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Enhanced Care Coordination Improves HIV Viral Load Suppression Rates
Ross G. Hewitt, MD; Debra Williams, EdD; Richard Adule; Ira Feldman, MPS; and Moe Alsumidaie, MBA, MSF
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Enhanced Care Coordination Improves HIV Viral Load Suppression Rates

Ross G. Hewitt, MD; Debra Williams, EdD; Richard Adule; Ira Feldman, MPS; and Moe Alsumidaie, MBA, MSF
Enhanced care coordination in New York City that leveraged surveillance data with a health plan’s Medicaid managed care roster improved its HIV viral load suppression rate.
DISCUSSION

Within our plan’s total HIV-positive Medicaid managed care population, approximately 76% were engaged in care and had viral suppression at the start of 2016. This is consistent with the citywide viral load suppression rate of 74% as reported by the New York City Department of Health and Mental Hygiene at the end of 2016.23 However, a quarter of the population has a viral load that remains or becomes unsuppressed at any given time. Of that quarter, 44% achieved viral load suppression over the program’s first 2 years.

The novel Data to Care public health strategy, which leveraged surveillance data to target HIV-positive individuals who are not engaged in care or who have unsuppressed viral loads despite being in care, was originally conceptualized as a state and local health department exercise. However, NYS took an innovative approach by involving Medicaid managed care plans that already had proven care coordination programs, and this approach proved to be successful in this study.

This pilot program resulted in other unexpected benefits. Our plan developed a good working collaboration with a community agency that continues to the present day. The placement of our care coordinators and peers on-site at provider clinics has engendered an improved collaboration with our providers and brought us closer to our members. Our care coordinators are no longer just a voice on the telephone. Finally, the process of hiring and working alongside HIV-positive peer educators and peer counselors has humanized the disease for our care coordinators and resulted in improved functioning as a team to support our HIV-positive membership.

Although the analysis focused on those participants with available data, it is likely that all members who received the interventions benefited. This analysis focuses on the first cohort we received, as it has the longest observation time. We have received additional lists annually from NYS in 2017, 2018, and 2019. We plan to report on these cohorts in the future. The program is ongoing and still being funded.

The results of this study suggest that HIV-positive members not engaged in care and those with high viral loads at baseline can achieve viral load suppression with outreach and enhanced care coordination from a Medicaid managed care organization. Such efforts positively contribute to overall improved engagement in HIV primary care and ART medication adherence.

Limitations

This study has some important drawbacks that chiefly involve data collection. Although significant effort was devoted to the collection of viral load values, collection was incomplete. Surveillance viral loads were reported in ranges and not in absolute values. For 8.6% of members, the range value was the only available viral load value. This caused the values in the high unsuppressed viral load ranges to be tightly centered around the 100,000 level, resulting in a distinct concentration within the KDE plot, especially in members whose values did not change. In addition, not all members of the cohort were able to be engaged, and some members achieved viral load suppression without program contact. Additionally, 13.6% of members were already engaged and had viral load suppression at program initiation because of the time lag of reporting viral loads to the HIV Surveillance Registry and the inability of MetroPlus to collect more real-time viral load data.

CONCLUSIONS

Although a large majority of identified people living with HIV can achieve and maintain viral load suppression with routine HIV care and support, there remains an important minority who do not. Viral load suppression is transient if adherence to ART is not maintained. Cross-referencing Medicaid plan rosters with health department surveillance data can help identify higher-risk populations to target. Medicaid managed care organization programs that provide enhanced care coordination and support can successfully contribute to improving viral load suppression within an urban HIV population. Such programs will continue to be needed as long as social determinants of health exist.

Author Affiliations: MetroPlus Health Plan (RGH, DW, RA), New York, NY; New York State Department of Health AIDS Institute (IF), Albany, NY; Annex Clinical Corporation (MA), New York, NY.

Source of Funding: New York State Department of Health C30813GG.

Author Disclosures: Dr Hewitt is employed with MetroPlus Health Plan, which contracts with New York State (NYS) to administer its Medicaid managed care plans; has received a grant for peer certification recruitment from the NYS Health Department; and attended the International Conference on AIDS in July 2018. Mr Adule is employed with MetroPlus Health Plan. Mr Alsumidaie was paid by MetroPlus to conduct statistical analysis. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (RGH, DW, IF); acquisition of data (RGH, DW, RA, IF); analysis and interpretation of data (RGH, RA, IF, MA); drafting of the manuscript (RGH, IF, MA); critical revision of the manuscript for important intellectual content (RGH); statistical analysis (MA); provision of patients or study materials (RGH, DW); obtaining funding (RGH, DW); administrative, technical, or logistic support (DW, RA); and supervision (RGH, DW).

Address Correspondence to: Ross G. Hewitt, MD, MetroPlus Health Plan, 160 Water St, Ste 18W-009, New York, NY 10038. Email: hewittr@metroplus.org.
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