Epividian / AHF: Positive Pathways - HIV Retention in Care

Retention in care and re-engagement in care is a primary concern in HIV treatment today and a major obstacle in the US to reach the UNAIDS 90-90-90 goal [1]. The U.S. CDC supports the use of HIV surveillance data to identify not-in-care (NIC) patients and re-link them to care (Data-to-Care). The optimal strategy for identifying patients for Data-to-Care is unknown. It has been postulated that by increasing follow up of high-risk patients not meeting the retention in care measures, the number of people living with HIV being retained in care may be increased by 10%.

Multiple HIV clinics within the AHF organization in the US are eligible for study participation. "Primary" HIV provider will be defined as the primary physician or advanced care practitioner following a patient, as recorded in their respective EHRs and identified through CHORUS, a CDSS developed by Epividian. The CDSS will track patient case status as active or inactive (loss to follow-up, transferred medical care, or deceased). Providers will be informed of the study and sites will be contracted to participate in this collaborative research study.

The CDSS will generate alerts to the providers warning of suboptimal patient attendance among the population. The alerts will be generated using the following four criteria of at-risk of loss to follow-up:

• At Risk #1: No visit in the previous 4 months and no scheduled appointment in the subsequent 2 months.
• High Risk #2: Single appointment in the previous year, a missed appointment in the previous month and no scheduled appointment in the next 2 months.
• High Risk #3: Those with 2 missed sequential appointments, and no scheduled appointment in the subsequent 7 days.
• High Risk #4: Those with an attended appointment >3 months ago and their most recent viral load >1000 copies/ml.

Inclusion criteria

• HIV-1+
• 18 years old or older
• Any sex
• Seen at least once in a US-based AHF clinic in the last 2 years with care documented in the EHR

Exclusion criteria

• Patients known to have left the practice
• Patients who choose not to be contacted about their care via telephone