Medical Care Coordination Program Can Increase Life Expectancy for People with HIV

A medical care coordination (MCC) program is a cost-effective way to address the medical and psychosocial needs of people with HIV, a new study of such a program implemented by the Los Angeles County Division of HIV and STD Programs found.

The study, published in Open Forum Infectious Diseases, evaluated the impact and cost-effectiveness of the MCC program, finding that life expectancy increased from 10.07 to 10.94 quality-adjusted life-years while lifetime medical cost increased from $311,300 to $335,100. At 2 years, viral suppression was 57% and retention in care was 72%, compared with 33% and 59% respectively for patients with no MCC.

“The innovative program of multidisciplinary services implemented by the Los Angeles County (LAC) Division of HIV and STD programs and supported through the Ryan White HIV/AIDS Program, known as the MCC program, nearly doubled viral suppression at 2 years for people at risk for poor health outcomes with major medical and behavioral comorbidities, at an annual cost of $2700 per person,” first author Moses Flash and senior author Emily Hyle, MD, MSc, of Massachusetts General Hospital told Contagion^®.

“Using computer modeling to project long-term outcomes from the program’s data, we found that the MCC program could substantially increase life expectancy and be cost-effective. Programs like this are likely to be of high value in other cities and regions in the United States and can build on additional strategies to improve HIV care and decrease new HIV infections as part of the national End the HIV Epidemic effort.”

The program was put in place in 2013 at 35 HIV clinics, where teams made up of a social worker, a registered nurse and a case manager worked together to address needs for people with HIV, including linkage and retention in care, adherence to treatment, risk reduction and psychosocial issues.

“We found that the MCC program offered the best value for people who had moderate severity of medical and psychosocial needs — this was because, at a moderate cost, this group of people had marked improvement in their engagement in care and viral suppression after starting the MCC program,” Flash and Hyle told Contagion^®. “Additional work to ascertain who will benefit the most from these services will help target the program to be most cost-effective.”

The study included 1204 people identified as at risk for poor health outcomes based on factors including high viral load, not currently receiving antiretroviral therapy, no HIV medical appointment in the past 7 months, sexually transmitted infection diagnosis or incarceration. It found that even if the estimated annual cost of the MCC program increased from $2700 to $8100 per person, the program would still be cost-effective as long as it increased 2-year suppression by at least 6 percentage point from 33% to 39%.

“Focused efforts to improve engagement in HIV care and viral suppression can offer excellent value, especially when aimed at addressing the psychosocial needs of people with HIV who are at increased risk for poor health outcomes,” Flash and Hyle told Contagion^®.

Average annual cost of the program ranged from $2200 for those with low acuity to $2900 for those at moderate acuity and $3800 for those at high/severe. Compared with no MCC, viral suppression at 2 years increased from 22% to 46% among those with high/serve acuity, 28% to 59% for those at moderate acuity and 64% to 67% at low acuity.

Further efforts to expand MCC programs to address the needs of people with HIV are underway.

“To expand the reach of the MCC program in LAC, a ‘patient retention specialist’ was added in 2016 to provide field-based re-engagement activities,” Flash and Hyle told Contagion^®. “Given the impact of mental health and substance use disorders on HIV outcomes, LAC will continue to increase the capacity of the MCC teams to improve access to treatment services. Beyond the traditional clinic setting, additional partnerships are planned to achieve population-level viral suppression targets. Increased collaboration with local partners in substance use, mental health, sexual health, and housing is critical to address the social determinants associated with HIV acquisition, transmission, and health outcomes.”

Reaching at-risk populations has been the focus of other programs, including one initiated by San Francisco General Hospital Ward 86 to reach homeless people with HIV. The Positive-health Onsite Program for Unstably housed Populations, or POP-UP, was launched in March to provide drop-in services for people living with HIV who are homeless.

Other efforts to improve HIV care have included offering antiretroviral therapy on the same days as home-based HIV testing, which was supported by a 2-year follow-up of the CASCADE trial in Lesotho, Africa, which showed improved outcomes in engagement in care and viral suppression.