Improved retention in care strategies could reduce HIV infections, costs
When coupled with other interventions, efforts to improve retention in care could be a cost-effective strategy to reduce the incidence of HIV in the U.S., according to recently published research.
“Despite widespread focus on testing and initiation of treatment, arguably the greatest barrier to prevention of both HIV-related morbidity and HIV transmission is suboptimal engagement in care,” the researchers wrote. “Once HIV diagnosis is made, engagement in care remains suboptimal. A sizable proportion of individuals do not link (eg, keep a first appointment) to HIV care in a timely manner; among those who link to care, lack of long-term retention remains an important challenge.”
To estimate the economic and epidemiologic impact of suboptimal engagement, researchers from the schools of medicine and public health at Johns Hopkins constructed a dynamic model incorporating HIV transmission, disease progression and health system engagement among U.S. adults. Projected over a 20-year period, this was combined with the estimated cost of various areas of HIV health care, assuming implementation of current guidelines and the continuation of ongoing trends. Researchers then observed the effect of four intervention strategies — targeted screening, targeted and general screening, linkage to care, and retention in care — on the model to predict changes in HIV incidence, mortality and costs.
With none of these strategies, the model projected 1,390,000 new HIV infections, 435,000 deaths and $256 billion in health care costs from 2015-2035. While all intervention strategies had some benefit, the largest was seen with the adoption of retention and re-engagement. An intervention reducing disengagement and increasing re-engagement by 50% each was estimated to prevent 494,000 new HIV infections over 20 years, costing $33,700 per quality-adjusted year of life gained. Adoption of targeted screening, linkage and retention and re-engagement interventions together was estimated to prevent 752,000 new infections 276,000 deaths at a cost of $45,300 per quality-adjusted year of life gained.
“Although guidelines often focus on testing and early treatment, suboptimal linkage and retention in care are also important drivers of ongoing HIV transmission and cost of care in the U.S. today,” the researchers wrote. “Increased screening and ensuring rapid linkage to care for 90% of all those testing positive was projected to reduce the burden of HIV incidence and mortality by 20% to 25%. By contrast, adding interventions to improve retention and re-engagement in HIV care could more than double this epidemiological impact while also improving cost-effectiveness.”
In a related editorial, Edward M. Gardner, MD, of Denver Public Health, wrote that retention in care is an underexamined area of the HIV care continuum with room for improvement. Along with challenges in devising appropriate implementation, he discussed issues surrounding funding of these long-term interventions.
“Despite cost-effectiveness, one issue that will need to be addressed is that the part of the system paying for the intervention may not be the one to gain the financial benefit,” Gardner wrote. “This is one reason why it is imperative for federal HIV funding sources, such as the Ryan White Care Act, to endure.
“As the Affordable Care Act continues to improve access to health care for low-income individuals in many states nationwide, the Ryan White program could increase support for dedicated retention in HIV care activities, allowing the entire U.S. health care system to reap the benefits of having improved HIV-related health outcomes, decreased costs for care and fewer new HIV infections.” – by Dave Muoio
Disclosures: Shah and Gardner report no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.