The Problem
In spite of all that is known about effective HIV care, recent studies have documented significant deficits in the quality of care in a substantial proportion of HIV-infected persons. [1,2,3] Under-use of needed medications occurs when patients have difficulty obtaining or attending appointments, or problems with obtaining prescriptions or drugs from appropriate HIV health professionals. Even when medications are provided, underutilization may occur when inadequate education and support are provided to people with HIV. [4] Considering the challenges of their infection, coupled with the psychosocial problems of many people confronting HIV infection, there is much difficulty adhering to complex medication and treatment regimes. [5] Marked reductions in HIV morbidity and mortality have been reported in recent years in spite of these limitations [6,7], yet there are inequities in the distribution of these gains. [1,2]

Current health care systems are not always designed to deliver the most efficient, comprehensive care for the estimated 850,000-950,000 people infected with HIV and approximately 40,000 individuals newly diagnosed with AIDS in the US this year. [8] Assuring that the daily practice of medicine meets the latest standards of medical care is a complex process. Providers must not only be made aware of the most current science but also become skilled in providing access and promoting health to vulnerable subpopulations. HIV medicine has become increasingly complex; the latest iteration of the Department of Health and Human Services (DHHS) HIV Guidelines for the Use of Antiretroviral Therapy is over 100 pages long. [9] The service delivery system must be designed so that the most effective care is also easier to deliver.

Models of outstanding care for people with HIV/AIDS are available in both community and academic medical settings, and yet the approach to care that produces the best possible quality of life and health outcomes is not widely used in the United States.

Support for Improvement

The Health Resources and Services Administration’s (HRSA) Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, enacted in 1990 and reauthorized and amended in 1996 and 2000, provides funding to cities, states, and other public and private entities to provide care and support services to address the unmet need of those living with HIV/AIDS. [10] A major focus of the CARE Act is to improve the quality of care that its clients receive. New and significant legislative requirements found in the Ryan White Reauthorization of 2000 direct grantees to develop, implement, and monitor quality management programs to assess and ensure consistency with the DHHS HIV Guidelines.

Several years after the Reauthorization, CARE Act grantees continue to face the challenge of developing and implementing quality improvement programs. They are in need of resources, materials and consultation to help them establish quality improvement programs which are linked to improved health outcomes. [11]

Sample Results

Many HIV/AIDS facilities have successfully embraced quality improvement models and documented quality improvement in their work. The graphs below showcase successful improvement in the areas of patient retention and access to services as well as patient self-management. More success stories can be found in the Improvement Stories section of this website.

Access
Regular clinic visits are essential to manage medications, focus on health promotion, and are associated with good adherence to antiretroviral therapy.

AID Atlanta, Inc. (Atlanta, Georgia, USA) and Grady Health System Infectious Disease Clinic (Atlanta, Georgia, USA) increased the number of patients with at least one primary care visit in the last 3 months by 15 to 20 percent over 6 months.

AID Atlanta, Inc.
Access and Retention
 

Grady Health System Infectious Disease Clinic
Retention

Self-Management
Self-management is defined as participation by the patient in establishing goals for treatment and monitoring their own care which would then contribute to greater emotional well-being and likely achieve better health outcomes.

AID Atlanta, Inc. (Atlanta, Georgia, USA) and Grady Health System Infectious Disease Clinic (Atlanta, Georgia, USA) increased the number of patients with documented self-management goals within the last 6 months. 

AID Atlanta, Inc.
Self-Management

Grady Health System Infectious Disease Clinic
Self-Management

 Sources:

1. Shapiro M, Morton SC, McCaffrey DF, et al. Variations in the care of HIV-infected adults in the United States: Results from the HIV Cost and Services Utilization Study. Journal of the American Medical Association. 1999;281(24):2305–2315.
2. Bozzette S, Shapiro M, Wu X, et al. The care of HIV-infected adults in the United States: HIV Cost and Services Utilization Study Consortium. New England Journal of Medicine. 1998;331:313-320.
3. Kaplan JE, Parham DL, Soto-Torres L, et al. Adherence to guidelines for antiretroviral therapy and for preventing opportunistic infection in HIV-infected adults and adolescents. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. 1999;21:228-235.
4. Strathdee SA, Palepa A, Cornelisse PG, et al. Barriers to the use of free antiretroviral therapy in injection drug users. Journal of the American Medical Association. 1998;280(6):547-549.
5. Sherer R. Adherence and antiretroviral therapy in injection drug users. Journal of the American Medical Association. 1998;280:567-568.
6. Whitman S, Murphy J, Cohen M, et al. Marked declines in human immunodeficiency virus-related mortality in Chicago in women, African Americans, Hispanics, young adults, and injection drug users, from 1995 through 1997. Archives of Internal Medicine. 2000;160:363-369.
7. Pallela FJ, Delaney KM, Moorman AC, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. New England Journal of Medicine. 1998;338:853-860.
8. Centers for Disease Control and Prevention Divisions of HIV/AIDS Prevention. Basic Statistics.
9. Department of Health and Human Services. Guidelines for the use of antiretroviral therapy in HIV-infected adults and adolescents. Annals of Internal Medicine. 1998;128:1079-1100.
10. Health Resources and Services Administration, HIV/AIDS Bureau (http://www.hab.hrsa.gov/history/purpose.htm)
11. Institute of Medicine. Measuring What Matters: Allocation, Planning and Quality Assessment for the Ryan White CARE Act. Washington, DC: National Academies Press; 2004.