Practice transformations to optimize the delivery of HIV primary care in community healthcare settings in the United States: A program implementation study

Autoři: Wayne T. Steward aff001;  Kimberly A. Koester aff001;  Mary A. Guzé aff001;  Valerie B. Kirby aff001;  Shannon M. Fuller aff001;  Mary E. Moran aff001;  Emma Wilde Botta aff001;  Stuart Gaffney aff001;  Corliss D. Heath aff002;  Steven Bromer aff003;  Starley B. Shade aff001
Působiště autorů: Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America aff001;  U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), HIV/AIDS Bureau, Rockville, Maryland, United States of America aff002;  Department of Family and Community Medicine, University of California San Francisco (UCSF), San Francisco, California, United States of America aff003;  Institute for Global Health Sciences, University of California San Francisco (UCSF), San Francisco, California, United States of America aff004
Vyšlo v časopise: Practice transformations to optimize the delivery of HIV primary care in community healthcare settings in the United States: A program implementation study. PLoS Med 17(3): e32767. doi:10.1371/journal.pmed.1003079
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003079



The United States HIV care workforce is shrinking, which could complicate service delivery to people living with HIV (PLWH). In this study, we examined the impact of practice transformations, defined as efficiencies in structures and delivery of care, on demonstration project sites within the Workforce Capacity Building Initiative, a Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS).

Methods and findings

Data were collected at 14 demonstration project sites in 7 states and the District of Columbia. Organizational assessments were completed at sites once before and 4 times after implementation. They captured 3 transformation approaches: maximizing the HIV care workforce (efforts to increase the number of existing healthcare workforce members involved in the care of PLWH), share-the-care (team-based care giving more responsibility to midlevel providers and staff), and enhancing client engagement in primary HIV care to reduce emergency and inpatient care (e.g., care coordination). We also obtained Ryan White HIV/AIDS Program Services Reports (RSRs) from sites for calendar years (CYs) 2014–2016, corresponding to before, during, and after transformation. The RSR include data on client retention in HIV care, prescription of antiretroviral therapy (ART), and viral suppression. We used generalized estimating equation (GEE) models to analyze changes among sites implementing each practice transformation approach. The demonstration projects had a mean of 18.5 prescribing providers (SD = 23.5). They reported data on more than 13,500 clients per year (mean = 969/site, SD = 1,351). Demographic characteristics remained similar over time. In 2014, a majority of clients were male (71% versus 28% female and 0.2% transgender), with a mean age of 47 (interquartile range [IQR] 37–54). Racial/ethnic characteristics (48% African American, 31% Hispanic/Latino, 14% white) and HIV risk varied (31% men who have sex with men; 31% heterosexual men and women; 7% injection drug use). A substantial minority was on Medicaid (41%). Across sites, there was significant uptake in practices consistent with maximizing the HIV care workforce (18% increase, p < 0.001), share-the-care (25% increase, p < 0.001), and facilitating patient engagement in HIV primary care (13% increase, p < 0.001). There were also significant improvements over time in retention in HIV care (adjusted odds ratio [aOR] = 1.03; 95% confidence interval [CI] 1.02–1.04; p < 0.001), ART prescription levels (aOR = 1.01; 95% CI 1.00–1.01; p < 0.001), and viral suppression (aOR = 1.03; 95% CI 1.02–1.04; p < 0.001). All outcomes improved at sites that implemented transformations to maximize the HIV care workforce or improve client engagement. At sites that implemented share-the-care practices, only retention in care and viral suppression outcomes improved. Study limitations included use of demonstration project sites funded by the Ryan White HIV/AIDS Program (RWHAP), which tend to have better HIV outcomes than other US clinics; varying practice transformation designs; lack of a true control condition; and a potential Hawthorne effect because site teams were aware of the evaluation.


In this study, we found that practice transformations are a potential strategy for addressing anticipated workforce challenges among those providing care to PLWH. They hold the promise of optimizing the use of personnel and ensuring the delivery of care to all in need while potentially enhancing HIV care continuum outcomes.

Klíčová slova:

Antiretroviral therapy – Health services administration and management – HIV – HIV diagnosis and management – HIV epidemiology – Insurance – New York – Primary care


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2020 Číslo 3
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