Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

12th World AIDS Conference

Abstracts 42415-42419 857

for DMAS, MCO's and providers. The implement/ation phase will 1) address risk
adjusted capitation rates and risk sharing, 2) identify carveouts, 3) improve care
coordination and effective use of resources, 4) address contract issues.
Lessons Learned: Few states have addressed Medicaid managed care for
HIV through a statewide system. In Va, there is now a planning process to provide
quality, coordinated HIV care through Centers of Excellence to persons receiving
Medicaid. The process must include providers, consumers, and MCO's, in partnership with the Medicaid agency to be effective. Evaluating what other states
have accomplished can save time, energy and prevent policy and implementation
errors. The process is a lengthy one.
42415 Responding to advances in HIV treatment: Planned
changes in primary health care by Ryan White CARE Act
Title I eligible metropolitan areas
Joseph O'Neill', J. Gelfand2, C. Scott1, K. Marconi1, A. Eichler'. 'US Public
Health Services/HRSA/HIV/AIDS, 5600 Fishers Lane, RM 7-055 Rockville,
Maryland 20857; 2lndepenpent Contractor, USA
Issue: Advances in HIV treatment have created the need for Ryan White Comprehensive AIDS Resources Emergency (CARE) Act grantees to reassess and
evaluate the primary care delivery system in their regions.
Project: A review of the Eligible Metropolitan Area's (EMA) 1998 grant application for Title I CARE act funds to examine their responses to advances in HIV
treatment.
Results: For Title I CARE Act grantees, 1998 is a transitional year of planning and reassessment of consumer needs resulting from new treatments. The
majority of EMAs are refocusing priorities on primary care and medications and
are shifting resources towards this goal. In addition, EMAs have recognized that
support services such as housing and transportation are critical due to the longer
life expectancy of people living with HIV. Coordination of services to create a
comprehensive health care delivery system is a theme throughout the 1998 grant
applications. EMAs with the strongest linkages to State AIDS Drug Assistance
Programs ensure optimum access to the most up-to-date drug combination therapies. Many grantees recognized the need for standards of care, which include
increasing provider knowledge. EMAs are also hiring treatment educators to
provide patients with individualized assistance in developing and maintaining adherence plans. EMAs able to quantify the unmet health care needs in their regions
report that 40-50% of the populations estimated to be infected with HIV are not
currently in the health care delivery system. There is a great deal of concern
that increased demands on the delivery system, due to a drop in HIV-associated
deaths and advances in HIV treatment, will result in overwhelming the system
and an inability to meet demands.
Lessons Learned: States receiving funds from the Ryan White CARE Act
in 1998 are reassessing the service delivery system in their regions to respond
effectively to advances in HIV treatment. EMAs recognize that more comprehensive quantitative needs assessment based on HIV diagnosis and service needs
are required for future service planning.
42416 Provider practice patterns: A 9-year retrospective
evaluation of HIV/AIDS clinical training
Jerry Gates1, S. Radecki', J. Nyquist2. 'Pacific AIDS Ed. and Training Center
1420 San Pablo St., PM B-B 2 05, L.A. CA2USC School of Medicine Los
Angeles, CA, USA
Objectives: We established an intensive week-long HIV/AIDS clinical training for
primary care providers 9 years ago to increase the number of providers delivering
HIV care. Can brief clinical training increase the number of providers treating
HIV/AIDS patients? What level of care is provided in subquent practice? Do
recently-trained providers deliver the same levels of care as those trained earlier?
Do providers not seeing HIV patients still screen for exposure to the HIV virus?
Design: A pre-post quasi-experimental design with self-reported retrospective
assessments.
Methods: Pre-training practice pattern data was obtained from application
forms. In 1997 all 463 trainees covering the years 1988-96 were surveyed. Excluding those who were deceased, no longer practicing, or who could not be
located despite extensive efforts, there were 156 respondents. Based upon pretraining data collected over the years it was possible to explore changes in levels
of HIV care and other practice profiles. Respondents assessed their training from
a perspective of 1 to 9 years.
Results: Of the 156 former trainees who were located, 72% report they routinely
screen patients' for risk status and 52% report they currently manage HIV/AIDS
patients. Further, 28% report caring for asymptomatic patients, 19% symptomatic
HIV patients, and 26% AIDS patients. Over 16% report having patients on AZT,
13% on protease inhibitor/combination therapies, and 4% on experimental protocols. In rating their confidence in providing HIV care after as compared to before
training, 73% indicated they were more confident, 10% report no change, and
17% indicated they were less confident.
Conclusions: Our week-long clinical training program is used as model for

training sponsored by the US Government and currently enrolls providers from
Asia. This evaluation shows that this type of training can have a lasting impact
on the practice patterns of primary care providers caring for persons living with
HIV/AIDS. Most primary care providers prevent the spread of HIV through screening, and over half are actively caring for HIV/AIDS patients even in light of the
complex new therapies.

42417 HIV and managed care: Cost-effectiveness of an
interdisciplinary disease management team
Terry Winter, C.T. Le, K. Boyd, L. Ackerson. Kaiser Permanente HIV Services
401 Bicentennial Way Santa Rosa, CA 95403, USA
Objective: To evaluate the function and effectiveness of an interdisciplinary disease management team for the management of HIV infection in a managed care
setting.
Design: Retrospective, controlled study.
Methods: A multidisciplinary team was created in 1992 to manage HIV positive
patients following a clinical care path. The study site is the Santa Rosa, California
(SRO), USA medical center of Kaiser Permanente, a staff-based health maintenance organization. The eighteen other medical centers of Kaiser Permanente
in Northern California (KP-other) served as the control group. Calculations were
made for utilization of medical and paramedical services in a outpatient setting;
hospital utilization; cost of drugs for HIV-related conditions
Results: In 1994, 230 and 4766 HIV positive health plan members received
care at SRO and at other KP-other, respectively. The % of patients with AIDS and
various stages of HIV infection by CD4 counts were similar. SRO patients had
72% more visits with nurse practitioners and 1230% more visits with nutritionists,
with 8% fewer visits with primary care physicians. Social workers at SRO had
visits with a much larger number of patients then KP-other. There was a trend for
8% less utilization of the emergency and 11% less for psychiatry at Santa Rosa.
The average number of days of hospitalization for AIDS patients dramatically
decreased in Santa Rosa from 7.8 days in 1991 to 2.01 days in 1994. Hospitalization was 33% less for AIDS patients at SRO and 65% less for those with HIV,
non-AIDS, in 1994. Average HIV-related drug costs (pre-protease inhibitor) at
SRO were 28% lower. Analysis of programs such as baseline patient evaluation,
routine prenatal HIV screen and hospice utilization, incidence of Pneumocystis
carinii pneumonia, and a patient satisfaction survey showed favorable marks for
SRO.
Conclusion: Managed care by a dedicated interdisciplinary team following a
clinical care path can significantly and favorably effect resource utilization as well
as quality of care.
42418 Immunisation against hepatitis B in HIV positive patients
Dorota Latarska', J. Higersberger2, H. Paprocka2, A. Ignatowska3,
E. Burkacka3, A. Horban3. Wolska St 37 01-201 Warszawa; 2Infectious
Deseases Hospital Warszawa; 3AIDS Diagnosis & Therapy Center Warszawa,
Poland
Background: The aim of the study is to define the efficacy and safety of vaccination against hepatitis B infection in HIV(+) patients (pts).
Methods: During years 1996-97 91 HIV positive, anti-HBc negative pts
(male-68, female-23, mean age 36.4 years) were vaccinated with 20 ug of
Engerix-B (Smith Kline Beecham) vaccine according to 0-1-6 months schedule.
The anti-HBs (Hepanostika anti-HBs, Organon Teknika) response was tested 2-4
months after the last dose of vaccine.
Results: As to December 1997 52 pts completed vaccination, 43 pts were
tested for anti-HBs titre. Pts were divided into 3 groups according to anti-HBs
titre: (i) non-responders - below 10 IU/L, responders: (ii) 10-100 IU/L, (x58.4 ~
35.5 IU/L) and (iii) >100 IU/L - very good responders. Statistical analysis done
using chi2 test.
Table: Relationship between CD4(+) level and vaccination results.

anti-HBs (IU/L)
-10 10-100
20 (46.5%) 13(30.2%)
282 ~ 211 401.1 + 3866

Number of pts (%)
x CD4(+) ~ SD cells/mL

- 100
10(23.3%)
469 ~ 199.2

chi2 (i) vs (ii) - SD; chi2 (ii) vs (iii) - NSD
Conclusions: In a group of non-responders mean CD4(+) cell count was significantly lower than in responders. Our results suggest that vaccination against
HBV infection should be done as early as possible in eligible HIV(+) patients.
42419 Computerization facilitates clinical decision making by
integrating medication profiles, adherence, and
surrogate markers in real time
Mark J. Shelton, L. Esch, S. Cousins, G.D. Morse, C. Steinwandel, R.G. Hewitt.
Sunny Buffalo, 462 Grider St Buffalo, New York 14215-3021, USA
Issue: The efficiency of monitoring virologic response to antiretroviral therapy
may be improved by computerization of antiretroviral history (use, adherence,
and tolerance) and surrogate markers.
Project: A computerized data base was designed and implemented in an
urban HIV clinic serving 700 patients. Prior to start-up, patient medical records
were manually reviewed to collect demographics and antiretroviral histories. A
structured progress note was developed and printed on duplicate paper. The note
prompts providers to record information in distinct sections: antiretrovirals, prophylaxis, other medications, chief compliant, and physical exam results. Additional
sections prompt for patient-reported adherence and the most recent surrogate
marker values. Starting 9/97, the progress notes were used for all clinic visits. The
original copy is filed in the medical record and the duplicate is sent for data entry.
All medication changes, adherence, and surrogate maker results (HIV-RNA and
CD4) are input within one week. When the latest surrogate marker results become