getting to virologic suppression

Getting to Virologic Suppression

Tess Barton, MDMedical Director, ARMS Clinic

Children’s Medical Center Dallas

Diagnosis & Linkage to Care

Routine Medical Care & Monitoring

HIV Treatment

Virologic Suppression

Improve healthy survival

Reduce HIV transmission



HIV Treatment




Timely appointments available

Patient keeps appointments

Monitoring/screening is done

Results/problems are addressed



HIV Treatment




Medical Assessment for Treatment

Patient Readiness Assessed

Funding for Medication Secured

Barriers to Adherence Recognized



HIV Treatment




Resistance Testing to Determine Best Regimen

Monitoring of Treatment Labs

Definition of Suppression

Adherence Assessment

Ongoing Funding

CMC Performance Measures3 patients with <2 visits in 12 months

2 in process of moving during reporting period

(both virologically suppressed!)

1 truly not seen >6 months

38%??? How is this possible?

Retention in Care• Appointment Processes– New patients

• Sources of most referrals: Health Dept, outside MDs, CMC inpatient

• Direct phone contact between family + program coordinator• Same day appointment available with MD (can see MD same

day of dx, if needed)• Financial counseling done on arrival

– Existing patients• Follow-up appointment made at time of checkout, provided

on written visit summary (most @ 3 month intervals)• Pre-registration 3-7 days before appointment• Phone call from program coordinator day before• Program coordinator cell # available for teens – text

reminders PRN

Retention in Care

• Minimizing lost-to-care– Missed appointments

• Same-day call from front desk or program coordinator• Multiple team members with access to electronic scheduling

(minimal phone transfers)• Telephone, email, Facebook, text msg, UTSW peers• If unable to make contact in 2 weeks, certified letter sent

– Overdue appointments• CareWare used to generate custom report of patients not

seen in >4 months• Program coordinator + social worker contact these families

to make appointment

Retention to Care

• Unmeasurable Factors– Personal touch

• Use of minimal personnel – family knows the person who is calling

• Friendly atmosphere– Hugs from MD, birthday treats, personal conversations

– Creating closer patient + team relationship• Camps, teen group, parent support group, Facebook

– Availability• Same-day appointments, sick visits, 24-hour on-call provider• Personal contact

Retention to Care

• Challenges– 20% no-show rate for each clinic session despite

efforts• 3-month visits + vigilant chasing of no-shows leads to good

performance on HAB measure– Staff effort/phone calls difficult to track and fund

• 10 phone calls/messages to get a patient to keep 1 appointment is not a billable or reimbursable service

• How much additional time is spent documenting– Additional activities to create relationships requires

time + money

CMC Performance Measures

Only 1 patient not seen in >6 months

14/108 (13%) not on treatment

42/108 = 38%

Viral Suppression

• In+Care Campaign Measure: Retention Measure 4: Viral Load Suppression– Percentage of patients, regardless of age, with a

diagnosis of HIV/AIDS with a viral load less than 200 copies/mL at last viral load test during the measurement year

• Why?– Critical link between efforts at medical care and

healthy patient survival– Recent indication of viral suppression as means of

preventing transmission

VL Not Suppressed

• Not on treatment = 13% (n=14)– CD4 >500 = 7– CD4 350-500 = 4

• 2 started on medications after reporting period

• 1 transitioned to adult care

• 1 disclosed in preparation

– CD4 <350 = 3 • all started on medications

after reporting period

VL Not Suppressed

• 27 had VL<200 within 6 months before/after – Blips– Assay variation– Re-suppression– Regimen change

• 25/94 (26%) treated patients had VL <1000– VL 200-500 = 16– VL 500-1000 = 9

Low Level Viremia – E.R. Case

• 18 year-old male• Tested HIV+ with blood donation 11/2010 -

12/2010 – received notification from Carter BloodCare

• 12/16 – CMC ER visit to get evaluated – PCR sent

• 12/21 – ARMS Clinic MD appointment to discuss results

Date Viral Load CD4 History

December 2010 14,000 256

February 2011 12,000 329 Started Atripla

March 2011 590 440

April 2011 950 501

July 2011340 576

Genotype – all drugs susceptible

October 2011 410 626 Loses Medicaid; Transfer to Parkland Young Adult Clinic (Barton)

January 2012 <20 650

April 2012 <20 585

August 2012 <20 691

Virologic History

Always reporting 100% adherenceIs the lab assay used at

PHHS different than the one used by CMC (sent to

ARUP)?

If purpose of treatment is improved healthy survival and reduced

transmission, am I concerned about this

viral load?

VL Not Suppressed

• 38% virologically suppressed

• 13% not requiring treatment

• 23% low level viremia, or having blips

26% truly not virologically suppressed

Chart Review of 62 non-suppressed patients revealed

that 30 had adherence problems

Adherence Problems

• Randomly chosen cases to present today:• D.H. – 17 y/o perinatal HIV– VL 23,000; CD4 442– Conflicts with dad over authority, sexual orientation– Asserting independence, exploring autonomy –

medications not a priority for him– Probable bipolar d/o, refusing treatment– Solution: JobCorps, needs to mature, keep engaged

in care during uncertain living situation, reinforce safe sex, wait

Adherence Problems• A.J. – 11 year-old perinatal HIV• VL 1100, CD4 1209• Recently moved to Dallas area (labs were 2nd visit)• Recently disclosed, does admit to missed doses (mostly

forgotten)• Mom with long hx non-adherence• Solutions: CPS involved at time of transfer to Dallas,

reminders, enlisted help of nearby aunt to assist mom, gave child task of reminding mom to take her own medicines, enroll in summer camp for HIV+ kids

Adherence Problems• J.T. – 10 y/o perinatal HIV/AIDS, lowest CD4 190s, no

AIDS illnesses• Not disclosed, mom not ready• Mom never adherent - recently hospitalized with PCP,

very ill; mom’s partner not aware of her HIV status• Older HIV-negative brother recently learned mom,

brother HIV status• VL 1100, CD4 914 (up from 200s 9 months ago)• Solutions: CPS involved numerous times; mom and

patient clearly trying now; regimen recently optimized for once-daily and reduced side effects; enlist help of older brother; pressuring mom to allow disclosure

Adherence Problems• B.E. – 12 month perinatal HIV, asymptomatic• VL 49,000; CD4 24.1%• Mom in denial about HIV during pregnancy, still not in

care for herself; struggling emotionally with infant infection

• After extended visit, she admitted to not giving infant medications due to emotional distress – expressed relief after confessing, and commitment to improving

• Next VL 870, CD4 43%• Solutions: Continue to support mom, encourage her to

stay in care, frequent appointments (transportation assistance needed)

CMC Performance Review

• How can CMC have 98% retention in care, but only 38% virologically suppressed?– Patients being brought into care, tracked closely,

monitored and assessed– Partly related to inherent reporting flaws

• Single time point of dynamic value• Denominator including untreated patients

– Nuances of viral load vs. clinical status – the art of medicine

• Our barrier to VL suppression is not lack of retention

CMC Performance Review

• Areas for improvement– Evaluation of VL assay– ADHERENCE• How often are adherence assessments done?• How are adherence assessments done?• Multifactorial solution

– Mental health issues– Adolescent emotional development– Caregiver role– Treatment readiness– Bribery?

Can make #s look prettier for reporting purposes with no real change in

patient care

Confounding issues of blood volume, cost

May investigate further to minimize provider

frustration and patient anxiety

Adherence barriers are highly individualized

Single solution approach will not impact overall suppression rate

Standardized adherence assessments

are NOT the solution in a setting where adherence barriers are already being

recognized



HIV Treatment




Timely appointments available

Patient keeps appointments

Monitoring/screening is done

Results/problems are addressed

✓



HIV Treatment




Medical Assessment for Treatment

Patient Readiness Assessed

Funding for Medication Secured

Barriers to Adherence Recognized

✓✓



HIV Treatment




Resistance Testing to Determine Best Regimen

Monitoring of Treatment Labs

Definition of Suppression

Adherence Assessment

Ongoing Funding

✓✓

Questions?

Follow-up Project

• Attempted to arrange duplicate viral load testing– ARUP vs. Mayo– Blood sent on 3, only able to obtain results for 1– VL 230 vs 270

• County hospital tests remain <20 for those transitioned patients

• Next step: Switch to county lab for 2-3 month trial period

Follow-Up Data

• From 4/1/2011-3/31/2012 – InCare Viral Load Suppression Measure 50/108=46.3% (this

is the measure we currently use in the Regional Group)– Viral Load Suppression for those clients who are on ARVs

(all ages): 47/88=53.41%– Viral Load Suppression for those clients who are on ARVs

and below 13 yrs: 24/35= 68.6%– Viral Load Suppression for those clients who are on ARVs

and 13 yrs and older: 23/53=43.4% – Viral Load Suppression for all ages using the new HAB

measure indicator definition: 46/84=54.8%

getting to virologic suppression

Documents

day of dx

th qtr1

chart data range

addresseddiagnosis linkage

lower right corner of

sick visits

chart1982salesmedical

fund10 phone callsmessages