CATIE News

11 April 2019 

Some medically complex HIV-positive patients are not resuming HIV treatment after a hospital stay

  • Researchers studied health data of patients discharged from a Toronto HIV hospital
  • 90% of discharged patients did not fill their HIV prescriptions in a timely manner
  • Prescriptions to treat other conditions unrelated to HIV were more likely to be filled

Some people with chronic health conditions, particularly those with multiple diagnoses in the context of underlying HIV infection, may require hospitalization from time to time. Prior to leaving a hospital, doctors, nurses and social workers engage in what is called “discharge planning”—helping a person transition from hospital-based care to care in the community. This can involve helping people to (re)connect to specialists, such as those in family medicine as well as nurses, pharmacists and social services. It can also involve providing prescriptions for a small supply of medicines until connections are made with a doctor outside of the hospital.

The small supply of prescription medicines, particularly those used for HIV treatment (ART), helps to keep the amount of HIV in the blood (the viral load) to very low levels (commonly called “undetectable”). Achieving and maintaining an undetectable viral load is important for keeping the immune system healthy. Also, clinical trials have found that people who achieve and maintain an undetectable viral load do not pass on HIV to their sexual partners. However, if after hospital discharge some people are unable to maintain a suppressed viral load, these benefits of ART can be lost.

A study in Toronto

Researchers in Toronto have conducted a study with a group of 206 HIV-positive people who sought care at a 14-bed downtown hospital called Casey House. According to the researchers, Casey House is “a community-based hospital providing inpatient and outpatient services to medically complex and socially vulnerable people with HIV, including those with a history of mental illness, unstable housing and substance use disorder.” Casey House has won awards for the care and services provided by its dedicated staff and volunteers to people with HIV.

The researchers found that nearly 90% of people discharged from Casey House did not fill their prescription for ART in a timely manner—within a week after leaving the hospital. The researchers noted it is unlikely that this was because these patients kept a supply of ART at home. To help improve the health of discharged patients, the researchers made several very useful recommendations in a report published in the journal Open Forum Infectious Diseases.

Inside Casey House

The researchers accessed several administrative databases to find health-related information for their study. They did not have access to results of lab tests, including CD4+ cell counts and viral load. They focused their work on the period between April 2009 and March 2015.

According to the researchers, the typical patient inside Casey House has the following:

  • mental health condition(s) – 90%
  • problems with memory and thinking clearly – 50%
  • unstable housing – 20%

The researchers stated that there are “approximately 100 admissions per year” for the following reasons:

  • help to suppress serious infections
  • respite care
  • controlling symptoms  
  • palliative care

The researchers stated that at Casey House “care is delivered by a multidisciplinary team, including physicians, nurses and social workers, and emphasizes attention to social determinants of health. Discharge planning includes the provision of prescriptions for ART and a follow-up appointment with a family physician or HIV physician within seven days of discharge.”

To assess whether this level of discharge planning helped to support continued HIV care, researchers at St. Michael’s Hospital, Casey House, McMaster University and the Institute for Clinical Evaluative Sciences (ICES) collaborated on a study.

Study details

Researchers focused on 206 patients who had been admitted to Casey House and who did not fill their ART prescriptions within seven days after being discharged. The researchers chose a period of seven days because upon discharge patients are given a two-day supply of ART and prescriptions for ART as part of routine discharge planning. They noted that failure to fill these prescriptions within seven days of leaving the hospital risks an interruption of treatment.

Researchers also used data from the average HIV-positive person living in Ontario to make comparisons with the people discharged from Casey House.

Results

Upon comparing patients in Casey House with the average HIV-positive person living in Ontario, the researchers found that patients at Casey House were more likely to have the following:

  • a low income and therefore be on social assistance
  • a greater burden of co-existing health conditions

For the first seven days after leaving Casey House, patients were given prescriptions for medicines doctors knew that they needed. According to the researchers, these medicines were filled by almost 70% of patients within seven days of discharge and were mostly as follows:

  • continued treatment for infections other than HIV
  • symptom management
  • pain control
  • treatment of mental health conditions

The researchers noted that prescriptions for some categories of medicines were filled to a greater extent than those for ART:

  • ART – 11%
  • antipsychotics – 15%
  • antidepressants – 26%

Analysis found no impact of age, gender or the number of comorbidities that a person had on whether or not they filled a prescription for ART.

After excluding people who died within 30 days of leaving Casey House, researchers found that about 76% of patients eventually connected with a family physician or HIV specialist within 30 days of discharge. There was no connection between a person’s age, gender or the number of comorbidities they had and their ability to connect to a family doctor or HIV specialist after discharge.

Could there be ART at home?

The researchers noted the argument that it is possible that some patients might have had a supply of ART at home prior to hospitalization and so did not need to fill a prescription after discharge. Against this possibility, they stated that it is unlikely that nearly 90% of patients did not fill an ART prescription seven days after discharge due to a pre-existing supply.

Furthermore, the researchers already mentioned that patients left the hospital with prescriptions for many medicines. It is at least plausible some patients had their ART changed during their hospital stay to avoid interactions with the many non-HIV medicines that were subsequently needed. In such cases, pre-hospital ART kept at home would not have been helpful, as it would have likely interacted with some of the non-HIV-related medicines that were prescribed during and after the hospital stay.

The researchers speculated that based on the categories of prescriptions that were filled patients likely prioritized filling prescriptions for “mental health conditions and symptom management” in the first seven days after leaving the hospital.

What to do?

The researchers stated that patients in the study were “provided with multidisciplinary HIV specialty care during their entire admission that emphasizes addressing social determinants of linkage to care, such as housing instability and substance use. We expected that this would have enhanced patients’ transition [to care in the community after hospital care].”

The researchers stated that the population in the study is “highly marginalized” and may find accessing care outside of the hospital “especially challenging.”

The researchers suggested the following “additional interventions” to help this population after hospital discharge:

  • peer navigators
  • ensuring basic needs such as food security are addressed at the time of discharge
  • supervised medication support

For the future

The report from Casey House is a good first step for helping people who grapple with the burden of multiple diagnoses, particularly mental health ones, and underlying HIV infection after they leave the hospital. Additional research is needed, including interviews with patients, to better understand how to help them overcome barriers to care.

—Sean R. Hosein

REFERENCE:

Antoniou T, Graves E, Plumptre L, et al. Antiretroviral prescription pick-up and physician follow-up after hospital discharge among medically complex people with HIV. Open Forum Infectious Diseases. 2019 Jan 19;6(2):ofz009.