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The State of Care for Veterans with HIV/AIDS: Summary, the Future and Concluding Remarks

for Health Care Providers

Chapter 7 - Summary, the Future and Concluding Remarks

7.1 Quality

For the past two years, PHSHG has used national CCR data to assess and report within the VHA on a number of quality indicators which are based on accepted guidelines or treatment recommendations. Information reported here supports the mission of PHSHG to improve the health of Veterans. On a regular basis, reports on patient volume, demographics, rates of common conditions, and accepted indicators of quality are disseminated to all VHA HIV providers. This information, along with assessing trends over time, has been useful within VHA in planning staffing, projecting cost, and understanding where improvements in care can be made.

This State of Care Report builds on the earlier quality indicator reports and presents a broad view of care for HIV infected Veterans. While there are several aspects of the VHA that make it a unique health care system, sharing the VHA HIV experience with other HIV care providers can provide important and useful information. For example, our HIV infected Veteran population, although predominantly male, is almost a decade older than the non-VHA HIV infected population. The difference in age provides insights that may help non-VHA providers understand what to expect as their patients with HIV/AIDS age in the decades ahead.

The National Quality Forum (NQF), a private, not-for-profit, public benefit corporation was established to develop and implement a national strategy for health care quality measurement and reporting. In July 2008, the NQF endorsed 13 new performance measures for evaluating the quality of HIV/AIDS care. Many of the topics included in PHSHG reporting over the past few years are included as NQF performance measures, including Hepatitis B screening and vaccination, Hepatitis C screening, TB screening, syphilis screening, and PCP prophylaxis.

The CQMPH has operationalized many of the NQF performance measures and assessed real world performance in VHA through its regular quality based HIV reporting using CCR data. CCR data can be used to approximate NQF performance measures for VHA nationally, for VISNs, and for local healthcare systems. Thus, the CCR provides a relatively rapid and reproducible way to identify care sites at which the initiation of quality programs might improve comprehensive HIV/AIDS care. Based on 2008 CCR data, national VHA rates for NQF HIV/AIDS performance measures and VHA quality indicators are generally high, although variation exists in the observed rates at facility and VISN levels, suggesting room for improvement.

Sites with higher rates of performance may provide models for replication at other facilities. Several facilities with very large HIV caseloads care for the majority of HIV infected Veterans, leaving many VHA systems with relatively small numbers of HIV patients. A challenge within VHA is to provide high quality care throughout the system so that outcomes for patients receiving care at low volume facilities are comparable to outcomes for those receiving care at high volume HIV facilities.

7.2 Future Initiatives

An important goal of the PHSHG is to support the earliest possible detection of HIV infection and prompt linkage to high quality care, including antiretroviral therapy. Earlier diagnosis of HIV infection allows for prompt clinical intervention, including therapy to decrease rates of disease progression. It is important to know more about the stage at which Veterans are first identified with HIV infection; at what stage they seek VHA care for HIV and how to identify opportunities within the VHA system for earlier diagnosis. The PHSHG currently has an active plan to address this important issue, ranging from policy revision to practice support.

Given the changing epidemiology of HIV with prolonged survival from potent antiretroviral therapy, it is important to understand the medical experience in the aging population living with HIV. Considering the size and age of VHA's HIV population, VHA can provide valuable information on this group. As the Veteran HIV population continues to age, it is important to recognize challenges they will face and to survey for emerging issues in order to ensure that they get the best possible care.

Issues related to therapy fatigue, adherence, and managing multiple co-morbidities will add to treatment complexity for treating HIV/AIDS for both Veterans and their providers. Activities such as consensus development of quality indicators helps capitalize on the knowledge and insight of HIV providers with years of experience as a source of guidance for future providers. Recent changes in VHA regulations to increase access to HIV testing will help identify previously undiagnosed cases of HIV/AIDS. Educating and training new providers to manage the aging cohort of veterans living with HIV is an important priority for the VHA.

New HIV infections continue to occur in the United States. This fact underscores the need for ongoing efforts to increase access to testing for HIV infection. We must ensure that each new generation of Veterans has the knowledge and skills to prevent HIV infection. Toward this goal, it is important to highlight the need for ongoing Veteran targeted programs that increase awareness of HIV testing and prevention throughout the course of Veteran's lives.

Conclusion

This State of Care Report provides a population view of VHA care for HIV disease. It serves to increase our understanding of the population of HIV infected Veterans being served by VHA, how VHA addresses clinical and preventive service needs, and helps to identify significant variations in service from VISN to VISN. It describes the VHA population in care "in the real world" and identifies trends that can help VHA as a system understand the needs of the HIV infected population currently in care and anticipate emerging needs.

The VHA cared for over 23,000 Veterans with HIV disease in 2008. The VHA population with HIV/AIDS is concentrated in the southern United States and receives care predominantly at facilities with 300 or more HIV patients. In general, the VHA's HIV population is overwhelmingly male, but includes over 600 female Veterans. The population has a median age of 53 years and 20% are age 60 or older. Almost half are Black. The population has substantial rates of mental health diagnoses, dyslipidemias, hypertension, and tobacco dependence. Though more than half of the HIV infected Veteran population in VHA care in 2008 had a history of advanced HIV infection, in that year just over 14% of the population had a CD4+ lymphocyte count below 200 cells/mm3 or a CD4+ lymphocyte percent below 14 percent, indicating clinical AIDS. Most HIV infected Veterans in VHA care have been under that care for quite some time and appear actively engaged in their healthcare as evidenced by the number of primary care or infectious disease clinic visits annually. Rates of monitoring of HIV severity have improved as have rates of receipt of other recommended treatments such as screening and vaccinations where indicated. Although there are some specific areas and sites where the quality of care could be improved, overall performance is good.