1. HIVQUAL – ARV Management October 17, 2003 Saneese Stephen, RPA Kings County Hospital Center Center for H.O.P.E.

2. Guidelines for the Use of ARV Agents in HIV Infected Adults and Adolescents. July 14, 2003. DHHS (AIDSinfo.nih.gov) Primary goals of ARV are maximal & durable suppression of plasma viremia, restore and preserve immunological function, improve QOL, reduce HIV related M&M Changes in therapy may be guided by viremia, Tcell response, ARV toxicity and adherence issues

3. NYS DOH AIDS INSTITUTE Definition of Unstable Patient OI in the last four month review period Viral load is increasing by more than 1 log and absolute value is over 1,000 CD4 is dropping by 50% since last four month review period Patient deemed unstable by physician

4. NYS DOH AIDS INSTITUTE Appropriate management options for unstable patients Decision made to d/c ART and clinical follow up plan noted within 3 months Regimen was changed and VL assay performed within 8 weeks of decision Justification provided not to change therapy and VL assay performed within 8 weeks of decision

5. NYS DOH AIDS INSTITUTE Justification not to change therapy Intercurrent illness Recent vaccination Adherence intervention documented Viral load reordered Resistance testing ordered Other

6. Review Period 12/00-12/01 ARV Experienced Patients (214 review periods) Unstable 21 (9.8%) Reviewed for Appropriate Management = 18 Managed Appropriately (56%) Managed Inappropriately (44%) 8 review periods consisted of 7 patients

7. Internal Review of Unstable Patients PA : New Rx on 11/01, next visit 4/02 SF: New Rx 6/01, b/w in 9/01 JS: ARV held 10/01, next visit 3/02 RC: New Rx 9/01, visit on 10/01, 1/02 JE: VL 8K in 4/01, missed f/u, b/w 7/31/01 GB: Noncompliant to ARV, refuses Labs JG: VL Incr., b/w not timely, adherence issues

8. Assessment of Data Management of Unstable patients is negatively impacted by: Provider follow up of laboratory values Provider documentation Client adherence to visits Client adherence to HAART Inadequate utilization of resources

9. Assessment of Data Acknowledge problem of patients becoming unstable in HIV Outpatient settings including at Center for HOPE Function of Medical staff Function of Support Staff Function of Client Multifactorial interventions are required

10. Action Review of data with Provider and Staff Educate on criteria and appropriate mgmt Emphasis on Documentation Reinforce use of Follow Up letters for missed appointments Emphasis on utilization of lab “review queue” – particularly from No Show pts

11. Action Educate staff to review for “unstable” patient during prescription refill visits Implement COBRA case mgmt follow up of “unstable” patients Encourage TAS referral for “unstable” pts Establish expedited referral process with Home Nursing Services for DOT