abstract.
    25. Irvine, M. K., Chamberlin, S. A., Robbins, R. S., Myers, J. E., Braunstein, S. L., Mitts, B. J., et al. (2015).  Improvements in HIV care engagement and viral load suppression following enrollment in a comprehensive HIV care coordination program Clinical Infectious Disease. 60(2), 298-310. PubMed abstract.
    26. Flickinger TE, Saha S, Moore RD, Beach MC. Higher quality communication and relationships are associated with improved patient engagement in HIV care. J Acquir Immune Defic Syndr. Jul 01 2013;63(3):362-366. PubMed abstract.
    27. Dang BN, Westbrook RA, Hartman CM, Giordano TP. Retaining HIV patients in care: the role of initial patient care experiences. AIDS Behav. Oct 2016;20(10):2477-2487. PubMed abstract.
    28. Magnus M, Herwehe J, Murtaza-Rossini M, et al. Linking and retaining HIV patients in care: the importance of provider attitudes and behaviors. AIDS Patient Care STDS. May 2013;27(5):297-303. PubMed abstract.

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