September 28, 2012
Comprehensive Care, Ryan White Funding, Means Survival Benefits at Inner-City Clinic
by Tim Horn
At an inner-city Baltimore HIV clinic serving a primarily poor and black population, the average life expectancy is now 73 years, according to a new 15-year analysis of patient outcomes reported by Johns Hopkins University researchers in Clinical Infectious Diseases. Importantly, long-term survival at the clinic was highly dependent on comprehensive disease management—a mix of primary, specialty and supportive health care services—underscoring the importance of funding streams like Ryan White to provide vital resources.
“We believe that our results reflect what is possible when HIV care is delivered based on state-of-the-art care guidelines with support from the Ryan White HIV/AIDS Program to address the challenge to deliver treatment that is highly effective, but also expensive, complex, and requires continuous patient engagement by populations that are often underserved by healthcare disparities,” Richard Moore, MD, and his colleagues write.
The study, which analyzed data from the Johns Hopkins HIV Clinical Cohort collected between 1995 and 2010, is the first to directly compare outcomes for patient groups affected most by health care disparities.
The Johns Hopkins-run clinic relies on a model that involves multiple levels of care. First is primary care, in which people living with HIV receive all of the necessary laboratory evaluations and treatment needed to manage HIV infection. The clinic also provides specialty care, such as substance abuse and mental health treatment and counseling. Finally the clinic offers a variety of supportive care services, such as case management, nutrition, treatment adherence counseling, emergency services and transportation.
“One reason for our ability to deliver HIV care to patients who might otherwise have financial and other barriers to care is the Ryan White HIV/AIDS program,” Moore and his colleagues write. Created in 1990, this program provides the clinic with financial assistance to offer care to low-income people living with HIV, who in 2010 made up 92 percent of the clinic’s patient population.
As a result of the “integrated multi-disciplinary program of care” the clinic was able to offer, and because of advances in antiretroviral therapy, HIV-positive people at the clinic can expect to live into their seventies. “In 2009 a 28-year-old HIV-infected person was estimated to have 45.4 years of life remaining,” Moore and his colleagues determined.
This dramatic life expectancy remained the same across all demographic and behavioral risk groups. Even adjustments made for patients’ source of medical insurance did not affect the outcomes.
There is one important caveat, the Johns Hopkins team notes. The study’s results include only those patients who were sufficiently engaged in care—those who showed up for lab testing and clinical follow-ups. They suggest that much more needs to be done to test people living with HIV and to successfully enter and retain them in clinical care.
“We believe that our results reflect an effective model of care, and should continue in the United States if individuals with HIV infection are to have the maximal benefit,” Moore and his colleagues wrote.
“The lesson learned from the remarkable outcomes within the HIV clinic at Johns Hopkins and other Ryan White-supported clinics in the U.S. is that supplemental funding for primary care is needed to overcome health disparities widely evident in our current system,” explained Michael Saag, MD, of the University of Alabama at Birmingham in an accompanying editorial.
The Ryan White CARE Act, which is up for reauthorization by the U.S. Congress in 2013, is considered by advocates to be an essential source of funding to reinforce primary care services for people living with HIV. They note that adequate Ryan White funding will still be necessary once the Affordable Care Act goes into full effect in 2014.
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