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The goals of controlling HIV sound like a straight forward series of three consecutive steps, one following another, when discussed in global and domestic epidemic-ending plans. If 90 percent of all people living with the virus knew it, 90 percent of them access antiretroviral treatment, and 90 percent of those on treatment -- that is 73 percent of all people living with HIV accessing treatment get it consistently enough to suppress the virus, transmission of HIV would dwindle to the point that it would cease to be a public health threat. But the last 90 can be a series of steps in its own right, particularly for people facing the greatest obstacles to consistent effective health services, write the authors of a report on a project seeking to meet the needs of those clients.
Noting that "maintaining viral suppression over time is more difficult for patients than achieving it once," in their report published in July's Open Forum Infectious Diseases, they looked at the impacts of the Seattle Max Clinic's enhanced efforts to retain clients living with HIV but not in care, not well engaged in care, or disengaged from care and unresponsive to outreach efforts. Identified by public health outreach programs, medical providers, peers and jail release programs, many faced challenges that included unstable housing, recent incarceration, mental illnesses and substance use. Enhancements to standard care included offering walk-in access to medical and non-medical services, food vouchers and snacks on site, no-cost bus passes, cell phones if needed for the first two years and cash incentives for achieving viral suppression as well as for clinic visits that included blood draws. With about 50 clients each, case managers had more time for clients than those in standard of care settings with as many as three times that number of clients.
Compared to clients with similar treatment histories and challenges accessing standard services, those at the Max Clinic were more than three times likely to achieve viral suppression and showed what the authors call "substantial improvements" in maintaining it.
"For those inclined to dismiss our approach as achievable only in relatively resource-rich environments, we urge consideration of several points," the authors, write. "First it is possible that low-intensity interventions simply do not work for some populations."
And they add, that with the possibility that the program's benefits were associated with reduced subsequent health system costs, it may be more cost-effective than it looks.
