Improving Engagement in HIV Care and Treatment Adherence: An Algorithmic Approach

Benjamin Young, MD, PhD


April 30, 2013

Advances in antiretroviral medications have revolutionized the care and prognosis of people living with HIV around the world. Where individuals have access to trained care providers and medications, HIV-related morbidity and mortality have decreased; in many highly affected regions, new infection rates are beginning to decrease.

Yet, as impressive as these gains seem, recent studies show that only a minority of people living with HIV in the United States are successfully engaged in care and achieve viral suppression.[1,2] Central problems in HIV care are related to delays in testing, delays in care, and early dropout from medical care, and late access to HIV testing and treatment have been associated with increased immune system damage, risk for HIV transmission, and increased hospitalizations.[3]

Unfortunately, these seemingly obvious barriers to successful implementation of therapeutics have only recently drawn systematic attention. Improving engagement in HIV medical care is hobbled by a relative dearth of scientific literature on the vast subject. In appreciating such challenges, our group, the International Association of Providers in AIDS Care (IAPAC), convened an international expert panel to identify best practices and evidence for engagement and adherence to HIV care and treatment. These first-ever evidence-based recommendations on improving entry into and retention in HIV care and treatment adherence were published in 2012.[4]

In the current issue of JIAPAC, we describe a clinical management algorithm based on the evidence-based recommendations that charts simple operational interventions for engagement and care and treatment adherence. We believe that such tools can assist busy care programs in improving the delivery of important health interventions.

The algorithm recommends:

  • Systematic monitoring of successful entry into and retention in HIV care; multiple data sources may need to be integrated to best achieve this monitoring goal. Intensive outreach is recommended for recently diagnosed individuals who do not enter care within 6 months of diagnosis. Peers or paraprofessionals may be considered to provide the needed human resources to achieve these goals.

  • The use of once-daily treatment for persons initiating therapy. Among regimens of equal efficacy and safety, fixed-dose combinations should be used to decrease pill burden.

  • Monitoring of adherence to treatment by routine self-reported adherence and pharmacy refill data. Reminder devices and the use of communications technologies with an interactive component and adherence-related educations and counseling are recommended.

  • Education and counseling through one-on-one and group education; multidisciplinary education and counseling are recommended.

It is important to note that although normative guidance is a necessary step in charting a pathway for improving care, recommendations frequently are not translated into operational improvements. Indeed, it is critical that agencies that author such documents take into consideration the operational and educational needs of implementation.

As a member-oriented organization, IAPAC strives to provide practical tools to assist front-line care providers in achieving the highest possible level of care in people living with HIV. In the past, efforts have focused primarily on the use of HIV treatment guidelines from the US Department of Health and Human Services and the World Health Organization. In constructing and publishing this algorithm, we extend this effort to improving engagement in care and treatment adherence.