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Background In the United States, patients with HIV face significant barriers to linkage to and retention in care which impede the necessary steps toward achieving the desired clinical outcome of viral suppression. Individual-level interventions, such as patient navigation, are evidence based, effective strategies for improving care engagement. In addition, use of surveillance and clinical data to identify patients who are not fully engaged in care may improve the effectiveness and cost-effectiveness of these programs. Methods and findings We employed a pre-post design to estimate the outcomes and costs, from the program perspective, of 5 state-level demonstration programs funded under the Health Resources and Services Administration’s Special Projects of National Significance Program (HRSA/SPNS) Systems Linkages Initiative that employed existing surveillance and/or clinical data to identify individuals who had never entered HIV care, had fallen out of care, or were at risk of falling out of care and navigation strategies to engage patients in HIV care. Outcomes and costs were measured relative to standard of care during the first year of implementation of the interventions (2013 to 2014). We followed patients to estimate the number and proportion of additional patients linked, reengaged, retained, and virally suppressed by 12 months after enrollment in the interventions. We employed inverse probability weighting to adjust for differences in patient characteristics across programs, missing data, and loss to follow-up. We estimated the additional costs expended during the first year of each intervention and the cost per outcome of each intervention as the additional cost per HIV additional care continuum target achieved (cost per patient linked, reengaged, retained, and virally suppressed) 12 months after enrollment in each intervention. In this study, 3,443 patients were enrolled in Louisiana (LA), Massachusetts (MA), North Carolina (NC), Virginia (VA), and Wisconsin (WI) (147, 151, 2,491, 321, and 333, respectively). Patients were a mean of 40 years old, 75% male, and African American (69%) or Caucasian (22%). At baseline, 24% were newly diagnosed, 2% had never been in HIV care, 45% had fallen out of care, and 29% were at risk of falling out of care. All 5 interventions were associated with increases in the number and proportion of patients with viral suppression [percent increase: LA = 90.9%, 95% confidence interval (CI) = 88.4 to 93.4; MA = 78.1%, 95% CI = 72.4 to 83.8; NC = 47.5%, 95% CI = 45.2 to 49.8; VA = 54.6, 95% CI = 49.4 to 59.9; WI = 58.4, 95% CI = 53.4 to 63.4]. Overall, interventions cost an additional $4,415 (range = $3,746 to $5,619), $2,009 (range = $1,516 to $2,274), $920 (range = $627 to $941), $2,212 (range = $1,789 to $2,683), and $3,700 ($2,734 to $4,101), respectively per additional patient virally suppressed. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess patients against themselves at baseline and not against standard of care during the same time period. Conclusions Patient navigation programs were associated with improvements in engagement of patients in HIV care and viral suppression. Cost per outcome was minimized in states that utilized surveillance data to identify individuals who were out of care and/or those that were able to identify a larger number of patients in need of improvement at baseline. These results have the potential to inform the targeting and design of future navigation-type interventions., Starley Shade and co-workers study outcomes and costs associated with interventions seeking to improve engagement with HIV care in the United States., Author summary Why was this study done? ➢ The Health Resources and Services Administration’s Special Projects of National Significance Program (HRSA/SPNS) funded an initiative that implemented 5 state-level interventions which used existing surveillance and/or clinical data to identify individuals who had never entered HIV care, had fallen out of care, or were at risk of falling out of care and navigation strategies to engage patients in HIV care. ➢ This study estimates the outcomes and incremental costs of these 5 state-level interventions relative to the standard of care provided prior to implementation of the interventions. What did researchers do and find? ➢ We estimated the additional cost of interventions during the first year of implementation (2013 to 2014). Among HIV–infected patients who enrolled in each intervention during the first year of implementation, we estimate how much the number and proportion of patients with viral suppression increased from before to up to 12 months after enrollment in the intervention. Then, we estimated the additional cost per additional patient with viral suppression for each intervention. ➢ We found that these interventions had similar or lower costs than similar previous interventions ($223 to $3,631 per patient), were associated with larger increases in the proportion of patients with viral suppression than similar previous interventions (47.5% to 90.9% increase in proportion of patients with viral suppression), and had similar or lower costs per additional patient with viral suppression compared to similar previous interventions ($920 to $4,415 per additional patient with viral suppression). What do these findings mean? ➢ These results show that using existing data to identify HIV–infected patients who are out of care and patient navigation to link, reengage, or retain patients in care is associated with increased viral suppression and had similar costs per outcome compared to patient navigation alone. These results also showed that use of surveillance data to identify HIV–infected patients who are out of care does not increase costs and may improve the cost per outcome of these interventions. ➢ This study did not include a contemporaneous comparison group. Therefore, we do not know the degree to which patients would have engaged or reengaged in care and achieved viral suppression due to other changes in care that occurred during the first year of implementation of the intervention.

Background The US National HIV/AIDS Strategy (NHAS) emphasizes the use of technology to facilitate coordination of comprehensive care for people with HIV. We examined cost-effectiveness from the health system perspective of 6 health information technology (HIT) interventions implemented during 2008 to 2012 in a Ryan White HIV/AIDS Program (RWHAP) Special Projects of National Significance (SPNS) Program demonstration project. Methods/findings HIT interventions were implemented at 6 sites: Bronx, New York; Durham, North Carolina; Long Beach, California; New Orleans, Louisiana; New York, New York (2 sites); and Paterson, New Jersey. These interventions included: (1) use of HIV surveillance data to identify out-of-care individuals; (2) extension of access to electronic health records (EHRs) to support service providers; (3) use of electronic laboratory ordering and prescribing; and (4) development of a patient portal. We employed standard microcosting techniques to estimate costs (in 2018 US dollars) associated with intervention implementation. Data from a sample of electronic patient records from each demonstration site were analyzed to compare prescription of antiretroviral therapy (ART), CD4 cell counts, and suppression of viral load, before and after implementation of interventions. Markov models were used to estimate additional healthcare costs and quality-adjusted life-years saved as a result of each intervention. Overall, demonstration site interventions cost $3,913,313 (range = $287,682 to $998,201) among 3,110 individuals (range = 258 to 1,181) over 3 years. Changes in the proportion of patients prescribed ART ranged from a decrease from 87.0% to 72.7% at Site 4 to an increase from 74.6% to 94.2% at Site 6; changes in the proportion of patients with 0 to 200 CD4 cells/mm3 ranged from a decrease from 20.2% to 11.0% in Site 6 to an increase from 16.7% to 30.2% in Site 2; and changes in the proportion of patients with undetectable viral load ranged from a decrease from 84.6% to 46.0% in Site 1 to an increase from 67.0% to 69.9% in Site 5. Four of the 6 interventions—including use of HIV surveillance data to identify out-of-care individuals, use of electronic laboratory ordering and prescribing, and development of a patient portal—were not only cost-effective but also cost saving ($6.87 to $14.91 saved per dollar invested). In contrast, the 2 interventions that extended access to EHRs to support service providers were not effective and, therefore, not cost-effective. Most interventions remained either cost-saving or not cost-effective under all sensitivity analysis scenarios. The intervention that used HIV surveillance data to identify out-of-care individuals was no longer cost-saving when the effect of HIV on an individual’s health status was reduced and when the natural progression of HIV was increased. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess sites against themselves at baseline and not against standard of care during the same time period. Conclusions These results provide additional support for the use of HIT as a tool to enhance rapid and effective treatment of HIV to achieve sustained viral suppression. HIT has the potential to increase utilization of services, improve health outcomes, and reduce subsequent transmission of HIV., Starley Shade and co-workers assess cost-effectiveness of information technology interventions in HIV care programs in the United States., Author summary Why was this study done? The Health Resources and Services Administration’s Special Projects of National Significance Program (HRSA/SPNS) funded a 4-year initiative (2007 to 2011) in 6 demonstration sites to enhance and evaluate existing health information electronic network systems for people living with HIV (PLHIV) in underserved communities. Each of the 6 demonstration sites implemented one or more health information technology (HIT) interventions to facilitate comprehensive care and enhance engagement in HIV medical services. These interventions included: (1) use of HIV surveillance data to identify out-of-care individuals; (2) extension of access to electronic health records to support service providers; (3) use of electronic laboratory ordering and prescribing; and (4) development of a patient portal. This study estimates the total costs, cost-effectiveness, and potential cost-savings of these 6 interventions. What did researchers do and find? We used information on the cost of each intervention and the health status of PLHIV in each setting before and after implementation of each intervention to estimate: (1) changes in the cost of care and other services for PLHIV in each setting; and (2) changes in expected health status (measured as quality-adjusted life-years or QALYs) among PLHIV in each setting. We then used this information to estimate additional healthcare costs and QALYs gained for each intervention. Four of the interventions were associated with lower healthcare costs and better health outcomes (QALYs gained) for PLHIV in each setting. These interventions saved between $6.87 and $14.91 per dollar invested. Two interventions that provided access to medical record information to support service providers were not associated with improved health outcomes for PLHIV in these settings. These interventions were not effective or cost-effective. What do these findings mean? These results show that HIT interventions that facilitate changes in patient or provider behavior have the potential to improve the health status of PLHIV and reduce healthcare costs. HIT interventions that only provided additional information to support service providers were less successful. This study did not include a contemporaneous comparison group. Therefore, we do not know the degree to which improvements in the health status of PLHIV in these settings were due to changes in the quality of care for PLHIV over the life of the interventions.

Demetrios Psihopaidas and co-authors discuss the implementation science framework of an HIV/AIDS program in the United States.

Interventions aiming to improve access to and retention in HIV care are optimized when they are tailored to clients' needs. This paper describes an initiative of interventions implemented by ten demonstration sites using a transnational framework to tailor services for Mexicans and Puerto Ricans living with HIV. Transnationalism describes how immigrants (and their children) exist in their "receiving" place (e.g., continental U.S.) while simultaneously maintaining connections to their country or place of origin (e.g., Mexico). We describe interventions in terms of the strategies used, the theory informing design and the tailoring, and the integration of transnationalism. We argue how applying the transnational framework may improve the quality and effectiveness of services in response to the initiative's overall goal, which is to produce innovative, robust, evidence-informed strategies that go beyond traditional tailoring approaches for HIV interventions with Latino/as populations.

Researchers, practitioners, and policymakers have long recognized the potential benefits of providing integrated substance abuse and medical care services, particularly for special populations such as people living with HIV/AIDS. Buprenorphine, an office-based pharmacological treatment for opioid dependence, offers new opportunities for integrating drug treatment into HIV care settings. However, the historical separation between the drug treatment and medical care systems has resulted in a host of policy barriers. The Buprenorphine and HIV Care Evaluation and Support initiative, a multisite demonstration project to assess the feasibility and effectiveness of integrating buprenorphine/naloxone into HIV care settings, provided an opportunity to evaluate if and how policy barriers affect efforts to integrate HIV care and addiction treatment. We found that financing issues, workforce and training issues, and the operational consequences of some conceptual differences between HIV care and addiction treatment are barriers to the full integration of buprenorphine into HIV care. We recommend changes to financing and reimbursement policies, programs to strengthen the addiction treatment skills of physicians, and cross training between the fields of addiction, medicine, drug treatment, and HIV medicine. By addressing some of the policy barriers to integration, this promising new treatment can help the thousands of people living with HIV/AIDS who are also opioid dependent.

There is high demand for care among the Hispanic population in states along the U.S.-Mexico border. The objective is to describe the standard of care received by people living with HIV/AIDS (PLWH/A) at enrollment into one of five Special Projects of National Significance (SPNS) Sites located along the U.S.-Mexico border. This cross-sectional study describes the presence of opportunistic infections (OIs), AIDS status and two types of standard of care received by 707 PLWH/A participating in SPNS. Patients receiving care through SPNS in one of the five sites between June 1, 2002 and December 31, 2003 were invited to participate to the medical chart review component of the study. The association between sociodemographic variables and the prevalence of OIs and AIDS at enrollment was estimated using multivariate hierarchical logistic models. More than one quarter of the 707 participants had at least one OI recorded and 58% of new and 60% of existing patients had AIDS at enrollment in SPNS. The association between being Hispanic and having higher prevalence of OI and AIDS at entry varied by SPNS site. Standard of care was well followed overall. This is the first study describing HIV stage and OI prevalences and standard of care in PLWH/A in all U.S.-Mexico bordering states. Being of Hispanic ethnicity may not fully explain discrepancy in access to care along the border.

The purpose of this study is to provide a description of personal lifestyles and demographic characteristics of 1,200 HIV seropositive individuals who volunteered to participate in a Health Resources and Services Administration (HRSA), Special Projects of National Significance (SPNS) Initiative conducted in five U.S. demonstration projects located along the U.S.-Mexico border between 2001 and 2004. The results show that HIV/AIDS patients receiving care along the U.S.-Mexico border are predominantly Hispanics (81%) and men who have sex with men (56%). In general, SPNS participants appear to be sociodemographically similar to the general HIV/AIDS population in the U.S. with a few noted exceptions such as age, labor force participation, and variations in mode of transmission by age and gender.

A Health Resources and Services Administration-Substance Abuse and Mental Health Services Administration collaboration was established to improve health outcomes for opiate-dependent HIV-infected patients through promotion of integrated models of HIV primary care and substance abuse treatment. The collaboration comprised 10 demonstration sites coordinated by a technical assistance/evaluation center that worked to refine planned interventions, address state-of-the-art treatment and policy issues relating to the use of buprenorphine opioid abuse treatment in HIV primary care settings, conduct local and multisite evaluations, and disseminate program findings. This article describes the goals and objectives of the collaborative as well as the interagency interactions and steps taken to establish the collaborative.

Having opioid dependence and HIV infection are associated with poor HIV-related treatment outcomes.HIV-infected, opioid-dependent subjects (N = 295) recruited from 10 clinical sites initiated buprenorphine/naloxone (BUP/NX) and were assessed at baseline and quarterly for 12 months. Primary outcomes included receiving antiretroviral therapy (ART), HIV-1 RNA suppression, and mean changes in CD4 lymphocyte count. Analyses were stratified for the 119 subjects not on ART at baseline. Generalized estimating equations were deployed to examine time-dependent correlates for each outcome.At baseline, subjects on ART (N = 176) were more likely than those not on ART (N = 119) to be older, heterosexual, have lower alcohol addiction severity scores, and lower HIV-1 RNA levels; they were less likely to be homeless and report sexual risk behaviors. Subjects initiating BUP/NX (N = 295) were significantly more likely to initiate or remain on ART and improve CD4 counts over time compared with baseline; however, these improvements were not significantly improved by longer retention on BUP/NX. Retention on BUP/NX for three or more quarters was, however, significantly associated with increased likelihood of initiating ART (β = 1.34 [1.18, 1.53]) and achieve viral suppression (β = 1.25 [1.10, 1.42]) for the 64 of 119 (54%) subjects not on ART at baseline compared with the 55 subjects not retained on BUP/NX. In longitudinal analyses, being on ART was positively associated with increasing time of observation from baseline and higher mental health quality of life scores (β = 1.25 [1.06, 1.46]) and negatively associated with being homo- or bisexual (β = 0.55 [0.35, 0.97]), homeless (β = 0.58 [0.34, 0.98]), and increasing levels of alcohol addiction severity (β = 0.17 [0.03, 0.88]). The strongest correlate of achieving viral suppression was being on ART (β = 10.27 [5.79, 18.23]). Female gender (β = 1.91 [1.07, 3.41]), Hispanic ethnicity (β = 2.82 [1.44, 5.49]), and increased general health quality of life (β = 1.02 [1.00,1.04]) were also independently correlated with viral suppression. Improvements in CD4 lymphocyte count were significantly associated with being on ART and increased over time.Initiating BUP/NX in HIV clinical care settings is feasible and correlated with initiation of ART and improved CD4 lymphocyte counts. Longer retention on BPN/NX was not associated with improved prescription of ART, viral suppression, or CD4 lymphocyte counts for the overall sample in which the majority was already prescribed ART at baseline. Among those retained on BUP/NX, HIV treatment outcomes did not worsen and were sustained. Increasing time on BUP/NX, however, was especially important for improving HIV treatment outcomes for those not on ART at baseline, the group at highest risk for clinical deterioration. Retaining subjects on BUP/NX is an important goal for sustaining HIV treatment outcomes for those on ART and improving them for those who are not. Comorbid substance use disorders (especially alcohol), mental health problems, and quality-of-life indicators independently contributed to HIV treatment outcomes among HIV-infected persons with opioid dependence, suggesting the need for multidisciplinary treatment strategies for this population.

Background: Surveillance points to an urgent public health need for HIV prevention, access, and retention among young men of color who have sex with men (YMSM). The purpose of this multisite study was to evaluate the association between organizational- and individual-level characteristics and retention in HIV care among HIV-positive YMSM of color. Methods: Data were collected quarterly via face-to-face interviews and chart abstraction between June 2006 and September 2008. Participants were aged 16-24 years, enrolled at 1 of 8 participating youth-specific demonstration sites, and engaged or reengaged in HIV care within the last 30 days. Generalized estimating equations were used to examine factors associated with missing research and care visits. Stata v.9.0se was used for analysis. Results: Of 224 participants, the majority were African American (72.7%), 19-22 years old (66.5%), had graduated high school or equivalent (71.8%), identified as gay or homosexual (80.8%), and disclosed having had sex with a man before HIV diagnosis (98.2%). Over the first 2 1/4 years of the study, only 11.4% of visits were missed without explanation or patient contact. Characteristics associated with retention included being

BACKGROUND Although information technology (IT) plays an increasingly important role in the delivery of healthcare, specific guidelines to assist human immunodeficiency virus (HIV) care settings in adopting IT are lacking. METHODS Through the experiences of six Special Projects of National Significance - (SPNS) funded HIV-specific IT interventions, key considerations prior to adoption and evaluation of IT are presented. The purpose of this article is to provide guidelines to consider prior to adoption and evaluation of IT in HIV care settings. RESULTS Six sites conducted comprehensive evaluations of IT interventions between 2002 and 2005, encompassing care delivered to 24,232 clients by 700 providers. Six key considerations prior to adoption of IT in HIV care delivery were identified, including IT and programmatic capacity, expectations, participation, organizational models, end-user types, and challenges. Specific evaluation techniques included implementation assessment, formative evaluation, cost studies, outcomes evaluation, and performance indicators. Grantee experiences are used to illustrate key considerations. DISCUSSION With proper preparation, even resource-poor HIV care delivery programs can successfully adopt IT.