Developing an Intervention to Retain HIV-infected Veterans in HIV Care

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Background: The VA is the largest single provider of HIV care in the United States, caring for about 5% of all HIV-infected persons in care in the US. Modern HIV treatment has transformed this deadly infection into a treatable chronic condition. To maximally benefit from HIV treatment, Veterans must navigate a continuum of HIV care. They must be diagnosed at an early stage of disease, access or link to HIV medical care, and be retained in HIV care, i.e., attend regularly scheduled medical appointments for the rest of their lives. We have shown that poor retention in HIV medical care is one of the primary reasons Veterans die of HIV/AIDS today. There are no proven interventions to better retain people in HIV primary care. Our team has been researching retention in HIV care for over 7 years. Objectives: Aim 1: To define where along the continuum of care Veterans with HIV infection experience the most challenges with retention in HIV care; and to identify where those Veterans having difficulty with retention in care eventually interface with the VA healthcare system. Aim 2: To identify the predictors of delayed linkage to care and poor retention in HIV care at care entry and over time, to identify the facilitators and barriers to successfully navigating the continuum of HIV care, and to identify methods to improve navigation of the continuum of care. Aim 3: To develop and preliminarily test an intervention to improve retention in HIV care in the VA. We expect that a reproducible, feasible intervention can be developed and tested. Methods: To accomplish these aims, we will conduct a variety of studies, both quantitative and qualitative. We will analyze the VA's Clinical Case Registry HIV (CCR HIV) to complete Aim 1 and part of Aim 2. This dataset is a comprehensive registry of all Veterans with HIV infection who have used the VA since 1989. We will conduct retrospective cohort studies with this national dataset. We will use qualitative research methods of Veterans from the Michael E. DeBakey VA Medical Center and the Birmingham VA Medical Center to complete the remainder of Aim 2 and Aim 3. The qualitative work will recruit Veterans in outpatient care, most of whom will have had some episode of poor adherence to appointments. We will also recruit patients hospitalized with HIV infection, many of whom will be presently out of HIV primary care. We will ask the Veterans directly for facilitators and barriers to care, suggestions for interventions, and feedback on possible interventions. These mixed methods will result in a complete picture of the factors predictive of retention in HIV care so that interventions can be appropriately targeted. They will also result in a comprehensive understanding of the facilitators and barriers to care, and the strategies to remedy these problems as recommended by HIV-infected Veterans themselves. These data will be coalesced and presented to an Advisory Panel, and through an iterative pilot testing process we will develop a preliminary intervention to improve retention in HIV primary care. The iterative pilot testing process will again solicit direct feedback from Veterans on how to maximize the intervention. The intervention developed as a result of this work will be fully tested and disseminated in subsequent work.