VA Maintained HIV Care Delivery During the COVID-19 Pandemic

During the COVID-19 pandemic, the Department of Veterans Affairs (VA) increased virtual visits and antiretroviral (ARV) refill length while still maintaining a high percentage of patients with suppressed viral load (VL), a study published in the Journal of the International AIDS Society found.

The study also showed that access to ARVs was not disrupted, despite decreased in-person services during the pandemic.

The VA is the largest provider of HIV care in the United States. As the pandemic forced changes on health care delivery, this study compared HIV health care delivery during the first year of the pandemic to a similar period pre-pandemic.

The study included 27,674 people living with HIV (PLWH) who were enrolled in the Veterans Aging Cohort Study (VACS) prior to March 1, 2019. These participants had at least 1 health care encounter between March 1, 2019 and February 29, 2020 (labeled 2019) and/or between March 1, 2020 and February 28, 2021 (labeled 2020). This represents almost half of the total number of people enrolled in VACS, which has 60,055 people living with HIV currently included.

Of the 27,674 people included, the median age was 59 years with ages ranging from 23 to 97 years. A majority (96%) were men; 45% were non-Hispanic Black, 35% were non-Hispanic White, 8% were Hispanic, 3% were other (Native American, Asian, Pacific Islander, or mixed race), and 9% were unknown.

Researchers conducted research using the following methods:

• Counting monthly general medicine/infectious disease (GM/ID) clinic visits and HIV-1 RNA VL tests
• Determining the percentage of participants with at least 1 clinic visit (in-person vs. telephone/video [virtual]) and at least 1 VL test (detectable vs. suppressed) for 2019 and 2020
• Using pharmacy records to summarize ARV medication refill length (<90 vs ≥90 days) and monthly ARV coverage

Almost every patient had at least 1 GM/ID clinic visit in 2019 (96%) and 2020 (95%), whether it was virtual or in-person. Data was similar among Black, White and Hispanic participants and among both men and women. The percentage of participants with at least 1 GM/ID visit in 2020 was slightly lower for those of other (93%) or unknown (91%) race/ethnicity.

Women were less likely to have in-person visits compared with men in both 2019 (91% vs 95%) and 2020 (77% vs 80%) and more likely to have virtual visits (62% vs 57% in 2019 and 92% vs 89% in 2020).

“Having any GM/ID clinic visits was similar by gender in both years ranging from 94% to 96%,” the authors noted.

HIV-1 RNA VL tests decreased, dropping from 82% in 2019 to 74% in 2020. Among those who had VL measured, 92% and 91% had suppressed VL in 2019 and 2020, respectively.

The authors noted that several other studies reported the disproportionate negative impact Black and Hispanic people faced during the pandemic, especially regarding testing, positivity rates, and vaccine rollout.

“In this study of PWH receiving care in the VA, we found that HIV care during and prior to the COVID-19 pandemic was similar by race/ethnicity except for those of unknown race/ethnicity and this is consistent with a previous study that reported that HIV clinical management and adherence in the VA was similar by race/ethnicity,” they wrote. “Because having unknown race/ethnicity in the VA is also associated with having fewer VA visits, this finding is difficult to interpret, but may suggest less engagement in VA care.”

They also noted limitations caused by the pandemic itself, both related and unrelated to changes in health care.

“More follow-up time is needed to determine whether overall health was impacted by the use of differentiated service delivery and to evaluate whether a long-term shift to increased virtual healthcare could be beneficial, particularly for PWH in rural areas or with transportation barriers,” the authors said. “Programmes to increase ARV use and VL testing for women are needed.”

Reference

McGinnis KA, Skanderson M, Justice AC, et al. HIV care using differentiated service delivery during the COVID-19 pandemic: a nationwide cohort study in the US Department of Veterans Affairs. J Int AIDS Soc. Published online October 28, 2021. doi:10.1002/jia2.25810