CMPH Journal

COV Period Encounters

During the COV period, 606 unduplicated pts had at least one physician encounters, of these 304 (50.2%) were TELE encounters, 89 (14.7%) IN-P, and 213 (35%) had a combination of both TELE and IN-P; 127 (21%) pts had a single encounter, 178 (29%) had 2 encounters, 200 (33%) had 3 encounters, 95(16%) had 4 encounters and 6 (1%) had 5 encounters. Median number of encounters was 2. Twenty-five clinic pts who missed appointments and were not seen during the pre-COV period had an encounter during the COV period. During COV 52(8.6%) new patients entered care compared to 36(7%) in the pre-COV (p=0.26).

Pre- COV period: CD4 and HIV Viral Loads

During the pre-COV period, 373/ 530 (70.3%) pts had their CD4 count and HIV VL measured at first and last encounter; median CD4 value at the first visit was 623µL (Range 5-2105) and 662µL (Range 8-2438) at the last visit. CD4 >200/µL at first visit was seen in 353/373(95%) and in 352/373 (94.3%) at the last encounter (p=.87).

HIV VL was undetectable in 330/373 (88.5%) at the first encounter and in 337/373(90.3%) at last encounter. (p=0.41) (Table 3a).

Table 3a: CD 4 and HIV VL at first and last visits: Pre-COV period.

COV Period: CD4 and HIV Viral Loads

During COV period, 445/606 (73.4%) pts had CD4 measured at first and last encounters, median CD4 at the first encounter was 617µL (Range 3-2486) and 627µL (Range 412-850) at the last encounter. CD4 count ≥ 200/µL at first encounter was seen in 402 (90.3%) and in 419(94.2%) at the last visit had (p=0.03); HIV Viral load was measured at first and last encounters in 448/606(73.9%) pts. HIV VL was undetectable in 389(87%) at the first visit and in 417 (93%) at the last visit (p=0.002) (Table 3b).

Table 3b: CD4 and HIV VL at first and last encounters: COV period.

During COV there were less changes to ART regimens compared to pre-COV 116 (19%) compared to 153(29%)] (p=0 .32). Significantly higher percentage of pts had CD4 >200μL during the first visit in pre-COV period compared to COV [353/373 (95%) vs. 402/445 (90.3%), p=0.02]. However, no statistical difference was noted by last visit (352/373 (94.3 %), 419/445 (94.2%), p=0.89). There was no significant difference in percent of patients with undetectable HIV VL in the first visit [330/373 (88. 5%) vs. 389/448(87%), p=0.47] or during the last visit [337/373 (90.3%) vs. 417/448(93%) p=0.15] between Pre-COV and COV (Table 4).

Table 4: Comparing Pre-COV and COV: CD4, HIV VL and ARV regimen changes.

Discussion

Despite changes in the delivery of care from exclusively IN-P to mainly TELE, our study found that more pts received care during COV compared to the pre-COV period. More new pts entered care in the COV period compared to the pre-COV; improvement in CD4 counts and VL suppression rates were significantly higher when measured at first and last encounters in the COV period. There were no significant differences in the percent of patients with CD4 counts >200µl or viral load suppression in first and last encounters during the two study periods. The study found that during COV there were less changes to ART regimens compared to the pre-COV period.

The COVID-19 pandemic has interrupted the delivery of care and forced clinics to shift to TELE in order to continue to provide care, to PLWH. Experience of HIV care with TELE has been described in a number of studies prior to the COVID-19 pandemic. In a study by OHL, et al. at the VA system, participants in TELE needed to travel to a clinic in order to connect with their health care provider for a TELE encounter [3]. These pts reported a high rate of satisfaction, a decrease in travel time to care but there was no difference in retention in care or viral suppression compared those who did not participate in TELE. The same investigators reported on a larger study and found that only 120/1670 (13%) elected to participate in TELE; Participants had a higher number of visits and more frequent viral load testing but there was no improvement in HIV suppression when compared to non-participants [4].

In a study of HIV care in a correctional institution using TELE [5] pts who participated in the TELE group had greater virological suppression and higher CD4 counts.

Experience in transition to TELE during the COVID-19 pandemic is starting to emerge, Fadul [6] reported that adoption of TELE utilizing phone communication in the early months of the pandemic, resulted in a reduction in the number of visits frequency but a maintenance of viral load suppression. Mayer, et al. reported that in the first 2 months of the pandemic, visit frequency and viral load suppression were not interrupted after transitioning to either phone or video encounters [7].

Spinelli, et al. evaluated viral suppression after implementing TELE in a clinic in San Francisco, the authors described a significant reduction in viral suppression rates of 31% when compared to the pre COVID- 19 pandemic [8]. The authors stated that despite access to TELE, the patients had reduced access to social support services likely affecting care. Homelessness in this study was 16% and was associated with non-viral suppression. Our study in comparison, has found that more pts were seen during COV compared to pre-COV; HIV viral load suppression rates were higher during the COV period between first and last encounters. When comparing first and last visit measurement between the two periods, there was no statistical difference, a fact that supports the notion that TELE can provide effective way to maintain good clinical outcomes to PLWH.

The study by Spinelli [8] and Mayer [7] had a much shorter follow up periods compared to our study, which had a one year follow up in each period.

Sorbera, et al. compared HIV pts’ viral load suppression in a clinic transitioning to TELE between two periods, pre-COV and post-COV [9]. They found that in their 211 pts there was no significant difference in viral load suppression rates, but the percent of patients with CD4 cell counts >200 µl were higher in the pre-COV compared to the post COV period. In comparison, our study showed no difference in either the percent of pts with CD4 counts >200 µL or those with viral load suppression between the two periods.

TELE has some limitations; pts may feel uncomfortable talking about their medical conditions / medications over the telephone, pts may have accessibility issues, and there may be language and communication barriers. Some studies found different uptake rates in different patient populations. Data on TELE uptake using phone from Cardiology and Gastroenterology clinics showed that population similar to ours: minority groups, relatively older and female gender were likely to use TELE via phone as was found in our study [10,11].

A cross sectional study in Italy using self-report questionnaire 80 PLWH and 60 doctors noted that 88% of the physicians and 40% of PLWH did not want to substitute IN-P with TELE [12]. Another study noted that most patients were satisfied in general with TELE but some pts mostly women had some concerns about lack of physical exam and worried about safety of personal information [13].

Wood, et al. found that older age, people of color and patients on Medicaid coverage tended to use less TEE services [14]. Amatavete, et al noted retention rates of 98% at 3 months and 98.4% at 6 months with the use of TELE during COVID in PLWH [15]. Our study followed pts for a year and noted that after implementation of TELE during COV, more r new pts were accepted to the clinic (8.6% vs. 7%) and more pts had HIV VL suppression at the end of one year supporting the notion that TELE is an effective platform for the delivery of care and can supplement IN-P care.

Our study has a few limitations; it is a single center observational study, the study took place in an inner city hospital and therefore results may not be generalized. The study was retrospective and therefore all limitations of a retrospective analysis apply. The study used only telephone encounters, and therefore we may have missed some pts who did not have means to communicate or that would have preferred to use another communication platform.

Some of the strengths of our study were the relatively long follow up periods of one year in each of study periods. The fact that viral load and CD4 counts were tabulated at first and last encounters allowed a better analysis of patients’ progression and effectiveness of TELE. Our study also recorded the number of new patients enrolled between the two periods a fact that allows a better perspective of TELE as a platform for the delivery of care for PLWH.

Conclusions

In our clinic, TELE was an effective tool to care for PLWH; this was evidenced by maintenance of high CD4 counts and virological suppression. In the face of a changing world of health care TELE seems to be an important tool in the care of PLWH.

Acknowledgement: Donna George for providing the data.

Author Contributions

Sandhya Nagarakanti (SN) wrote the manuscript, Eliahu Bishburg (EB) and Kristen Ehlers (KE) edited the manuscript. All authors reviewed the manuscript.

Data availability Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

1. HR 6074- Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020.
2. CMS (2022) COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers.
3. Ohl M, Dillon D, Moeckli J, Ono S, Waterbury N, et al. (2013) Mixedmethods evaluation of a telehealth collaborative care program for persons with HIV infection in a rural setting. J Gen Intern Med 28: 1165-1173.
4. Ohl ME, Richardson K, Rodriguez-Barradas MC, Bedimo R, Marconi V, et al. (2019) Impact of availability of telehealth programs on documented HIV viral suppression: a cluster randomized program evaluation in the Veterans Health Administration. Open Forum Infect Dis 6: ofz206.
5. Young JD, Patel M, Badowski M, Mackesy-Amiti ME, Vaughn P, et al. (2014) Improved virologic suppression with HIV subspecialty care in a large prison system using telemedicine: an observational study with historical controls. Clin Infect Dis 59: 123-126.
6. Fadul N (2020) A quality management project of a Midwestern academic HIV clinic operating during COVID-19: Implementation strategy and preliminary outcomes. Open Forum Infect Dis 7: S184-S185.
7. Mayer KH, Levine K, Grasso C, Multani A, Gonzalez A, et al. (2020) Rapid migration to telemedicine in a Boston community health center is associated with maintenance of effective engagement in HIV care. Open Forum Infect Dis 7: S337 -S338.
8. Spinelli MA, Hickey MD, Glidden DV, Nguyen JQ, Oskarsson, et al. (2020) Viral suppression rates in a safety net HIV clinic in San- Francisco destabilized during COVID-19. AIDS 34: 2328-2331.
9. Sorbera M, Fischetti B, Khaimova R, Niewinski M, Wen K (2021) Evaluation of virologic suppression ratesduring the COVID-19 pandemic with interdisciplinary HIV care. J Am Coll Clin Pharm 4: 964968.
10. Eberly LA, Khatana SAM, Nathan AS, Snider C, Julien HM, et al. (2020) Telemedicine outpatient cardiovascular care during the COVID-19 pandemic bridging or opening the digital divide? Circulation 142: 510-512.
11. Serper M, Nunes F, Ahmad N, Roberts  D, Metz DC, et al. (2020) Positive early patient and clinician experience with telemedicine in an academic gastroenterology practice  during the COVID-19 pandemic. Gastroenterology 159: 1589-1591.e4.
12. Massaroni V, Delle Donne V, Ciccarelli N, Ciccullo A, Borghetti A, et al. (2021) Use of telehealth for HIV care in Italy: Are doctors and patients on the same page? A cross-sectional study. Int J Med Inform 156: 104616.
13. Galaviz KI, Shah S, Gutierrez M, Collins LF, Lahiri C, et al. (2021) Patient Experiences with Telemedicine for HIV Care during the first COVID-19 Wave in Atlanta, Georgia. AIDS Res Hum Retroviruses 38: 415-420.
14. Wood BR, Lan KF, Tao Y, Mose EY, Aas E, et al. (2021) Visit Trends and Factors Associated With Telemedicine Uptake Among Persons With HIV During the COVID-19 Pandemic. Open Forum Infect Dis 8: ofab480.
15. Amatavete S, Lujintanon S, Teeratakulpisarn N, Thitipatarakorn S, Seekaew P, et al. (2021) Evaluation of the integration of telehealth into the same-day antiretroviral therapy initiation service in Bangkok, Thailand in response to COVID-19: a mixed-method analysis of realworld data. J Int AIDS Soc 24: e25816.