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HIV and health care: The good, bad & ugly
Many have insurance, risky behavior continues
In selected data analysis for 2007, most people with HIV infection who were receiving medical care were taking antiretroviral therapy and had some form of health insurance or coverage, the Centers for Disease Control and Prevention reports.1 However, some were not receiving needed critical ancillary services, such as HIV case management or help finding dental services. In addition, some living with HIV infection engaged in behaviors, such as unprotected sex, that increase the risk for transmitting HIV to sexual partners, and some used noninjection or injection drugs for nonmedical purposes, which might decrease adherence to antiretroviral therapy and increase health-risk behaviors, the CDC found.
In a surveillance summary of the most recent data available, the CDC emphasizes that data on the clinical and behavioral characteristics of people receiving medical care for HIV infection are critical to reduce HIV-related morbidity and mortality and guide prevention planning, assess unmet medical and ancillary service needs, and help develop interventions at the local, state, and national levels.
As of December 31, 2008, an estimated 663,084 persons were living with a diagnosis of HIV infection in the 40 U.S. states that have had confidential name-based HIV infection reporting since at least January 2006. Data were collected during June 2007-September 2008 for patients who received medical care in 2007 (sampled from January 1-April 30). The Medical Monitoring Project (MMP) is an ongoing, multisite supplemental surveillance project that assesses behaviors, clinical characteristics, and quality of care of HIV-infected persons who are receiving medical care. Participants must be at least 18 years old. Self-reported behavioral and selected clinical data were collected using an in-person interview. A total of 26 project areas in 19 states and Puerto Rico were funded to collect data during the 2007 MMP data collection cycle.
The results from the 2007 MMP cycle indicated that among 3,643 participants, a total of 3,040 (84%) had some form of health insurance or coverage during the 12 months before the interview; of these, 45% reported having Medicaid, 37% reported having private health insurance or coverage through a health maintenance organization, and 30% reported having Medicare. A total of 3,091 (85%) of the participants were currently taking antiretroviral medications. Among 3,609 participants who reported ever having a CD4 T-lymphocyte test, 2,996 (83%) reported having three or more CD4 T-lymphocyte tests in the 12 months before the interview. Among 3,567 participants who reported ever having an HIV viral load test, 2,946 (83%) reported having three or more HIV viral load tests in the 12 months before the interview. Among 3,643 participants, 45% needed HIV case management, 33% needed mental health counseling, and 32% needed assistance finding dental services during the 12 months before the interview; 8%, 13%, and 25% of these participants who needed the services, respectively, had not received these services by the time of the interview.
Noninjection drugs were used for nonmedical purposes by 1,117 (31%) participants during the 12 months before the interview, and 122 (3%) participants had used injection drugs for nonmedical purposes. Unprotected anal intercourse was reported by 527 (54%) of 970 men who reported having anal sex with a man during the 12 months before the interview. Unprotected anal or vaginal intercourse was reported by 176 (32%) of the 553 men who reported having anal or vaginal intercourse with a woman during the 12 months before the interview. Unprotected anal or vaginal intercourse was reported by 216 (42%) of the 516 women who reported having anal or vaginal intercourse with a man during the 12 months before the interview.
Selected key issues
Access to health care: The benefits of treatment provided early in the course of HIV infection are well documented and include increased survival, reduced morbidity, and reduced HIV transmission. One goal outlined in the U.S. national HIV/AIDS strategy is to increase access to care and optimize health outcomes for persons living with HIV infection in the United States. A step toward establishing this goal is creating a seamless system to immediately link patients to continuous and coordinated quality care when they receive a diagnosis of HIV infection. One benchmark measure of the national HIV/AIDS strategy is to increase from 65% to 85% by 2015 the percentage of HIV-infected persons who are linked to clinical care within 3 months of receiving an HIV infection diagnosis. In this survey, approximately three fourths of respondents with valid self-reported dates of HIV diagnosis and subsequent initiation of medical care reported going to a health-care provider within 3 months of receiving the diagnosis. Delayed medical care after HIV diagnosis has been well documented in the literature. Current HIV care guidelines recommend HIV care visits every 3-6 months. Monitoring patterns of care, as well as entry into medical care, among persons with HIV is critical and will continue to be an important use of MMP data to help measure progress on objectives set forth by the national HIV/AIDS strategy.
STD testing: STD infection might suggest recent or ongoing sexual behaviors that could result in HIV transmission, and many STDs can increase the risk for acquisition and transmission of HIV. Identifying and treating STDs can reduce the potential for spread of these diseases among groups at high risk for infection (i.e., sexual networks). Current primary care guidelines for persons infected with HIV recommend that those at risk for STDs be screened annually for syphilis, gonorrhea, and chlamydia. Among the 3,643 participants, 1,545 (42%) reported being tested for an STD during the past 12 months; most were tested for syphilis, gonorrhea, and chlamydia. These findings suggest that too few HIV-infected persons in care are being tested annually. Screening HIV-infected persons for STDs is critical to identify those at risk for transmitting HIV and other STDs. Health-care providers should be encouraged to test sexually active HIV-infected patients for STDs annually.
Antiretroviral medications and adherence: Adherence to therapy is necessary for HIV viral suppression and to prevent the emergence of resistant mutations. Understanding the reasons for nonadherence to antiretroviral therapy is critical for developing strategies to increase adherence. MMP provides data to measure adherence to antiretroviral medication regimens and specific reasons for nonadherence among HIV-infected persons. The 35% of participants who were not completely adherent gave various reasons for not taking the last antiretroviral dose they missed, including forgetting to do so, a change in daily routine, and being busy with other things. As recommended in the current HIV treatment guidelines, strategies to improve adherence include prescribing less complex regimens (e.g., fewer pills, fewer doses, or both), using a multidisciplinary team approach to care (e.g., nurses, social workers, pharmacists, and medication managers), and using clinician encounters as an opportunity to assess adherence and, if needed, to provide counseling. Other strategies include providing resources such as pill boxes and medication alarms to remind patients to take medication. Data from MMP can increase clinician awareness about the extent of and reasons for nonadherence to antiretroviral medications and be used in the development of new interventions to improve adherence.
CD4 T-Lymphocyte and HIV viral load testing: HIV CD4 T-lymphocyte testing is used to assess immune function, and HIV viral load testing is used to monitor the amount of HIV in the blood; both can be used to monitor access to and use of care. HIV viral load is the most important indicator of response to therapy. Thirty-six percent of participants reported that their most recent CD4 count during the past year was ≤500 cells/mm3, and 58% reported that their most recent viral load in the past year was undetectable. Guidelines for the treatment and management of HIV infection include monitoring CD4 T-lymphocyte and viral load results every 3-4 months after diagnosis. However, some health-care providers perform HIV viral load testing every 6 months for patients who are adherent to antiretroviral therapy, who have had their HIV viral load suppressed for more than 2-3 years, and whose clinical and immunologic status is considered stable. Eighty-three percent of MMP participants who had ever had a CD4 test reported having three or more CD4 tests during the past 12 months, and 83% of participants who had ever had a viral load test reported having three or more viral load tests during the past 12 months, suggesting that most MMP participants received CD4 T-lymphocyte and HIV viral load testing at regular intervals as recommended in the antiretroviral treatment guidelines.
Alcohol and Drug Use: Injection drug use can result in direct transmission of HIV; in addition, the use of alcohol, noninjection drugs, and injection drugs are associated with risky sexual behaviors and might complicate the medical management of HIV infection. Persons who use drugs for nonmedical purposes might also have other conditions that increase morbidity and mortality. MMP data on the use of alcohol, noninjection drugs, and injection drugs can be used by persons developing measures to prevent alcohol and substance abuse among those infected with HIV. Fifty-one percent of MMP participants reported drinking alcohol during the past 12 months, 42% reported drinking alcohol in the past 30 days, and 14% reported excessive drinking during the past 30 days. In addition, 31% of participants reported using noninjection drugs, and 3% reported injecting drugs during the past 12 months. Clinicians who provide medical care to HIV-infected persons can play a critical role in helping them reduce drug use behaviors that increase risk of HIV transmission by screening for these behaviors, delivering prevention messages, positively reinforcing changes to safer behavior, and referring patients for substance abuse treatment.
Sexual behavior: Studies have found that the prevalence of high-risk sexual behaviors decreases after persons become aware that they are infected with HIV. Risky sexual behaviors were reported by a high proportion of MMP participants. The proportion of MMP participants who had unprotected anal or vaginal intercourse with at least one partner during the past 12 months varied by the sex of the participants and their partners: 32% for males with female sex partners, 42% for females with male sex partners, and 54% for males with male sex partners. However, the proportion of males and females who reported that they knew the HIV status of their most recent sex partner was similar: 80% for males who had male partners, 78% for males who had female partners, and 83% for females who had male partners.
Assessment of prevention activities: Measuring exposure to and use of prevention services can identify missed opportunities for prevention counseling or the need for additional services. Seventeen percent of respondents reported participating in organized group sessions to discuss HIV prevention; however, 86% of these reported discussing ways to talk to a partner about safe sex, 75% practiced ways to talk with a partner about safe sex, and 84% discussed ways to use condoms effectively. Male latex condoms, when used correctly and consistently, are effective in preventing HIV and other STDs. MMP monitors receipt and use of free condoms and access to and use of other prevention services. Fifty-nine percent of participants reported receiving free condoms during the past 12 months; of these, 65% reported using the free condoms they received, and 72% reported that receiving these free condoms made them more likely to use them. MMP data can be used to monitor exposure to HIV prevention programs and for efforts to develop and improve local, state, and national HIV prevention interventions.