Impact of Streamlined HIV Care on Economic Burden among Infected Adults

 
Provision of streamlined HIV care associated with
reduced economic burden of care-seeking among
HIV-infected adults
 
Aleksandra Jakubowski, Jane Kabami, Daniel Mwai,
Katherine Snyman, Tamara Clark, James Ayieko,
Asiphas Owaraganise, Florence Mwangwa, Maya
Petersen, Craig Cohen, Elizabeth Bukusi, Moses Kamya,
Diane Havlir, Edwin Charlebois, Harsha Thirumurthy
 
Background
 
Despite free treatment, patients face various costs
associated with healthcare utilization
Transportation, time away from work, out-of-pocket
expenditures
 
Alternative models of delivering ART have potential
to reduce economic burden of receiving care
 
In communities that began receiving streamlined HIV
care, we examined changes in healthcare costs
incurred by patients
 
SEARCH trial
 
SEARCH: HIV test-and-treat cluster
randomized trial in Kenya and Uganda
(NCT:01864603)
 
Key interventions
Population-based testing
Supported linkage
ART irrespective of CD4
Streamlined HIV care
SEARCH Streamlined Care Model
1.
 Efficient Visits for Patients and Staff
 
• ART start at first clinic visit as indicated
• Triage by nurse or other extender at
     all follow-up visits
 
• Clinic visits and ART dispensation every
     3 months rather than every 1-2 months
 
Integration of services: HIV care, NCD care,
     general medical care
2. 
Patient-centered approach to care
 
Welcoming environment
 
Fostering trust, connection, and a sense of
investment in the patient
Flexible clinic hours
Tiered tracking
Multi-disease chronic care model
 
3.
 Telephone hotline
access for patients
 
• Easy triage of medical
questions
 
• Appointment/scheduling
logistics for retention
4.
 Appointment
reminders by phone/SMS
 
• One week to few days in
advance
 
• Retention tool
5.
 Viral Load Counseling
 
• Structured format for
discussion of undetectable and
detectable results
 
 
Methods
 
Longitudinal surveys conducted among a
random sample of households with HIV+ and
HIV- adults
 
200 households enrolled in each community,
revisited each year
100 with & without HIV+ adults
July 2013 – Aug. 2014: 
after SEARCH baseline testing
Oct. 2014 – Sept. 2015: follow-up year 1
 
Methods
 
Survey questionnaires obtained information
on various dimension of healthcare costs
Adapted from Living Standards Measurement
Surveys
 
Survey data from linked to SEARCH data on
HIV status and ART status of individuals
 
 
Outcomes
 
Outcomes selected to characterize multiple
dimensions of healthcare burden
 
Number of hours spent seeking healthcare in
past month
Number of hours lost from work in past month
Reported being hospitalized in past year
Healthcare expenditures in past month (US$)
 
Statistical analyses
 
Baseline data analyzed to compare outcomes
for various sub-populations
HIV+ and HIV- adults
 
Trends between baseline and follow-up year 1
analyzed for HIV+ adults receiving ART
Regression models that included data for HIV- adults
were used to adjust for temporal patterns
 
Values above 95
th
 percentile replaced with 95
th
percentile to limit effect of outliers
 
RESULTS
 
Adult participants in household survey –
intervention communities
 
HIV- adults
4,562 at baseline
4,229 at follow-up year 1
HIV+ adults on ART
1,324 on ART at baseline
1,707 on ART at  follow-up year 1
 
At baseline, health expenditures and time
seeking care 30-50% higher for HIV+ adults
 
Non-financial costs are a significant
component of healthcare burden
 
Among all HIV+ adults receiving ART, economic
burden of healthcare tended to decline over time
 
Data for adults receiving ART
 
Time spent seeking healthcare
Relative to baseline levels for those on ART, ~40% decline in
hours seeking care
 
Time lost from work
Relative to baseline levels for those on ART, ~25% decline in
hours lost from work
 
Healthcare expenditures (US$)
 
Relative to baseline levels for those on ART, 47% reduction in
healthcare expenditures
 
Probability of hospitalization in past 12 months
 
Relative to baseline levels for those on ART, 30% reduction in
hospitalizations
 
In Kenyan communities, rising wealth may
contribute to higher healthcare utilization
 
ART households more likely to be in top 3
wealth quintiles in follow-up year 1
 
Summary
 
Costs incurred by patients receiving ART
declined 1 year after introduction of
streamlined care
Largest reductions seen in time costs of care
 
Results likely to be due to lower 
frequency
 &
duration
 of visits as well as improved health
 
Summary
 
Substantial heterogeneity in costs and time
trends across communities
In Kenya, no significant change in costs of care
Higher wealth for those on ART may have
increased healthcare utilization
Other potential explanatory factors: (a) rainfall
variation; and (b) inclusion of ART initiation costs
at baseline
 
Conclusions
 
While there is heterogeneity between
communities, results consistent with hypothesis
that streamlined care delivery model can reduce
the economic burden on patients receiving ART
 
Further research using additional longitudinal data
and comparison to non-intervention communities
and households needed to verify these findings
 
COLLABORATING ORGANIZATIONS
 
Acknowledgments
 
Research reported in this presentation was supported by Division of
AIDS, NIAID of the National Institutes of Health under award number
U01AI099959 and in part by the President’s Emergency Plan for AIDS
Relief and Gilead Sciences.
The content is solely the responsibility of the authors and does not
necessarily represent the official views of the NIH, PEPFAR, or Gilead.
The SEARCH project gratefully acknowledges the Ministries of Health of
Uganda and Kenya, our research team, collaborators and advisory
boards, and especially all communities and participants involved.
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Streamlined HIV care models aim to reduce the economic burden faced by HIV-infected adults by minimizing healthcare costs and improving access to care. The SEARCH trial in Kenya and Uganda implemented population-based testing and supported linkage to antiretroviral therapy (ART) regardless of CD4 counts. The streamlined care model focused on efficient visits, patient-centered care, telephone hotlines, appointment reminders, and viral load counseling. Longitudinal surveys assessed changes in healthcare costs among households with HIV-positive adults, showing potential benefits of streamlined care in reducing financial strain on patients seeking treatment.


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  1. Provision of streamlined HIV care associated with reduced economic burden of care-seeking among HIV-infected adults Aleksandra Jakubowski, Jane Kabami, Daniel Mwai, Katherine Snyman, Tamara Clark, James Ayieko, Asiphas Owaraganise, Florence Mwangwa, Maya Petersen, Craig Cohen, Elizabeth Bukusi, Moses Kamya, Diane Havlir, Edwin Charlebois, Harsha Thirumurthy

  2. Background Despite free treatment, patients face various costs associated with healthcare utilization Transportation, time away from work, out-of-pocket expenditures Alternative models of delivering ART have potential to reduce economic burden of receiving care In communities that began receiving streamlined HIV care, we examined changes in healthcare costs incurred by patients

  3. SEARCH trial SEARCH: HIV test-and-treat cluster randomized trial in Kenya and Uganda (NCT:01864603) Key interventions Population-based testing Supported linkage ART irrespective of CD4 Streamlined HIV care UGANDA KENYA Tororo Mbarara Nyanza

  4. SEARCH Streamlined Care Model 1. Efficient Visits for Patients and Staff 2. Patient-centered approach to care ART start at first clinic visit as indicated Triage by nurse or other extender at all follow-up visits Welcoming environment Fostering trust, connection, and a sense of investment in the patient Flexible clinic hours Tiered tracking Multi-disease chronic care model Clinic visits and ART dispensation every 3 months rather than every 1-2 months Integration of services: HIV care, NCD care, general medical care 3. Telephone hotline access for patients 4. Appointment reminders by phone/SMS 5. Viral Load Counseling Structured format for discussion of undetectable and detectable results Easy triage of medical questions One week to few days in advance Appointment/scheduling logistics for retention Retention tool

  5. Methods Longitudinal surveys conducted among a random sample of households with HIV+ and HIV- adults 200 households enrolled in each community, revisited each year 100 with & without HIV+ adults July 2013 Aug. 2014: after SEARCH baseline testing Oct. 2014 Sept. 2015: follow-up year 1

  6. Methods Survey questionnaires obtained information on various dimension of healthcare costs Adapted from Living Standards Measurement Surveys Survey data from linked to SEARCH data on HIV status and ART status of individuals

  7. Outcomes Outcomes selected to characterize multiple dimensions of healthcare burden Number of hours spent seeking healthcare in past month Number of hours lost from work in past month Reported being hospitalized in past year Healthcare expenditures in past month (US$)

  8. Statistical analyses Baseline data analyzed to compare outcomes for various sub-populations HIV+ and HIV- adults Trends between baseline and follow-up year 1 analyzed for HIV+ adults receiving ART Regression models that included data for HIV- adults were used to adjust for temporal patterns Values above 95th percentile replaced with 95th percentile to limit effect of outliers

  9. RESULTS

  10. Adult participants in household survey intervention communities HIV- adults 4,562 at baseline 4,229 at follow-up year 1 HIV+ adults on ART 1,324 on ART at baseline 1,707 on ART at follow-up year 1

  11. Non-financial costs are a significant component of healthcare burden At baseline, health expenditures and time seeking care 30-50% higher for HIV+ adults

  12. Among all HIV+ adults receiving ART, economic burden of healthcare tended to decline over time Data for adults receiving ART

  13. Time spent seeking healthcare SW Uganda E Uganda -2.76*** (0.72) Kenya 0.12 (0.38) All regions -0.92*** (0.28) On ART * Follow-up year 1 -0.94** (0.36) Observations Robust standard errors in parentheses. P-value notation: *** p<0.001, ** p<0.01, * p<0.05 3,760 3,797 3,865 11,422 Relative to baseline levels for those on ART, ~40% decline in hours seeking care

  14. Time lost from work SW Uganda -1.66 (1.27) E Uganda -2.98 (2.53) Kenya -1.99 (1.69) All regions -2.46* (1.05) On ART * Follow-up year 1 Observations Robust standard errors in parentheses. Models were adjusted for gender, age, age, education, wealth, community and month of interview. Outliers censored at 95th percentile. P-value notation: *** p<0.001, ** p<0.01, * p<0.05 3,760 3,797 3,865 11,422 Relative to baseline levels for those on ART, ~25% decline in hours lost from work

  15. Healthcare expenditures (US$) SW Uganda E Uganda -0.95* (0.45) Kenya 0.18 (0.40) All regions -0.64** (0.24) On ART * Follow-up year 1 -1.31*** (0.38) Observations Robust standard errors in parentheses. . Models were adjusted for gender, age, age, education, wealth, community and month of interview. Outliers censored at 95th percentile. P-value notation: *** p<0.001, ** p<0.01, * p<0.05 3,760 3,797 3,864 11,421 Relative to baseline levels for those on ART, 47% reduction in healthcare expenditures

  16. Probability of hospitalization in past 12 months SW Uganda E Uganda -0.04 (0.03) Kenya -0.02 (0.02) All regions -0.03* (0.01) On ART * Follow-up year 1 -0.02 (0.02) Observations Robust standard errors in parentheses. Models were adjusted for community and month of interview. Outliers censored at 95th percentile. P-value notation: *** p<0.001, ** p<0.01, * p<0.05 3,760 3,797 3,865 11,422 Relative to baseline levels for those on ART, 30% reduction in hospitalizations

  17. In Kenyan communities, rising wealth may contribute to higher healthcare utilization ART households more likely to be in top 3 wealth quintiles in follow-up year 1

  18. Summary Costs incurred by patients receiving ART declined 1 year after introduction of streamlined care Largest reductions seen in time costs of care Results likely to be due to lower frequency & duration of visits as well as improved health

  19. Summary Substantial heterogeneity in costs and time trends across communities In Kenya, no significant change in costs of care Higher wealth for those on ART may have increased healthcare utilization Other potential explanatory factors: (a) rainfall variation; and (b) inclusion of ART initiation costs at baseline

  20. Conclusions While there is heterogeneity between communities, results consistent with hypothesis that streamlined care delivery model can reduce the economic burden on patients receiving ART Further research using additional longitudinal data and comparison to non-intervention communities and households needed to verify these findings

  21. COLLABORATING ORGANIZATIONS

  22. Acknowledgments Research reported in this presentation was supported by Division of AIDS, NIAID of the National Institutes of Health under award number U01AI099959 and in part by the President s Emergency Plan for AIDS Relief and Gilead Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, PEPFAR, or Gilead. The SEARCH project gratefully acknowledges the Ministries of Health of Uganda and Kenya, our research team, collaborators and advisory boards, and especially all communities and participants involved.

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