Improving Quality Care for Marginalized HIV-Positive

Patients• The Prevention and Access to Care and

Treatment (PACT) ProjectA Complementary Community-Based

HIV Disease Management Model

Heidi Behforouz, MD and Jessica Aguilera-Steinert, LICSW

03/10/05

AIDS MORTALITY

DESPITE OUR ADVANCING TECHNOLOGY…

In Roxbury, a black women is 16x more likely to die from her AIDS than

a white man in Boston.

Time

Improved Outcomes

Introduction of effective

technology

Low SES

High SES

The Outcome Gap Grows

Why the disparities in outcome?

• Poverty forces priorities other than health

• Poor access to care (eg insurance)

• Poor utilization of care (eg not getting tested till late in disease)

• System problems

• Differential treatment once in care

• Problems with adherence

The relationship between adherence and AIDS progression

% of Cohort % Progression

Low adherence

(<50 %)

31 41

Medium adherence

(51-90%)

49 8

High adherence

(>90%)

20 0

Impact of ART on Hospitalization Rates in HIV-

Infected PatientsGilbert et al, New York Presbyterian Hospital

AIDS Research and Human Retroviruses. 18(7):501, 2002

HospitalAdmissions Per 100 Pt-Yr

0

10

20

30

40

50

60

70

80

90

100Median CD4: 231

Median CD4: 364

1995 1997 11999 2001

n= 883 in 1995n=1990 in 2001

ART is Cost-Effective K. Freedberg et al. NEJM 2001 344: 824

Greater than benefit of thrombolytic therapy in acute MI, XRT for early stage breast CA,

and anti-hyperlipidemics

Adherence Interventions are cost effective

Sue Goldie et al.

Any intervention that increases ART adherence by 30% will be cost effective

Prevention and Access to Care and Treatment (PACT)

Project• Started in 1999 through Partners In Health; Now a

joint project of PIH & the DSMHI at BWH•

Participant-driven

• Health promoters improve access to care for marginalized HIV patients in Boston’s inner city as well as promote harm reduction in the community

• Health promoters work in conjunction with physicians, medical students, social scientists.

PACT Organizational Structure

7 P e er lea de rs

F ue rza L a tinaM a ya D o e S im k ins

4 Y o uth le a de rs

F u erza Y ou thJ ina J ib r in

P reve n tion In i tia tiveL ex ie P ie rson

R e se arch In i t ia t iveA u drey K a lm us

Ju an a C a bra lM ag a lie L am o ur

D ev in A ta llah

H e a lth P rom oter

S or i S an tanaC r is t ina S u arezS a ira G e orge

D O T -P lusT e rre nce B urek

A cce ss In i t ia t iveJe ssica S te in e rt

H e id i B e h fo rou z, M DP A C T d irec to r

PACT PROJECT

• Harm Reduction Initiative• Knowledge is important but not enough• Prevention case management services• Peer leader outreach and harm reduction in hot

zones• Media campaigns, needle exchange,

accompaniment• Working with adults in early recovery and inner

city youth

PACT Project

• Health Promotion Initiative

• Low intensity: Monitored self- administration with monthly health promotion

• Moderate intensity: Weekly health Promotion

• High intensity: DOT-Plus initiative

WHAT HEALTH PROMOTERS DO…

• Accompaniment to appointments…more than just getting the patient there

• Home based support to pt and network• Work in concert with clinicians and other social service

personnel to coordinate care• Health education and translation of treatment

recommendations into the home• Facilitate access to and utilization of resources• Extensive adherence counseling• Surrogate support network and sounding board• Normalization/setting new norms• Advocacy• Empowerment

DOT-Plus

• In addition to the weekly services of a health promoter, patients receive daily visits from the DOT specialist who assists them in

taking their once daily ART medication

• Designed with instruction from patients

Cristina at work…

Movement through PACT

Outcomes of Interest for HP Program• Improved clinical outcomes (CD4/VL/OI)• Improved engagement with health care• Improved practice of harm reduction• Improved self management• Improved health care utilization• Number of referrals to PACT • Number graduated to successful self administration • Number of relapses• Length of time in each arm and number of movements

between arms over time• Resource utilization• Sustainability

PACT and the PDSA Cycle

• Participant action plans

• Quarterly personal objectives for peer prevention leaders

• Patient progress (eg Q patient report cards)

• Health promoter report card

• Program goals: eg referral rates, retention rates, etc.

PACT ALONE GRAPHS

• Insert Ariel Cruz graph Viral Load (thousands/ml)

-4 4

Months Pre and Post PACT CD4 in ( ) = hospitalization

0

50

100

150

200

250

300

350

400

AC

PACT

(26)

(153)

Viral Load(thousands /ml)

MONTHSCD4= ( ) = hospitalization = EW visit

-40 -30 -20 -10 0 10 20 30 40 50 60

DOT

PACT

(102)(102)

(22)

(10)

(139)

(30)

(43)

40

80

120

160

Data to date

Health Promotion

• Of those 31 meeting our new eligibility criteria at entry who have been enrolled for at least one year:

• (Baseline mean CD4 =131 with mean VL 61K)• 10 with VL<assay at present• Mean –1.35 log decrease in VL• Mean increase in CD4 after 1 year=79 cells/µl

Data to date: DOT-Plus

• Of 20 enrolled into DOT Plus for at least one year…

• (Baseline mean CD4 122 with mean VL of 57K)

• Retention rate at one year= 85%

• 11 achieving VL<assay to date

• Mean increase in CD4= 108.5 cells/µl

• Means VL reduction = –1.13 log

Yearly Expenditures for Care of HIV/AIDS Patients

$28,128

$16,332

$11,100

$6,384

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

<50 50-199 200-500 >500

CD4 Immune Cell Count (cells/ml)

Ann

ual E

xpen

ditu

re P

er P

atie

nt

(199

8)

Average ($20,300)

Source: Bozette, S et. al. Expenditures for the Care of HIV-Infected Patients in the Era of Highly Active Antiretroviral Therapy. NEJM, 2001.

•Today we estimate annual expenditures for patients with CD4<50 to be around $40,000•CD4 count measures immune strength•PACT CD4 eligibility criteria: <350, most PACT patients have CD4 <200 at enrollment

What does this mean in terms of medical cost savings?

Average cost of PACT/patient = $3200/month

(across all three programs)

Patients whose CD4 counts have risen from <50 to >200…medical savings of

up to $17,000/ year

Sustainability/ Funding Challenges• PACT is primarily a service organization as

opposed to focusing on research or policy• Care gets less attention than prevention• PACT staffing ratios are deemed too costly• It takes time and resources to prove ourselves and

become competitive for funding• Shrinking federal, state, and private funds-

particularly for HIV service programs and harm reduction programs

• Not much interest in the plight of poor minority individuals with HIV or substance abuse

Spread Challenges First establish best practice…develop the

package…curricula, training manuals, process guides

THEN barriers include:

Lack of similar organizations from whom to learn collaboratively, politics, money

BUT

The proof is in the pudding…do the work, show the data, always strive for quality in a systematic way

For more HIV-related resources, please visit www.hivguidelines.org