Telephonic intervention to support high risk patients

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Retention in HIV care among patients with mental health and/or drug and alcohol problems can be improved with a telephone-based support intervention, but only if staff are able to establish regular contact with patients. Overall results of the study showed that enhanced support – regular contact with reminders to attend appointments and follow-up after missed appointments – did not improve retention in care among patients with anxiety, depression and drug and alcohol problems. However, closer analysis of the results revealed that the intervention did work when staff were able to contact patients.

“Looking at these higher-risk patients as a whole, without considering delivery of the intervention, one would conclude that patients did not respond well to the intervention,” write the investigators. “But a more nuanced picture emerged. We found that the intervention arm patients in the higher-risk group received less contact…a significant percentage did receive most of the intervention elements, and this part did, in fact, benefit from the intervention.”

The researchers therefore believe that patients living with mental health and substance abuse problems who have dropped out of care can be re-engaged, provided they can be contacted and supported.

The Centres for Disease Control and Prevention (CDC) estimates that 45% of patients with diagnosed HIV infection in the US are not fully engaged with care and therefore are unlikely to be getting the full benefit of antiretroviral therapy. Mental health and substance abuse problems are highly prevalent among HIV-positive individuals in the US and are a possible reason why some patients disengage with care.

Investigators designed an intervention to boost clinic attendance among patients who had dropped out of care. Consisting of reminder calls, missed visit calls, interim visit calls and brief face-to-face meetings in clinic, it was shown to improve retention among patients with irregular clinic attendance.

The researchers wanted to see if the intervention could successfully boost clinic attendance among patients living with potential barriers to engagement with care, such as severe anxiety, depression, heavy drinking and illicit drug use. They conducted a sub-analysis of their principal findings. The study population consisted of 1838 patients who received care at six HIV clinics. All had irregular clinic attendance patterns. Their mental health and drug/alcohol use was assessed using accredited measures. Patients were randomised to receive the enhanced support intervention or standard of care for twelve months. The study outcome was attendance at regular outpatient follow-up visits over the next year.

Over two-thirds of patients were African American, approximately 60% were men and a third were in their 40s. At baseline, 78% were taking ART and approximately 56% had an undetectable viral load.

A fifth reported using illicit drugs in the previous three months and 15% were classified as heavy drinkers. Severe anxiety/depression was present in 14% of participants.

Initial analysis showed that the intervention did not boost clinic attendance among patients facing drug/alcohol or mental health issues. Patients were then categorised according to their risk of dropping out of care. Over a third (36%) had one or more risk factor – such as mental health or substance abuse problems – for irregular clinic attendance. Analysis of the efficacy of the intervention according to risk profile showed that it had a strong, positive effect among low-risk patients, boosting the chances of engagement with care by 35% (p < 0.009). However, it did not have a positive effect for higher-risk individuals.

The investigators noted higher-risk patients were contacted on 41% of attempted telephone contacts, compared to a success rate of 51% for lower-risk individuals, a significant difference. The lower success rate with higher-risk patients was not due to fewer attempted contacts (mean 16 attempts for both groups).

Further analysis showed that the intervention had a strongly positive effect (equal to that observed in low-risk patients) for higher-risk patients who received at least 60% of attempted telephone contacts.

“Twenty-six percent of the higher-risk participants in the intervention arm had at least 60% successful contacts and exhibited a strong response to the intervention,” write the authors. “These phone contact results for the higher-risk group give us confidence that there are some patients at high risk of disengaging from care who will respond to an enhanced contact-type intervention.”

They conclude, “improving receipt of the intervention among higher-risk patients may be possible by simply altering the enhanced contact intervention to more effectively stay in contact with these patients. This concept is supported by other research findings that more intense and frequent contact from HIV care managers resulted in fewer gaps in care.”

Abstract
Objective: We evaluated whether heavy alcohol use, illicit drug use or high levels of anxiety and depression symptoms were modifiers of the Retention through Enhanced Personal Contact (‘REPC’) intervention. The intervention had previously demonstrated overall efficacy in the parent study.
Design: Randomized trial.
Methods: A total of 1,838 patients from 6 U.S. HIV clinics were enrolled into a randomized trial in which intervention patients received an “enhanced contact” protocol for 12 months. All participants completed an ACASI interview that measured depression and anxiety symptoms from the Brief Symptom Inventory, alcohol use from the AUDIT-C instrument, and drug use from the WHO (ASSIST) questions. The 12-month binary outcome was completing an HIV primary care visit in three consecutive 4-month intervals. The outcome was compared between intervention and standard of care patients within subgroups on the effect modifier variables using log-binomial regression models.
Results: Persons with high levels of anxiety or depression symptoms and those reporting illicit drug use, or heavy alcohol consumption had no response to the intervention. Patients without these “higher-risk” characteristics responded significantly to the intervention. Further analysis revealed higher-risk patients were less likely to have successfully received the telephone contact component of the intervention. Among higher-risk patients who did successfully receive this component, the intervention effect was significant.
Conclusions: Our findings suggest that clinic-based retention in care interventions are able to have significant effects on HIV patients with common behavioral health issues, but the design of those interventions should assure successful delivery of intervention components to increase effectiveness.

Aidsmap material
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