Coordinated Care May Not Improve HIV Viral Load

Structured patient navigation interventions, with or without financial incentives, had no beneficial effect on improved HIV-1 viral suppression rates among hospitalized patients with elevated viral loads and substance use, according to a study published in JAMA.

It has been estimated that in 2011, only 30% of 1.2 million people living with HIV in the United States were virally suppressed. Furthermore, data showed that during 1999-2007, many HIV-positive individuals were hospitalized with conditions that are preventable through HIV treatment.

It is likely that substance use is a major factor in poor clinical outcomes for HIV patients. To address this, patient navigation, which includes care coordination with case management, and financial incentives, are increasingly promoted to engage patients in substance use disorder treatment and HIV care to achieve predetermined outcomes.

However, there is still little evidence provided for the efficacy of the interventions and the improvement in HIV viral suppression rates. For the study, researchers used 801 patients with HIV infection and substance use from 11 hospitals in the United States.

Participants were randomized to receive either patient navigation alone (n=266), patient navigation plus financial incentives (n=271), or treatment as usual (n-264). Patient navigation included 11 sessions of care coordination with case management and motivational interview techniques for 6 months.

The financial incentives provided were up to $1160 to help achieve targeted behaviors aimed at reducing substance use, improving HIV outcomes, and increasing engagement in HIV care.

The treatment as usual was defined as the standard practice at each hospital for linking hospitalized patients to outpatient HIV care and substance use treatment. The HIV-1 plasma viral load was measured at study entry, 6 months, and 12 months.

The results of the study showed that among the 3 groups, there was no difference in rates of viral suppression (? 200 copies/ml) versus nonsuppression or death at 12 months. Out of 249 patients in the usual-treatment group, 85 (34%) experienced HIV viral suppression compared with 89 of 249 (36%) patients in the navigation-only group for a treatment difference of 1.6%.

In the navigation plus financial incentives group, 98 of 254 patients (39%) experienced HIV viral suppression for a treatment difference of 4.5%. The treatment difference between the navigation-only and the navigation plus financial plus incentives group was -2.8%.

“Among hospitalized patients with HIV infection and substance use, patient navigation with or without financial incentives did not have a beneficial effect on HIV viral suppression relative to nonsuppression or death at 12 months compared with treatment as usual,” the study authors wrote. “These findings do not support these interventions in this setting and indicate that other approaches are needed to improve HIV outcomes in this vulnerable population.”