Abstract
Background:
Data are needed to assess the capacity of HIV care facilities to implement recommended Ending the HIV Epidemic (EHE) activities.
Setting:
U.S HIV care facilities.
Methods:
We analyzed 2021 survey data from a census of 514 facilities providing care to a national probability sample of U.S. adults with HIV. We present weighted estimates of facility characteristics, services, and policies, and estimates of the proportion of all U.S. HIV patients attending these facilities.
Results:
Among HIV care facilities, 37% were private practices, 72% were in areas with population > 1 million, and 21% had over 1000 HIV patients. Most provided preexposure prophylaxis (PrEP, 83%) and postexposure prophylaxis (PEP, 84%). Over 67% of facilities provided HIV-specific stigma or discrimination training for all staff (covering 70% of patients) and 66% provided training on cultural competency (covering 74% of patients). A majority of patients attended facilities that provided on-site access to HIV/STI transmission risk reduction counseling (89%); fewer had on-site access to substance use disorders treatment (35%). We found low provision of on-site assistance with food banks or meal delivery (14%) and housing (33%). Approximately 71% of facilities reported using data to systematically monitor patient retention in care. On-site access to adherence tools was available at 58% of facilities; 29% reported notifying patients of missed prescription pickups.
Conclusion:
Results indicate some strengths that support EHE-recommended strategies among HIV care facilities, such as high availability of PrEP/PEP, as well as areas for improvement, such as provision of staff anti-stigma trainings and adherence supports.
Keywords: HIV/AIDS, Ending the HIV Epidemic, health facilities, health services, health care delivery
Introduction
The Ending the HIV Epidemic in the U.S. (EHE) initiative was established in 2019 with the aim of ending the HIV epidemic in the United States by 2030.1 EHE’s goal to drastically reduce HIV transmission is supported by strategies in 4 key areas: early HIV diagnosis, prevention of new infections, rapid and effective HIV treatment, and quick response to outbreaks. EHE stresses the importance of expansion of preexposure prophylaxis (PrEP) and access to syringe services programs (SSPs), HIV stigma reduction, provision of essential clinical and supportive services, rapid linkage to care and antiretroviral therapy (ART), retention in care and adherence support, and collaboration with health departments to identify persons in need of support to remain in care and achieve viral suppression. HIV care facilities play a key role in these activities, but the capacity of U.S. HIV care facilities to deliver them is unknown. We conducted a survey of HIV care facilities providing care to a national probability sample of adults with HIV to assess their adoption of recommended EHE activities.
Methods
For the MMP Facility Survey (MMPFS), surveys were sent to a census of 1,023 HIV medical care facilities identified by participants in the 2019 cycle (June 2019—May 2020) of the Medical Monitoring Project (MMP) as their most frequent source of HIV care during the previous 24 months and at which a medical record abstraction took place as part of MMP. MMP is a multi-stage complex sample survey that produces nationally representative estimates among U.S. adults with diagnosed HIV.2
For the MMPFS, all 1,023 HIV care facilities with unique geographic locations were recruited. Surveys were completed by a senior facility administrator, nurse manager, and/or clinical director. Facilities were recruited using a modified Dillman’s Tailored Design Method3 and given the option of completing the 30-minute questionnaire online or via mail or phone. Staff at nonresponding facilities were asked to complete an abbreviated subset of the questionnaire that took an average of 5 minutes to complete. Staff at 45% of facilities responded to the full survey (N=455), and an additional 6% responded to the abbreviated survey (N=59). Because respondents were facilities and no information was collected on individuals, human subjects approvals were not obtained.
The survey collected information on facility type, Ryan White HIV/AIDS Program (RWHAP) funding, staffing, staff training on HIV stigma and cultural competency, and pre- and post-exposure prophylaxis (PEP) provision. The survey also assessed clinical and supportive services available on-site and through established referrals. Finally, the survey asked about availability of, and barriers to, rapid intake, rapid provision of ART, retention in care practices, and monitoring of ART adherence through pharmacy data.
Publicly available data collected for all facilities included: Primary Care Health Professional Shortage Area (HPSA) designation4, Medically Underserved Area/Population (MUA/P) designation5, Rural-Urban Continuum Code6, and RWHAP funding; the number of respondents with medical records abstracted from the facility was also obtained from MMP data. In addition to providing information of interest about facilities, these data were used for nonresponse analysis, weighting, and imputation.
MMPFS data were weighted based on weighting classes informed by the nonresponse analysis to reduce any bias in facility-level estimates due to nonresponse. Weighted facility estimates were based on the 44% of surveyed facilities that responded to the full survey. Additionally, because facility data are linkable to MMP participant data, we also present estimates of facility characteristics at the patient level to describe the proportion of patients whose primary HIV care facility had selected characteristics. To generate patient-level estimates, we imputed missing facility data using two steps: recursive partitioning (trees) to create imputation classes, and weighted sequential hot deck to produce imputed values. This ensured that patient-level facility estimates had no missing values and minimized potential non-response bias. The imputed facility data that were linked to the MMP patient data used all available information from the 50% of surveyed facilities that responded to either the full or abbreviated survey. No significant differences were found between the characteristics of full and abbreviated survey respondents; therefore, we did not use the abbreviated survey responses in the weighted MMPFS dataset because doing so would not reduce bias and would lead to more item nonresponse for questions not included in the abbreviated survey. We did not find significant differences in the point estimates generated by the weighted and imputed facility-level datasets, thus we conclude that these methods were comparable.
We used SAS 9.4 (Cary, NC: SAS Institute Inc.) to generate weighted estimates and confidence intervals (CI) of HIV care facility characteristics and imputed estimates of the proportion of US adults in HIV medical care whose primary HIV care facility had selected characteristics.
Results
HIV care facility characteristics
Among facilities providing HIV care to a probability sample of U.S. adults with HIV, 37% were private practices, 21% were hospital-based infectious disease (ID) practices, 18% were Federally Qualified Health Centers (FQHC), and 10% were hospital-based primary care clinics (categories not mutually exclusive; Table 1). Over 44% of facilities were in Primary Care Health Professional Shortage Areas and 45% in areas with a Medically Underserved Area/Population designation. Over 72% were in metro areas with population ≥ 1 million, 22% in metro areas with population < 1 million, and 6% in non-metro counties. Over 43% received any RWHAP funding, 92% accepted private insurance, 91% accepted Medicare, 82% accepted Medicaid, and 59% accepted AIDS Drug Assistance Program or other RWHAP-funded coverage. Approximately 9% of facilities had a past 12-month HIV patient load of <50, 28% had 50–249, 26% had 250–499, 16% had 500–999, and 21% had >1000 HIV patients. Nearly 93% of facilities also saw patients without HIV, 83% provided PrEP, and 84% provided PEP.
Table 1.
Characteristics of HIV care facilities and the proportion of persons receiving HIV care by facility characteristics—Medical Monitoring Project Facility Survey 2021, United States.
| HIV care facility characteristics | Proportion of persons receiving HIV care by facility characteristics | ||||||
|---|---|---|---|---|---|---|---|
| n | % | 95% CI | n | % | 95% CI | ||
| Total | 455 | 100 | 4100 | 100 | |||
| Type of facility | Federally Qualified Health Center | 97 | 18.0 | (14.5–21.5) | 830 | 22.0 | (17.7–26.2) |
| FQHC look-alike | 12 | 2.1* | (0.8–3.3) | 55 | 1.6 | (0.7–2.4) | |
| Hospital-based (infectious disease clinic) | 96 | 21.3 | (17.3–25.3) | 1242 | 30.7 | (26.7–34.6) | |
| Hospital-based (primary care clinic) | 44 | 9.5 | (6.6–12.3) | 520 | 12.2 | (6.9–17.5) | |
| Private practice | 134 | 36.7 | (31.9–41.6) | 907 | 25.1 | (21.8–28.4) | |
| State or local health department | 38 | 6.0 | (4.0–8.0) | 319 | 8.3 | (4.5–12.1) | |
| Veterans administration | 10 | 2.7* | (1.0–4.3) | 49 | 1.8 | (1.0–2.5) | |
| STD Clinic | 34 | 6.4 | (4.1–8.7) | 258 | 5.9 | (4.3–7.6) | |
| Research | 14 | 3.3 | (1.5–5.0) | 195 | 5.1 | (2.3–7.9) | |
| Other community-based organization | 53 | 9.2 | (6.7–11.8) | 375 | 9.7 | (6.8–12.6) | |
| Correctional Facility | 10 | 2.9* | (1.1–4.7) | 83 | 2.5 | (1.2–3.7) | |
| Primary Care Health Professional Shortage Area (HPSA) Designation | Yes | 213 | 44.1 | (39.3–48.9) | 1894 | 52.2 | (44.9–59.5) |
| Medically Underserved Area/Population (MUA/P) Designation | Yes | 225 | 44.7 | (39.9–49.6) | 2159 | 53.9 | (46.7–61.1) |
| Rural-Urban Continuum Code (RUCC) | Counties in metro areas of 1 million population or more | 318 | 72.1 | (67.9–76.4) | 2898 | 73.0 | (62.3–83.7) |
| Counties in metro areas of 250,000 to 1 million population | 75 | 15.2 | (11.8–18.5) | 558 | 17.6 | (8.9–26.3) | |
| Counties in metro areas of fewer than 250,000 population | 31 | 6.6 | (4.2–9.0) | 228 | 5.6 | (4.8–6.4) | |
| Nonmetro counties | 31 | 6.1 | (3.9–8.3) | 114 | 3.8* | (1.2–6.4) | |
| Any Ryan White HIV/AIDS Program funding | Yes | 257 | 43.1 | (38.4–47.7) | 2432 | 62.1 | (55.4–68.7) |
| Type of Ryan White funding | Ryan White Part A | 122 | 22.1 | (18.3–26.0) | 1497 | 37.3 | (33.0–41.6) |
| Ryan White Part B | 150 | 24.1 | (20.3–27.9) | 1574 | 41.6 | (36.8–46.3) | |
| Ryan White Part C | 153 | 24.3 | (20.5–28.1) | 1410 | 34.9 | (30.6–39.2) | |
| Ryan White Part D | 68 | 10.0 | (7.5–12.6) | 1059 | 25.5 | (21.0–30.1) | |
| Ryan White Part F | 94 | 9.2 | (7.3–11.1) | 684 | 15.8 | (11.6–20.0) | |
| Ryan White SPNS | 19 | 1.9 | (1.0–2.8) | 149 | 3.6* | (1.2–6.1) | |
| Ryan White AETC | 23 | 2.3 | (1.3–3.2) | 339 | 6.8 | (4.5–9.1) | |
| Ryan White Dental | 39 | 3.9 | (2.7–5.1) | 180 | 4.5 | (3.2–5.8) | |
| Ryan White MAI | 52 | 5.2 | (3.8–6.6) | 294 | 8.1 | (4.3–11.9) | |
| Type of health coverage accepted | Medicaid | 388 | 82.3 | (78.3–86.2) | 3375 | 87.6 | (84.5–90.8) |
| Medicare | 417 | 91.4 | (88.5–94.2) | 3535 | 92.2 | (89.8–94.5) | |
| Private Insurance | 417 | 91.6 | (88.8–94.4) | 3549 | 92.3 | (90.1–94.6) | |
| ADAP or Ryan White Coverage | 305 | 59.0 | (54.1–64.0) | 2873 | 74.4 | (70.2–78.5) | |
| Veterans Administration | 163 | 36.2 | (31.5–40.9) | 1288 | 34.7 | (29.9–39.6) | |
| Tricare | 244 | 55.3 | (50.4–60.1) | 1818 | 48.5 | (43.6–53.4) | |
| Has a sliding fee scale for patients without health coverage | Yes | 304 | 63.1 | (58.2–68.0) | 2837 | 72.6 | (67.7–77.5) |
| HIV patient load | <50 | 31 | 9.3 | (6.2–12.5) | 126 | 3.6 | (2.7–4.6) |
| 50–249 | 108 | 27.7 | (23.1–32.3) | 614 | 16.3 | (14.2–18.3) | |
| 250–499 | 108 | 25.9 | (21.5–30.4) | 694 | 17.7 | (16.0–19.3) | |
| 500–999 | 71 | 16.1 | (12.4–19.8) | 673 | 19.3 | (14.7–23.8) | |
| 1000+ | 95 | 21.0 | (16.9–25.0) | 1691 | 43.2 | (39.1–47.2) | |
| Does the facility provide medical care for people who do not have HIV? | Yes | 407 | 92.8 | (90.5–95.1) | 3348 | 87.5 | (81.9–93.1) |
| Does the facility provide HIV pre-exposure prophylaxis (PrEP)? | Yes | 366 | 83.3 | (79.7–86.9) | 3085 | 79.9 | (74.0–85.8) |
| Does the facility provide HIV post-exposure prophylaxis (PEP)? | Yes | 362 | 83.6 | (80.2–87.1) | 3007 | 78.1 | (72.5–83.8) |
| On-site physician who can provide HIV care at least 5 days per week | Yes | 342 | 77.6 | (73.5–81.6) | 3216 | 85.2 | (82.7–87.8) |
| HIV care provider staffing | Only full-time HIV care providers | 174 | 42.2 | (37.3–47.1) | 1371 | 35.5 | (32.3–38.8) |
| A mix of full-time and part-time HIV care providers | 202 | 43.6 | (38.7–48.4) | 2011 | 54.0 | (50.7–57.3) | |
| Only part-time HIV care provider | 65 | 14.2 | (10.8–17.7) | 416 | 10.5 | (8.9–12.0) | |
| Facilities with 1 or more of each HIV care provider type | Physicians | 423 | 97.7 | (96.2–99.1) | 3713 | 98.1 | (96.8–99.4) |
| Nurse practitioners | 267 | 57.2 | (52.2–62.2) | 2658 | 69.4 | (66.2–72.7) | |
| Other advance practice nurses | 29 | 5.3 | (3.3–7.4) | 335 | 8.7 | (5.0–12.5) | |
| Physician assistants | 116 | 25.9 | (21.5–30.2) | 1116 | 29.2 | (24.5–33.9) | |
| Registered pharmacists | 96 | 19.6 | (15.8–23.5) | 1187 | 29.0 | (25.1–33.0) | |
| Other provider type | 60 | 12.9 | (9.6–16.1) | 703 | 19.1 | (14.1–24.1) | |
| Physician specialties | Infectious disease | 329 | 72.2 | (67.7–76.6) | 3015 | 77.3 | (72.0–82.6) |
| Internal medicine | 271 | 61.0 | (56.2–65.8) | 2459 | 63.2 | (59.3–67.1) | |
| Family medicine | 218 | 46.4 | (41.5–51.2) | 1789 | 43.2 | (39.8–46.7) | |
| Other general practice | 90 | 19.4 | (15.6–23.3) | 727 | 18.7 | (13.6–23.7) | |
| Hematology/Oncology | 62 | 13.8 | (10.4–17.2) | 853 | 21.4 | (18.1–24.6) | |
| Neurology | 68 | 15.3 | (11.8–18.9) | 802 | 20.9 | (16.4–25.5) | |
| Dermatology | 61 | 13.6 | (10.2–17.0) | 821 | 20.8 | (17.7–24.0) | |
| Pulmonary | 73 | 16.6 | (12.9–20.3) | 809 | 21.0 | (17.6–24.5) | |
| Obstetrics and gynecology | 115 | 24.3 | (20.1–28.4) | 1076 | 28.3 | (24.5–32.1) | |
| Cardiology | 76 | 16.8 | (13.1–20.5) | 719 | 18.8 | (16.2–21.4) | |
| Psychiatry | 128 | 26.8 | (22.5–31.1) | 1427 | 36.4 | (32.4–40.3) | |
| Ophthalmology | 57 | 13.1 | (9.8–16.5) | 647 | 16.2 | (12.8–19.7) | |
| Does the facility provide HIV-specific stigma or discrimination training at least once for all staff who interact with patients? | Yes | 319 | 67.5 | (62.8–72.2) | 2718 | 70.1 | (65.7–74.5) |
| Does the facility provide training in other areas of cultural competency at least once for all staff who interact with patients? | Yes | 314 | 66.4 | (61.6–71.2) | 2862 | 73.9 | (67.5–80.2) |
Notes: FQHC, Federally Qualified Health Center; STD, sexually transmitted disease; ADAP, AIDS Drug Assistance Program; MAI, Minority AIDS Initiative; Numbers are unweighted, percentages are weighted.
Estimates are unstable and should be viewed with caution.
Approximately 78% had on-site physicians who could provide HIV care at least 5 days per week, and 14% had only part-time HIV care providers (Table 1). Nearly all (98%) had ≥1 physician on staff, 57% had ≥1 nurse practitioner, 26% had ≥1 physician assistant, and 20% had ≥1 registered pharmacist. The most common physician specialties were infectious disease (72% of facilities), internal medicine (61%), and family medicine (46%). Over 67% of facilities provided HIV-specific stigma or discrimination and 66% provided training in other areas of cultural competency at least once for all staff who interact with patients.
The most common clinical services provided on-site were sexually transmitted infection screening and treatment (85%) and HIV testing for HIV patients’ partners and others (74%) (Table 2). The most common substance use and mental health services provided on-site were tobacco cessation services (49%) and mental health services (47%). Gynecologic care (43%) and long-acting contraception (31%) were the most common women’s health services available on-site. The most common supportive clinical services available on-site were HIV/STI transmission risk-reduction counseling (88%) and ART adherence support tools (58%). Language interpretation services (63%) and non-clinical case management (52%) were the most common supportive non-clinical service available on-site.
Table 2.
Services provided by HIV care facilities and the proportion of persons receiving HIV care by availability of services—Medical Monitoring Project Facility Survey 2021, United States.
| HIV care facility characteristics | Proportion of persons receiving HIV care by facility characteristics | |||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Onsite | Established outside referral relationship | No/unknown | Onsite | Established outside referral relationship | No/unknown | |||||||||||||
| n | % | 95% CI | n | % | 95% CI | n | % | 95% CI | n | % | 95% CI | n | % | 95% CI | n | % | 95% CI | |
| Clinical-clinical services | ||||||||||||||||||
| STI screening and treatment | 387 | 85.4 | (81.8–88.9) | 24 | 6.1 | (3.6–8.5) | 36 | 8.6 | (5.8–11.4) | 3341 | 87.3 | (85.0–89.6) | 181 | 5.2 | (4.4–6.0) | 276 | 7.5 | (5.3–9.6) |
| HIV testing for partners of HIV patients and others | 341 | 73.8 | (69.4–78.3) | 53 | 13.3 | (9.9–16.8) | 53 | 12.8 | (9.4–16.2) | 2820 | 73.6 | (69.7–77.5) | 528 | 14.3 | (10.9–17.7) | 450 | 12.1 | (9.5–14.8) |
| Transgender hormone therapy | 185 | 40.2 | (35.4–45.0) | 144 | 31.7 | (27.1–36.3) | 118 | 28.1 | (23.6–32.6) | 1735 | 45.0 | (39.5–50.6) | 1161 | 30.1 | (26.1–34.1) | 902 | 24.9 | (20.5–29.2) |
| Medical nutrition therapy | 199 | 38.8 | (34.1–43.5) | 130 | 31.5 | (26.8–36.1) | 118 | 29.7 | (25.1–34.3) | 1753 | 46.0 | (39.9–52.1) | 1148 | 28.4 | (22.8–33.9) | 897 | 25.7 | (21.0–30.3) |
| Dental care | 128 | 23.9 | (19.9–27.9) | 229 | 51.4 | (46.5–56.4) | 90 | 24.7 | (20.2–29.1) | 1020 | 24.6 | (22.4–26.8) | 1973 | 53.7 | (49.8–57.5) | 805 | 21.8 | (17.5–26.0) |
| Free home HIV testing for partners of HIV patients and others | 94 | 17.1 | (13.6–20.5) | 159 | 37.7 | (32.9–42.5) | 194 | 45.2 | (40.3–50.1) | 718 | 18.9 | (14.5–23.4) | 1369 | 34.6 | (28.1–41.0) | 1711 | 46.5 | (41.3–51.7) |
| High resolution anoscopy | 60 | 12.1 | (9.0–15.3) | 231 | 51.3 | (46.3–56.2) | 156 | 36.6 | (31.8–41.4) | 878 | 22.2 | (19.5–24.9) | 1749 | 45.0 | (41.5–48.5) | 1171 | 32.8 | (28.0–37.7) |
| Clinical-substance use and mental health services | ||||||||||||||||||
| Tobacco cessation services | 229 | 48.9 | (44.0–53.8) | 124 | 27.7 | (23.3–32.1) | 94 | 23.4 | (19.2–27.7) | 1897 | 49.7 | (46.7–52.6) | 1015 | 26.7 | (23.5–29.9) | 886 | 23.6 | (20.1–27.1) |
| Mental health services | 234 | 46.7 | (41.9–51.6) | 146 | 36.9 | (32.1–41.7) | 67 | 16.4 | (12.6–20.1) | 2242 | 56.4 | (50.0–62.8) | 1064 | 29.2 | (24.0–34.5) | 492 | 14.4 | (12.0–16.7) |
| Substance use disorders treatment | 141 | 29.5 | (25.1–34.0) | 207 | 46.2 | (41.3–51.1) | 99 | 24.3 | (20.0–28.6) | 1386 | 35.0 | (28.8–41.1) | 1661 | 44.4 | (39.8–49.0) | 751 | 20.6 | (16.2–25.0) |
| Medication-assisted treatment (MAT) for substance use disorders. | 139 | 28.3 | (24.0–32.6) | 176 | 38.4 | (33.7–43.2) | 132 | 33.3 | (28.6–38.0) | 1311 | 31.8 | (26.4–37.2) | 1450 | 38.2 | (32.8–43.6) | 1037 | 30.0 | (24.7–35.3) |
| Syringe services | 36 | 7.8 | (5.3–10.4) | 191 | 42.3 | (37.5–47.2) | 220 | 49.8 | (44.9–54.8) | 243 | 6.8 | (5.7–7.8) | 1695 | 41.8 | (34.7–48.9) | 1860 | 51.4 | (43.8–59.1) |
| Clinical-women's health care | ||||||||||||||||||
| Gynecologic care | 211 | 42.9 | (38.1–47.8) | 143 | 33.7 | (29.0–38.4) | 93 | 23.3 | (19.1–27.6) | 1881 | 47.1 | (42.6–51.7) | 1204 | 32.7 | (27.6–37.9) | 713 | 20.1 | (16.5–23.8) |
| Long-acting contraception (injection or implant) | 152 | 30.8 | (26.4–35.3) | 169 | 37.7 | (33.0–42.5) | 126 | 31.5 | (26.8–36.1) | 1294 | 32.7 | (27.0–38.4) | 1480 | 38.1 | (32.3–44.0) | 1024 | 29.2 | (24.9–33.4) |
| Prenatal care | 110 | 21.6 | (17.7–25.5) | 227 | 49.9 | (45.0–54.8) | 110 | 28.5 | (24.0–33.1) | 875 | 21.7 | (17.5–25.9) | 2041 | 54.7 | (50.4–59.0) | 882 | 23.6 | (19.3–27.8) |
| Colposcopy | 98 | 20.1 | (16.3–23.9) | 231 | 50.4 | (45.5–55.3) | 118 | 29.5 | (24.9–34.1) | 1058 | 26.1 | (23.7–28.6) | 1840 | 47.7 | (42.6–52.8) | 900 | 26.2 | (20.6–31.7) |
| Supportive clinical services | ||||||||||||||||||
| Counseling about reducing risk of HIV and STI transmission | 399 | 87.9 | (84.6–91.3) | 12 | 3.4 | (1.5–5.2) | 36 | 8.7 | (5.8–11.6) | 3397 | 89.1 | (86.6–91.7) | 81 | 2.3* | (0.9–3.7) | 320 | 8.6 | (6.8–10.4) |
| Access to tools that support ART adherence, such as pill trays or dose reminder apps | 289 | 57.5 | (52.6–62.5) | 70 | 19.3 | (15.2–23.4) | 88 | 23.2 | (18.9–27.5) | 2579 | 66.5 | (59.8–73.2) | 559 | 15.6 | (11.9–19.3) | 660 | 17.9 | (13.3–22.4) |
| Patient navigation | 267 | 53.6 | (48.6–58.5) | 65 | 17.1 | (13.3–21.0) | 115 | 29.3 | (24.7–33.9) | 2622 | 67.7 | (62.6–72.9) | 402 | 10.5 | (7.4–13.6) | 774 | 21.8 | (18.9–24.7) |
| Clinical case management provided by a nurse. | 239 | 47.9 | (43.0–52.8) | 84 | 22.7 | (18.4–27.0) | 124 | 29.4 | (24.9–33.9) | 2197 | 56.4 | (52.6–60.3) | 594 | 16.6 | (14.5–18.7) | 1007 | 27.0 | (24.4–29.5) |
| Supportive non-clinical services | ||||||||||||||||||
| Language interpretation services | 296 | 62.9 | (58.1–67.7) | 88 | 20.6 | (16.6–24.7) | 63 | 16.4 | (12.6–20.2) | 2682 | 69.3 | (63.6–75.0) | 675 | 18.0 | (13.2–22.9) | 441 | 12.7 | (9.2–16.1) |
| Non-clinical case management | 265 | 51.9 | (47.0–56.8) | 99 | 26.6 | (22.1–31.1) | 83 | 21.5 | (17.3–25.7) | 2501 | 63.7 | (59.3–68.0) | 615 | 17.6 | (13.0–22.2) | 682 | 18.7 | (16.0–21.5) |
| Social work | 245 | 48.4 | (43.5–53.3) | 117 | 30.0 | (25.4–34.6) | 85 | 21.6 | (17.4–25.8) | 2336 | 59.7 | (54.8–64.7) | 702 | 19.3 | (15.3–23.2) | 760 | 21.0 | (16.6–25.4) |
| Assistance with transportation | 232 | 44.7 | (39.9–49.5) | 138 | 34.8 | (30.0–39.5) | 77 | 20.5 | (16.4–24.7) | 2087 | 55.7 | (52.5–59.0) | 1152 | 28.5 | (25.5–31.5) | 559 | 15.8 | (12.3–19.2) |
| Peer support counseling | 163 | 30.9 | (26.5–35.3) | 159 | 39.0 | (34.2–43.9) | 125 | 30.1 | (25.5–34.6) | 1439 | 37.0 | (30.3–43.8) | 1271 | 32.9 | (28.7–37.1) | 1088 | 30.1 | (24.6–35.6) |
| Peer support groups | 148 | 27.9 | (23.7–32.1) | 183 | 44.1 | (39.2–49.0) | 116 | 28.0 | (23.5–32.5) | 1340 | 33.4 | (26.0–40.8) | 1414 | 37.2 | (31.5–43.0) | 1044 | 29.4 | (25.1–33.6) |
| Assistance with housing | 144 | 26.7 | (22.5–30.8) | 208 | 47.5 | (42.6–52.4) | 95 | 25.8 | (21.3–30.3) | 1303 | 32.7 | (27.7–37.6) | 1894 | 49.8 | (44.6–55.1) | 601 | 17.5 | (14.3–20.8) |
| Food bank or meal delivery | 73 | 13.1 | (10.0–16.2) | 250 | 54.2 | (49.3–59.1) | 124 | 32.7 | (28.0–37.4) | 561 | 13.9 | (11.7–16.1) | 2364 | 61.8 | (58.8–64.8) | 873 | 24.3 | (20.4–28.2) |
| Childcare | 20 | 4.0 | (2.2–5.9) | 185 | 40.5 | (35.7–45.3) | 242 | 55.5 | (50.6–60.4) | 177 | 4.5 | (3.9–5.2) | 1569 | 40.6 | (35.9–45.2) | 2052 | 54.9 | (50.1–59.6) |
Notes: STI, sexually transmitted infection; ART, antiretroviral therapy; Numbers are unweighted, percentages are weighted.
Estimates are unstable and should be viewed with caution.
Free home HIV testing (45%) and high-resolution anoscopy (37%) were the clinical services most frequently reported as not available on-site or through referral (Table 2). Syringe services (50%) and medication assisted treatment for substance use disorders (33%) were the substance use and mental health services most frequently reported as not available on-site or through referral. Long-acting contraception (32%) and colposcopy (30%) were the women’s health services most frequently reported as not available on-site or through referral. Nurse-provided clinical case management (29%) and patient navigation (29%) were the supportive clinical services most frequently reported as not available on-site or through referral. Childcare (56%) and food bank or meal delivery (33%) were the supportive non-clinical services most frequently reported as not available on-site or through referral.
The median number of business days within which a new patient can obtain an appointment with an HIV care provider was 5 days (95% CI 4–6), estimate not presented in tables). The most common barriers to offering new patients an appointment with an HIV care provider within 1 business day of the initial request were insufficient provider capacity (56%) and patient preference (50%; Table 3). Nearly 73% of facilities reported that new patients could obtain a 30-day supply of ART on their first provider visit; the most common barrier was unavailable laboratory test results (20%). Providing HIV clinical care for patients via remote conferencing was common (82%). Nearly three-quarters (71%) used data to systematically monitor patient retention in care, most often internal data such as electronic health records or billing data (66%). Approximately 73% reported collaborating with the state or local health department to identify or contact patients who are out of care. Nearly all (92%) sent patient reminders before all appointments—most often through live phone calls (71%) and text, email, or patient portal message (70%). Over 59% of facilities had direct access to information about prescriptions fulfillment and pick-up by patients and 29% notify patients of missed prescription pickups.
Table 3.
Provision of care among HIV care facilities and the proportion of persons receiving HIV care by care characteristics—Medical Monitoring Project Facility Survey 2021, United States.
| HIV care facility characteristics | Proportion of persons receiving HIV care by facility characteristics | ||||||
|---|---|---|---|---|---|---|---|
| n | % | 95% CI | n | % | 95% CI | ||
| Total | 455 | 100 | 4100 | 100 | |||
| What are the barriers to offering new patients an appointment with an HIV care provider within 1 business day of an initial request? | Patient preference | 217 | 50.4 | (45.3–55.5) | 1991 | 51.5 | (45.1–57.8) |
| Insufficient provider capacity to see rapid entry patients | 223 | 55.5 | (50.5–60.5) | 1626 | 45.4 | (40.4–50.4) | |
| Patients lack documents required for facility enrollment | 83 | 18.6 | (14.7–22.5) | 975 | 23.3 | (18.0–28.6) | |
| Patients lack documents required for Ryan White HIV/AIDS Program enrollment | 69 | 12.1 | (9.1–15.0) | 803 | 19.4 | (15.5–23.4) | |
| Facility administration is not committed to rapid enrollment | 10 | 2.6* | (1.0–4.3) | 42 | 0.9 | (0.6–1.2) | |
| Other staff are not committed to rapid enrollment | 8 | 1.6* | (0.4–2.7) | 51 | 1.3* | (0.5–2.2) | |
| Which of these documents are required for scheduling the first appointment with an HIV care provider? | Proof of income | 122 | 21.8 | (17.9–25.6) | 1326 | 32.9 | (29.6–36.2) |
| Proof of residence | 129 | 24.1 | (20.1–28.1) | 1348 | 33.2 | (29.7–36.7) | |
| Government-issued identification | 164 | 35.9 | (31.1–40.6) | 1417 | 37.3 | (34.6–40.0) | |
| Result of a test for tuberculosis (PPD or IGRA) | 28 | 5.6 | (3.4–7.8) | 318 | 7.3 | (4.6–10.0) | |
| Positive HIV antibody or detectable viral load | 247 | 51.5 | (46.6–56.4) | 2405 | 62.2 | (56.1–68.3) | |
| CD4 lymphocyte count result | 90 | 19.2 | (15.3–23.0) | 904 | 23.0 | (20.5–25.5) | |
| None of the above | 134 | 32.3 | (27.7–37.0) | 1016 | 27.9 | (23.7–32.1) | |
| Which of the following patients are routinely able to obtain a 30-day supply of antiretroviral medication on the day of their first visit with an HIV care provider? | All patients | 274 | 72.9 | (68.1–77.7) | 2555 | 66.1 | (60.9–71.3) |
| Patients with no prescription coverage, e.g. by using a pharmaceutical patient assistance program or funds designated for this purpose | 359 | 94.7 | (92.2–97.2) | 3541 | 93.5 | (90.8–96.2) | |
| Patients without results of baseline laboratory tests | 308 | 82.1 | (78.0–86.2) | 3016 | 77.7 | (73.9–81.4) | |
| Which of these are barriers to patients obtaining a 30-day supply of antiretroviral therapy on the day of the first HIV care provider visit? | Patient preference | 41 | 10.0 | (6.9–13.1) | 440 | 11.3 | (9.0–13.6) |
| Prescription not given because test results are not available | 81 | 19.5 | (15.5–23.5) | 725 | 20.0 | (16.3–23.7) | |
| Delay getting medication paid for | 65 | 17.1 | (13.2–21.0) | 556 | 14.0 | (11.9–16.2) | |
| Antiretroviral starter packs are not available to be given to patients | 52 | 12.6 | (9.2–16.0) | 497 | 12.5 | (9.6–15.3) | |
| Lack of trained staff to submit patient assistance program applications for free antiretrovirals | 10 | 3.0* | (1.2–4.9) | 50 | 1.1 | (0.6–1.7) | |
| Patient cannot afford copayment | 41 | 10.8 | (7.5–14.0) | 399 | 9.9 | (7.3–12.5) | |
| Providers are not committed to immediate antiretroviral initiation | 16 | 4.1 | (2.1–6.2) | 117 | 3.3 | (2.2–4.4) | |
| Facility administration is not committed to immediate antiretroviral initiation | 7 | 1.5* | (0.3–2.8) | 76 | 6.3 | (3.0–9.5) | |
| Lack of a standardized protocol for all clinicians to follow | 14 | 3.6 | (1.7–5.5) | 193 | 5.1 | (2.3–8.0) | |
| Have any providers provided HIV clinical care for patients via remote conferencing? | Yes | 366 | 82.0 | (78.1–85.9) | 3301 | 87.3 | (84.4–90.2) |
| Have any patients received HIV clinical care from outside HIV providers via remote conferencing during a visit (in-person or virtual) at your facility? | Yes | 118 | 27.0 | (22.6–31.5) | 987 | 27.6 | (22.5–32.8) |
| Have any providers received HIV clinical consultation or mentoring from outside providers via remote conferencing, e.g., HIV ECHO? | Yes | 156 | 34.1 | (29.4–38.8) | 1520 | 38.9 | (34.0–43.9) |
| Have any providers provided HIV clinical consultation or mentoring for outside providers via remote conferencing, e.g., HIV ECHO? | Yes | 174 | 36.9 | (32.1–41.6) | 1823 | 45.6 | (41.6–49.6) |
| Does the facility use data to systematically monitor retention in care of all HIV patients? | Yes | 342 | 71.0 | (66.4–75.7) | 3214 | 83.6 | (78.8–88.5) |
| Which types of data does the facility use to monitor retention in care? | Internal data (e.g., electronic health record or billing data) | 312 | 65.6 | (60.8–70.5) | 2941 | 77.6 | (72.8–82.3) |
| Health department surveillance data | 112 | 20.6 | (16.8–24.4) | 1139 | 28.2 | (24.4–32.0) | |
| CAREWare | 143 | 24.2 | (20.3–28.1) | 1573 | 37.5 | (29.9–45.1) | |
| Pharmacy refill data | 176 | 37.8 | (33.0–42.5) | 1703 | 43.7 | (37.7–49.7) | |
| Does the facility collaborate with the state or local health department to identify or contact patients who are out of care, e.g., by providing clinic data or contact information to the health department? | Yes | 340 | 72.6 | (68.0–77.2) | 3016 | 78.1 | (72.3–83.8) |
| Does the facility send patient reminders before all provider appointments? | Yes | 415 | 92.4 | (89.7–95.2) | 3648 | 96.3 | (95.5–97.1) |
| Which of these patient reminders are routinely used at the facility? | Text, email, or patient portal message | 317 | 70.4 | (65.8–75.0) | 2948 | 76.0 | (72.1–80.0) |
| Automated phone calls | 239 | 52.0 | (47.1–57.0) | 2194 | 58.1 | (51.7–64.5) | |
| Live phone calls | 330 | 71.2 | (66.6–75.8) | 2918 | 77.7 | (72.0–83.4) | |
| Letter | 134 | 27.9 | (23.5–32.2) | 1253 | 33.9 | (28.8–38.9) | |
| Does the facility follow-up on all missed appointments? | Yes | 379 | 83.9 | (80.2–87.7) | 3244 | 85.0 | (80.3–89.8) |
| With which methods does the facility follow-up on missed appointments? | Text, email, or patient portal message | 209 | 44.8 | (39.9–49.7) | 1799 | 48.4 | (44.6–52.2) |
| Automated phone calls | 82 | 16.5 | (13.0–20.1) | 541 | 14.5 | (11.6–17.4) | |
| Live phone calls | 342 | 75.4 | (71.1–79.8) | 2923 | 77.1 | (70.4–83.7) | |
| Letter | 210 | 44.0 | (39.2–48.9) | 1807 | 47.1 | (42.7–51.6) | |
| Outreach in the field by a facility employee | 119 | 23.0 | (19.1–27.0) | 1249 | 30.7 | (26.5–35.0) | |
| Is there a pharmacy at the same geographic location as the facility (onsite)? | Yes | 244 | 53.8 | (48.9–58.7) | 2422 | 62.9 | (57.4–68.4) |
| Does the facility have direct access to information about prescription fulfillment and pick-up by patients? | Yes | 283 | 59.1 | (54.2–64.0) | 2662 | 69.8 | (66.2–73.5) |
| Does the facility notify patients of all missed prescription pickups? | Yes | 146 | 29.3 | (24.9–33.7) | 1511 | 38.4 | (32.2–44.7) |
| With which methods does the facility notify patients of missed prescription pick-ups? | Text, email, or patient portal message | 89 | 17.7 | (14.0–21.3) | 780 | 20.3 | (15.2–25.5) |
| Automated phone calls | 50 | 9.7 | (6.9–12.5) | 476 | 12.3 | (9.8–14.8) | |
| Live phone calls | 126 | 24.9 | (20.8–29.0) | 1348 | 34.1 | (28.0–40.2) | |
| Letter | 32 | 6.2 | (4.0–8.5) | 254 | 7.8 | (3.8–11.9) | |
Notes: PPD, purified protein derivative; IGRA, interferon-gamma release assay; Numbers are unweighted, percentages are weighted.
Estimates are unstable and should be viewed with caution.
Proportion of persons receiving HIV care by facility characteristics
Among persons receiving HIV care, 31% received care at a hospital-based infectious disease clinic, 25% at a private practice, and 22% at an FQHC (Table 1). An estimated 73% of patients received care at facilities in metro areas of ≥1 million population and 62% attended facilities receiving RWHAP funding. Almost 4% received care at facilities providing HIV care to less than 50 persons with HIV and 43% at facilities serving ≥1000 persons with HIV. Almost 11% attended facilities with only part-time HIV care providers. Roughly 70% received care at facilities that provide HIV-specific stigma or discrimination training and 74% at facilities that provide training in other areas of cultural competency at least once for all staff who interact with patients.
Over 87% of patients attended HIV care facilities that provide onsite STI screening and treatment and 74% attended facilities that provide HIV testing for partners of HIV patients (Table 2b). Approximately 33% attended facilities where high-resolution anoscopy was not provided onsite or through referral. Over 56% attended facilities providing onsite mental health services and 14% attended facilities where mental health services were not provided onsite or through referral. Approximately 35% attended facilities providing onsite substance use disorders treatment and 21% attended facilities where treatment was not provided onsite or through referral. Over 89% attended facilities providing onsite counseling about reducing the risk of HIV and STI transmission and 9% attended facilities where counseling was not available onsite or through referral. Nearly 67% attended facilities that provided onsite access to ART adherence support tools and 18% attended facilities where tools were not provided onsite or through referral. Approximately 37% of patients attended facilities with onsite peer support and 30% attended facilities without availability of peer counseling either onsite or through referral.
Over 66% of patients attended facilities where they could obtain a 30-day supply of ART on the day of their first visit. Approximately 87% attended facilities where providers provided HIV clinical care via remote conferencing. Nearly 84% attended facilities that used data to systematically monitor retention in care for all patients with HIV, 85% attended facilities that follow up on all missed appointments, and 70% attended facilities with access to information about prescription fulfillment and pick-up by patients.
Discussion
Using data collected from HIV care facilities attended by a representative sample of persons with HIV in the United States, we documented facility characteristics, services, and policies that support the health and well-being of persons with HIV and the goals of the EHE initiative. The findings revealed some areas of strength among U.S. HIV care facilities, such as high availability of PrEP/PEP and ability to provide a 30-day supply of ART on a patient’s first visit. These services support EHE goals for preventing new infections and rapid treatment of ART to reach sustained viral suppression. However, areas for improvement were also identified, such as low availability of on-site ART adherence support tools and use of pharmacy data for adherence monitoring—expansion of these services in U.S. HIV care facilities can help ensure that EHE goals for sustained viral suppression are met.
Expansion of preexposure prophylaxis (PrEP) and access to syringe services programs (SSPs)
Use of PrEP is highly effective at preventing HIV acquisition7, but uptake is suboptimal8 and disparities by gender, race, and ethnicity are evident.9,10 Almost all (93%) facilities reported providing care for persons without HIV, and most reported providing PrEP (83%) and PEP (84%), indicating a substantial role for HIV care facilities in the provision of PrEP/PEP. A study of a national pharmacy database found increases in the number of U.S. PrEP providers from 2014 to 2019, with the prevalence of prescribing PrEP being highest among infectious disease physicians.11 Over 72% of facilities reported having at least 1 infectious disease physician on staff. HIV care providers can play a key role in delivery of PrEP, particularly to the sexual partners of their patients with HIV. For example, over 74% of facilities reported having onsite HIV testing for partners of HIV patients and others; HIV care facilities could implement social networking-based HIV testing strategies for partners and social contacts of patients with HIV, with direct linkage to PrEP/PEP or ART as needed. A status neutral approach in which persons are linked to PrEP or ART depending on their status could increase provision of PrEP/PEP—in addition to having other benefits, such as decreasing stigma and offering more wholistic, person-centered care.12 Approximately half of facilities reported providing no access to syringe services for their patients. Increasing the capacity of facilities to provide access to these services—either on-site or through referral—would directly support the EHE strategy to prevent new HIV transmissions through the delivery of effective interventions like syringe services programs.
HIV stigma reduction
Reducing HIV stigma is an EHE priority that is monitored by the National HIV/AIDS Strategy (NHAS)13 to achieve the vision of every U.S. person with HIV living a life free from stigma and discrimination. Reducing stigma experienced in care settings is particularly important because stigma is associated with lower use of HIV testing and prevention services14–16, use of PrEP17,18, ART adherence19,20, and use of medical care.21,22 Over 67% of facilities reported providing HIV-specific stigma or discrimination training at least once for all staff who interact with patients (covering 70% of patients) and 66% reported providing training in areas of cultural competency (covering 74% of patients), indicating substantial room for improvement. Facility-based stigma reduction and cultural competency training may need to be offered more routinely, as a systematic review found more recent training was associated with lower stigma.23 In addition to training, facilities should demonstrate their commitment to enforcing anti-stigma policies. One study found that perceptions that policies were not enforced was associated with more stigmatizing attitudes by providers.24 However, while facility anti-stigma training and policies are important, the extent to which they reduce stigma experienced by patients should also be assessed.
Provision of essential clinical and supportive services
Ensuring access to needed clinical and supportive services is crucial to achieve the goals of EHE, reduce new HIV infections, and promote the health of people with HIV (PWH). While a substantial majority of PWH attended HIV care facilities that provided access to STI screening and treatment and HIV/STI transmission risk reduction counseling, nearly 8% and 9% (respectively) attended facilities with no access, indicating room for improvement in provision of these essential services. Fewer patients had access to substance use services such as substance use disorders treatment, medication-assisted treatment, and syringe services. Expanding access to substance use treatment for those who need it is crucial for meeting HIV care and prevention goals because PWH are more likely to have substance use disorders, which are associated with poor HIV outcomes.25 Further, the NHAS Federal Implementation Plan introduced ambitious goals for improving quality of life among PWH, including decreasing food insecurity and unstable housing by 50% by 2025. We found low provision of on-site assistance with food banks or meal delivery and housing, which some evidence suggests is associated with higher uptake and effectiveness in reducing social needs.26
Rapid linkage to care and antiretroviral therapy (ART)
Rapid linkage to care and ART initiation are key EHE strategies that lead to better outcomes for PWH.27–29 Facilities reported being able to offer an appointment with an HIV care provider for patients new to the facility in a median of 5 business days. The most common barriers to seeing new patients within 1 business day were insufficient provider capacity (56%) and patient preference (50%); support for rapid enrollment among administration and staff was not reported to be a barrier. Other surveys have found relatively high dissatisfaction with remuneration and time spent on administrative tasks among HIV care providers and estimate that provider attrition will not keep pace with projected increases in patients requiring HIV care.30 Enhanced training of non-HIV primary care providers and family medicine residents to provide care for patients with HIV and improved care coordination in FQHCs has shown promise in addressing provider capacity issues.31 Many facilities (73%) reported that all patients were routinely able to receive a 30-day supply of ART on their first visit, and most reported being able to provide ART regardless of prescription coverage (95%) or baseline laboratory test results (82%). This indicates that most facilities have the capacity to implement rapid ART, as recommended by guidelines.32
Retention in care, adherence support, and collaboration with health departments
Although most facilities reported using data to systematically monitor retention in care, 29% did not, indicating substantial room for improvement in efforts to improve this EHE recommended activity. Positively, approximately 73% of facilities reported collaborating with health departments in efforts to reach patients who are not engaged in care. On-site access to tools that support ART adherence, such as pill trays or dose reminder apps, was only available at 58% of facilities. Adherence support tools can be effective at improving ART adherence, as forgetting is the most common reason for missing ART doses.33 In addition, while 59% of facilities had direct access to patient prescription fulfillment and pick-up information, only 29% reported notifying patients of missed pickups, which can be helpful to support patient adherence.34
Limitations
Some limitations of this analysis include low facility response rate, although we were able to minimize potential bias by weighting the data based on information known for all facilities. Additionally, facilities responded to the survey July-November 2021 while the patients participated in MMP during June 2019-May 2020. To the extent that services and practices changed between these time-frames, the estimates of the proportion of patients attending facilities with certain characteristics may be affected. Finally, the survey did not measure the implementation of reported practices, nor was their quality assessed. Facility patients’ perspectives on the availability of services and their quality may differ from those of facility staff. Due to social desirability bias in reporting on facility practices, our estimates should be viewed as upper bounds.
A strength of this analysis is its use of data from facilities attended by a probability sample of persons with HIV who are diverse in demographics, HIV care status and clinical outcomes, and geography.
Conclusion
We documented the provision of services and practices that support EHE-recommended strategies among HIV care facilities attended by a geographically diverse probability sample of US adults. Results indicate some strengths, such as high availability of PrEP/PEP, as well as areas for improvement, such as provision of staff anti-stigma trainings and adherence supports.
Acknowledgements
We thank the Medical Monitoring Project facility survey participants, project area staff, and Provider and Community Advisory Board members. We also acknowledge the contributions of the Clinical Outcomes Team and Behavioral and Clinical Surveillance Branch at CDC and RTI International. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Footnotes
Conflicts of Interest and Source of Funding: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding for the Medical Monitoring Project is provided by the Centers for Disease Control and Prevention. The authors received no financial support for the research, authorship, and/or publication of this article.
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