By Rebecca Stachurski, MPH; Lisa Shah, PhD; Anthony Frachioni, PhD; Stan Pogroszewski; Dean Beals; Steven Haimowitz, MD; Kimberly Northrip, MD, MPH
This case study won the Alliance 2022 Outstanding Outcomes Award.
Background
In 2018, more than half of adults in the United States had never been tested for HIV, with undiagnosed HIV infection accounting for 40% of new HIV cases. Currently, it is estimated that 1 in 7 people with HIV are unaware of their status. Nationally, incidence rates for both HIV and undiagnosed HIV have been declining steadily. However, the incidence of HIV in Kentucky has been stagnant at approximately 300 new infections every year. Kentucky’s rate of undiagnosed HIV is also stagnant and is 15.6% higher than the national average.
The Kentucky Screen, Treat, Overcome, Prevent HIV (STOP HIV) initiative was established to address this practice gap and improve patient outcomes for HIV screening, treatment and prevention. STOP HIV was developed in collaboration with The University of Kentucky HealthCare (UKHC) CECentral, University of Kentucky Postgraduate Institute for Medicine (PIM), DKBmed, RealCME, AIDS Volunteers, Inc., and 16 community clinics in the Family Health Center and Health First networks, and it was implemented in 16 clinics in the greater Lexington area and southern and eastern counties of Kentucky in July 2020.
STOP HIV included a multifaceted approach to improve clinical practice consisting of education for clinicians and social workers about HIV screening, preventive medications and treatments. In addition, it included the development of treatment and referral services for patients who tested positive for HIV and recommendations for the use of pre-exposure prophylactic (PrEP) to prevent HIV infection. The program also included measurement of HIV screening rates before and after the educational initiative.
Methodology
The educational activity deployed a “backwards design,” in which the program results and outcomes methodology were determined prior to activity development. As identified gaps were found at the levels of performance, knowledge and awareness; project implementers selected outcomes measurement techniques to assess changes in each of those domains. To better understand performance outcomes, intermediate measures for performance improvement were included in analysis of the gap including knowledge, educational engagement and self-efficacy. Patient-level electronic health record (EHR) data was used to measure both clinical adherence to best practices and patient outcomes before and after the education. The education consisted of a two 30-minute on-demand modules that clinicians were encouraged to complete.
Key Themes and Outcomes
Overall, 1,080 learners participated in the education. Results from pre- and post-learning assessments indicate that healthcare provider knowledge improved greatly after the education in the following areas: (1) assessing barriers associated with HIV prevention methods, including safer sex practices and PrEP, increased by 221%; (2) effective screening strategies for populations at high risk for HIV infection improved by 42%; (3) discussing interventions that could prevent HIV transmission, such as safer needle use, increased by 20%; (4) considerations related to starting PrEP, including laboratory tests, increased by 20%; (5) identifying barriers for initiating HIV prevention methods for persons who inject drugs (PWID) and discussing preventive interventions, such as syringe exchange programs, increased by 5%.
EHR data from participating clinics showed an overall improvement in HIV screening of 22%. The clinic with the greatest improvement saw an 178% increase in screening. Educational engagement was directly linked with the magnitude of improvement in screening rates. Clinics with the lowest screening rates at the start of the program also engaged more with the education, leading to the highest increases. This suggests that the clinics in most need also benefitted the most from the STOP HIV program.
Improvements were seen in all age categories except for in patients over 85 years of age. The greatest increase in screening, 51%, was observed in the 13–18-year age category. Improvements were also made across patient race categories, with the strongest improvements seen in Black/African American (26%, p<0.05) and white population (23%, p<0.05). Other races represented much smaller parts of the patient population, and corresponding improvements, while notable, were not statistically significant. When stratified by insurance types, patients with Medicaid saw the largest increase (44%), followed by those with Medicare (39%) and private insurance (24%). However, screening declined among patients without insurance.
Discussion
The implementation of this project led to increased HIV screenings, potentially reducing onward transmission of HIV attributed to undiagnosed HIV. Improvements were correlated with participation in the educational intervention. Kentucky, having seven of the top 10 highest risk areas for HIV transmission, greatly benefited from this initiative.
The strong increase in screening rates for teen, Black and Medicaid populations is particularly significant because those groups are at high risk for HIV. Young Black men aged 13–24 years are at the highest risk of acquiring HIV compared with people from other races and age groups. The largest group of people with undiagnosed HIV are the youth and young adult population, with 51% unaware of their infection status. Nearly half (43%) of all sexually active high school students and 49% of male students who had sexual contact with other males did not use a condom the last time they had sexual intercourse, demonstrating high-risk behaviors among this age demographic. In 2018, 21% of new HIV diagnoses in Kentucky were in youth aged 13–24 years.
Additionally, Black men who have sex with men (MSM) are at a particularly high risk for contracting HIV compared with their white counterparts. Black MSM account for 38% of new infections on a national scale and 22% of new infections in Kentucky.
While socioeconomic status was not directly measured, insurance provider was used as a proxy for socioeconomic status. The marked improvement for patients with Medicaid is important because about 48% of people with HIV have Medicaid/Medicare as compared to 33% of the general population.
Limitations
STOP HIV proved to be a successful program; however, many lessons were learned along the way. STOP HIV was strongly impacted and delayed by the COVID-19 pandemic. However, the online, on-demand design of the education made it accessible throughout the pandemic. The pandemic also impacted provider engagement with the educational material, which proved to be variable. However, this allowed the research team to directly link educational engagement with screening improvement outcomes.
Conclusions
Despite challenges presented by COVID-19, HIV screening improved by 22% after the intervention. The relationship between this improved clinical performance and participation in the education further supports the assertion that well-designed education improves clinical performance and outcomes.
Funding
Financial support was provided by Gilead Sciences, Inc., in the form of an educational grant.