Outreach Can Provide Needed Boost to Begin, Continue ART

Direct recruitment into HIV care via peer-to-peer referral is effective in men who have sex with men (MSM), a recent study found. However, the percentage who were recruited into care and subsequently achieved viral suppression by 1 year was 48%—no better than viral suppression levels of MSM who were offered the standard of care in the same study.

The study was part of a clinical trial sponsored by the National Institutes of Health (NIH) and conducted by the NIH-funded HIV Prevention Trials Network. It screened more than 1300 individuals in 4 cities where HIV is prevalent—Atlanta, Boston, Baltimore, and Birmingham, Alabama—eventually identifying 154 individuals who were living with HIV and not virally suppressed. Of those, 144 (94%) agreed to enroll in the study, at which point they were put into either the enhanced intervention arm or the standard of care arm.

In the enhanced HIV-prevention strategy arm, participants were assigned a case manager who personally guided them through the complexities of the health care system, connected with them resources and support services, and offered individualized help when it came to sticking with an antiretroviral therapy (ART) regimen. The participants also were offered phone or electronic messages of motivation along with reminders to take medication and keep appointments, all of which were delivered according to the participants’ desired frequency.

Nearly all (91%) of the participants were still involved in the study at the 12-month mark.

Although peer-to-peer counseling and outreach proved no more effective than standard methods of care engagement when it came to the percentage achieving viral suppression after this time, the investigators were encouraged by the subjects’ willingness to be involved. “The [study] findings demonstrate that populations not engaged in care are indeed reachable when a concerted effort is made, underscoring the importance of developing and optimizing strategies to identify people with HIV and connect them to HIV treatment services,” Anthony Fauci, MD, director of the NIH National Institute of Allergy and Infectious Diseases (NIAID), said in a statement.

Although the high rate of study subjects entering care was encouraging, the fact that just under half of them were able to achieve viral suppression by 1 year gave pause. “This population is very hard to reach,” Carl Dieffenbach, PhD, director of the Division of AIDS at the NIAID, told Contagion®, referring to people who may begin ART therapy but eventually stop adhering to it. “Part of the challenge is that a lot of these people have very chaotic lives. They may not have enough food. They may have inadequate housing. HIV may be the least of it.”

Two-thirds of the study subjects were unemployed, and 64% subsisted on less than $20,000 a year. The overwhelming majority of participants—86%—said that they previously had used ART, pointing out the difficulty that many people living with HIV experience adhering to this lifesaving regimen.

Dieffenbach noted that he had expected subjects in the peer-to-peer arm to have higher levels of viral suppression than those in the standardized arm and wondered if the fact that they were participating in a clinical trial was somehow off-putting to them despite being the beneficiaries of enhanced, individualized outreach. No matter the reason, he conceded, the medical community must do a better job of lowering barriers that discourage or prevent many from entering or continuing care.

“We need to think about different ways of structuring access to these hard-to-reach populations,” he said. “If we’re going to end the epidemic in the US, we need to develop ways to find people who are falling through the cracks.”