Minority AIDS Initiative (MAI)


The Issue

Despite significant advances in medical care and treatment for people living with HIV and AIDS (PLWHA) in the United States, only 25% of the 1.1 million HIV-positive Americans have achieved “viral suppression” to improve health outcomes and reduce the risk of transmitting the virus. Gaps in diagnosis, linkage to and retention in medical care, and access to treatment contribute to this result. Furthermore, there are significant health disparities along the continuum of care for minority populations; only 21% of African Americans and 26% of Hispanics/Latinos achieved viral suppression compared to 30% of Whites.

In 2010, the Pittsburgh Regional Health Initiative (PRHI) analyzed Pennsylvania Health Care Cost Containment Council (PHC4) data to understand the reasons for hospital admissions and readmissions in southwestern Pennsylvania for HIV-positive individuals in order to identify opportunities for improving care and reducing avoidable admissions.

Data confirmed that, as a result of the development of more effective HIV medications, life expectancy at diagnosis has increased dramatically, transitioning HIV into a chronic disease that needs to be managed. The picture that emerged was one of extraordinarily complex patients, with conditions ranging from HIV-related infections to comorbid common chronic diseases to the side effects of mental illness, drug abuse, and the medications used to treat HIV itself.

The Solution

As part of the JHF fiscal agency, in April 2012, the Jewish Healthcare Foundation (JHF) was awarded a grant from the Pennsylvania Department of Health Special Pharmaceutical Benefits Program to tackle this difficult problem. Since the start of the Minority AIDS Initiative (MAI), JHF has worked with twenty AIDS Service Organizations (ASOs) across the state to improve the quality of patient services, develop or strengthen programs to re-engage individuals lost to care, and reduce avoidable hospital readmissions for persons with HIV/AIDS.

Each ASO receives training and coaching to improve the quality of outreach services. Many organizations already work hard to re-engage individuals lost to care, but most did not have access to the program models, staff training, or quality improvement systems necessary to do so effectively. Programs for effective outreach exist, and MAI training and coaching is geared to helping organizations adopt a specific model or develop their own based on the core components of existing models.

MAI has trained and coached outreach workers (peers, medical assistants, social workers, etc.) in Motivational Interviewing techniques and skills,) so that they can effectively reach out to individuals lost to care. ASOs have also been trained in Perfecting Patient CareSM (PPC), the flagship quality improvement system developed by PRHI. Twice a year, JHF facilitates a statewide learning session for partner agencies. The session provides an opportunity for peer-to-peer learning, organizational planning, and synthesis of successful strategies for re-engaging clients in care.

In February 2014, PRHI researchers completed a report for the Pennsylvania Minority AIDS Initiative exploring HIV/AIDS hospital admissions and readmission data for the entire Commonwealth. By analyzing PHC4 data on all hospitalizations of HIV-positive patients between July 2010 and October 2012, and comparing the results to public health data on the HIV-positive population across Pennsylvania counties, the report points out what groups of patients are most likely to have experienced hospital admissions or readmissions (both can be indicators of missed prevention opportunities).

Furthermore, the report also documents striking variations across PA counties and hospitals in admission and readmission rates, especially in Pennsylvania’s non-urban counties. Both sets of findings can be used to help providers target outreach to vulnerable patients and to help policy makers ensure that all PA providers have the information needed to provide appropriate primary care for people living with HIV/AIDS.

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Measure of Success

  • The focus of MAI is on individuals with HIV/AIDS who are not in treatment. The goal is to get those individuals not receiving treatment on antiretroviral drugs which keep them healthy and out of the hospital.
  • Working with each of agencies to improve their work processes will improve patient care, reduce costs, and free up capacity for better outreach.
  • Ongoing statewide collaboration also enhances implementation through shared learning of best practices.
  • Consistent with the purpose of the funding, this program seeks to eliminate racial and ethnic disparities in health by targeting beneficial educational services to persons living with HIV/AIDS from racial and ethnic minority groups.

Lessons Learned

  • Community Health/Outreach Workers require a diverse range of skills in behavioral health, managing chronic conditions, and navigating systems to support vulnerable clients.
  • Lessons from Community Health Worker models in HIV services could apply to other chronic conditions.
  • A dedicated staff member to focus on “the unseen clients” reduces the community viral load within disproportionate populations.
  • Fostering trusting relationships is essential to successfully re-engaging clients in care.

Results to Date

During the first phase of the initiative (July 2012-June 2014), 15 agencies:

  • Identified 1,255 lost-to-care clients
  • Contacted 1,058 of these clients
  • Linked 81% (860) of contacted clients to medical care. 433 of these clients attended three medical appointments.

From June 2015 – July 2016 (the most recent completed grant period), 11 agencies:

  • 985 clients received outreach services, including 413 newly identified clients
  • 363 were linked to medical care
  • 311 attended 2 or more medical appointments and achieved suppressed viral load

Richard Smith
HIV/AIDS Program Manager