In the Journals

Viral suppression not improved by interventions among patients with HIV, substance use

Patient navigation, with or without financial incentives, did not have a beneficial effect on viral suppression among hospitalized patients with HIV infection and substance use, compared with treatment as usual, according to data published in JAMA.

The researchers added that their findings do not support the use of such interventions in this setting.

“The U.S. National HIV/AIDS Strategy calls for improved engagement in care and increased viral suppression for people living with HIV,” Lisa R. Metsch, PhD, of the department of sociomedical sciences, at the Columbia University Mailman School of Public Health, in New York, and colleagues wrote. “Yet it has been estimated that only 30% of the 1.2 million persons with HIV infection in the United States in 2011 were virally suppressed, and according to data collected during 1999 to 2007 from an observational HIV natural history study, many were hospitalized with conditions preventable through HIV treatment. Substance use is likely a major factor in poor HIV clinical outcomes.”

To determine the effect of a patient navigation intervention, with and without financial incentives, on HIV-1 viral suppression rates among hospital patients with elevated HIV-1 viral loads and substance use, the researchers recruited 801 patients from 11 hospitals throughout the United States. Participants were randomly assigned to one of three groups, with 266 receiving patient navigation alone, 271 receiving patient navigation with financial incentives, and 264 receiving treatment as usual.

Patient navigation involved up to 11 sessions of care coordination with case management and motivational interviews over a period of 6 months. Those in the financial-incentive group were offered up to $1,160 for achieving targeted behaviors aimed at reducing substance use, increasing engagement in HIV care, and improving HIV outcomes. Treatment as usual involved the standard practice at each hospital for linking hospitalized patients with outpatient HIV care and substance use disorder treatment. HIV-1 plasma viral load was measured at baseline, 6 months and 12 months.

According to the researchers, 34.1% of patients assigned to the treatment-only group saw success, compared with 35.7% of those in the navigation-only group, representing a treatment difference of 1.6% (95% CI, –6.8 to 10; P = .8). In addition, 38.6% of patients in the navigation-plus-incentives group saw success, representing a treatment difference of 4.5% (95% CI, –4 to 12.8; P = .68). The treatment difference between the navigation-only and navigation-plus-incentives groups was -2.8% (95% CI, –11.3 to 5.6; P = .68).

“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,” Metsch and colleagues 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.” – by Jason Laday

Disclosure: Metsch reports receiving grants from the NIH’s National Institute on Drug Abuse. See the full study for additional relevant financial disclosures.

Patient navigation, with or without financial incentives, did not have a beneficial effect on viral suppression among hospitalized patients with HIV infection and substance use, compared with treatment as usual, according to data published in JAMA.

The researchers added that their findings do not support the use of such interventions in this setting.

“The U.S. National HIV/AIDS Strategy calls for improved engagement in care and increased viral suppression for people living with HIV,” Lisa R. Metsch, PhD, of the department of sociomedical sciences, at the Columbia University Mailman School of Public Health, in New York, and colleagues wrote. “Yet it has been estimated that only 30% of the 1.2 million persons with HIV infection in the United States in 2011 were virally suppressed, and according to data collected during 1999 to 2007 from an observational HIV natural history study, many were hospitalized with conditions preventable through HIV treatment. Substance use is likely a major factor in poor HIV clinical outcomes.”

To determine the effect of a patient navigation intervention, with and without financial incentives, on HIV-1 viral suppression rates among hospital patients with elevated HIV-1 viral loads and substance use, the researchers recruited 801 patients from 11 hospitals throughout the United States. Participants were randomly assigned to one of three groups, with 266 receiving patient navigation alone, 271 receiving patient navigation with financial incentives, and 264 receiving treatment as usual.

Patient navigation involved up to 11 sessions of care coordination with case management and motivational interviews over a period of 6 months. Those in the financial-incentive group were offered up to $1,160 for achieving targeted behaviors aimed at reducing substance use, increasing engagement in HIV care, and improving HIV outcomes. Treatment as usual involved the standard practice at each hospital for linking hospitalized patients with outpatient HIV care and substance use disorder treatment. HIV-1 plasma viral load was measured at baseline, 6 months and 12 months.

According to the researchers, 34.1% of patients assigned to the treatment-only group saw success, compared with 35.7% of those in the navigation-only group, representing a treatment difference of 1.6% (95% CI, –6.8 to 10; P = .8). In addition, 38.6% of patients in the navigation-plus-incentives group saw success, representing a treatment difference of 4.5% (95% CI, –4 to 12.8; P = .68). The treatment difference between the navigation-only and navigation-plus-incentives groups was -2.8% (95% CI, –11.3 to 5.6; P = .68).

“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,” Metsch and colleagues 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.” – by Jason Laday

Disclosure: Metsch reports receiving grants from the NIH’s National Institute on Drug Abuse. See the full study for additional relevant financial disclosures.