Self Management
Can lay health workers promote better medical self-management by persons living with HIV? An evaluation of the Positive Choices program

https://doi.org/10.1016/j.pec.2012.06.010Get rights and content

Abstract

Objective

To evaluate Positive Choices (PC), a program that employed lay health workers to motivate antiretroviral adherence among persons living with HIV with coverage from Indiana's high-risk insurance pool.

Methods

Four hundred and forty nine participants living in the greater Indianapolis area were randomly allocated to treatment (n = 91) or control (n = 358) groups and followed for one year.

Results

Compared to control subjects, PC subjects were more likely to adhere to HIV medications (medication possession ratio adherence ≥0.95, OR = 1.83, p = 0.046), and to achieve undetectable viral load (<50 copies/mL, OR = 2.01, p = 0.011) in the 12 months following introduction of PC. There were no significant differences observed between groups in any of self-reported health status indicators.

Conclusion

Estimates suggest that PC clients were 16% more likely to have undetectable viral loads than clients in standard care. The incremental program cost was approximately $10,000 for each additional person who achieved an undetectable viral load.

Practice implications

As persons living with HIV experience greater longevity and healthcare reform expands coverage to these high-risk populations, greater demands will be placed on the HIV-care workforce. Results suggest lay health workers may serve as effective adjuncts to professional care providers.

Introduction

Medical advances have greatly improved the life expectancy for individuals living with Human Immunodeficiency Virus (HIV). In particular, highly active antiretroviral treatment (HAART) has transformed this once-terminal illness to a chronic disease with considerable potential longevity. The success of these therapies depends critically on maintaining a very high degree of adherence to the treatment regimen over the entire life of the person living with HIV (PLWH). Even relatively short lapses in treatment can have important consequences, including inadequate viral suppression, drug resistance, poorer health and higher health care costs [1], [2], [3], [4], [5]. Unfortunately, approximately 30–50% of PLWH fail to achieve the levels of drug adherence needed for HAART to be most effective [6], [7], [8], [9], [10], [11].

Adherence has been found to depend on the complexity of the regimen, financial barriers, and social support [12]. Interventions to improve adherence usually target one or more of these areas. Of the various support-related strategies that have been used to increase adherence to medication regimens, no single strategy has been found that works in all contexts [13]. It does appear that education alone is insufficient to achieve significant improvement, and that successful long-term strategies require more complex interventions [14], usually with some degree of health coaching to foster self-management by the PLWH [15]. As more PLWH experience long-term survival, the existing HIV-related healthcare workforce will struggle to cover their regular care management activities, and are unlikely to be able to provide the additional social support required by such interventions. Indeed, concerns have been raised that current levels of reimbursement for HIV-related care will result in an even greater exacerbation of this problem in the future [16].

One possible remedy is to supplement the formal healthcare workforce with lay health workers (LHW) [17]. A LHW is defined as “any health worker carrying out functions related to healthcare delivery, trained in some way in the context of the intervention, and having no formal [clinical] professional or paraprofessional certificate or tertiary education degree” [18]. LHW have been used as supports in less developed countries where workforce shortages are more acute [19]. LHW have been found to be effective in promoting adherence with childhood immunizations [18] and medication for heart disease in the elderly [20] in more developed countries, but their effectiveness in promoting self-management in PLWH remains largely untested in the United States. A recent review of the literature found 16 studies that evaluated the impact of LHW on medication adherence in PLWH, but 12 of these used LHW in direct-observation-of-treatment interventions rather than self-management programs, one used LHW only in teams with formal healthcare workers, and the remaining three considered the impact of LHW only in group settings [21].

In this paper, we report the results of a prospective, randomized trial designed to assess the impact of Positive Choices, a program that employs LHW to provide one-on-one support for PLWH who are covered by Indiana's high-risk insurance pool. In addition to medication adherence, we also evaluated the impact of the program on costs and health outcomes.

Section snippets

Setting

The evaluation was conducted on the PC program as it was implemented in Marion County between October 2008 and March 2010. The PC program was developed by the Indiana Comprehensive Health Insurance Association (ICHIA), the state's high-risk pool, for PLWH who were also enrolled in the Health Insurance Assistance Plan (HIAP), a program operated by the Indiana State Department of Health. HIAP provides enrollees a comprehensive major medical insurance policy that covers all premium, co-payment,

Descriptive statistics

Baseline characteristics are reported in Table 1. No clinically meaningful differences in baseline characteristics were found between intervention and control groups.

Estimated effects

Clinical and adherence outcomes are shown in Table 2. Logistic regression using the GEE method showed that adherence to antiretroviral medications was greater among PC than controls, controlling for viral load at baseline. Logistic regression showed that intervention subjects were more likely than controls to get a viral load test

Discussion

This paper reports on the effects of the Positive Choices program that employed LHWs to promote better self-management of PLWH covered by Indiana's high-risk insurance pool. These LHWs used individualized collaborative problem-solving to help PLWH achieve greater adherence with medications necessary to achieve optimal health outcomes. This is in contrast to other LHW-based interventions in the United States that have focused primarily on direct-observation strategies and group therapy. Program

Financial support

This research was funded, in part, by the Indiana Comprehensive Health Insurance Association. The views expressed in this paper are those of the authors and do not necessarily represent the views of, and should not be attributed to, the Indiana Comprehensive Health Insurance Association.

Confidentiality statement

We confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.

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