Remaining in HIV Care: Improvements in North America but Much Still Needs to Be Done

Understanding the Results

The findings from the NA-ACCORD should be seen as an overview of what is happening to a clinic's population. The results cannot give a precise account of what is happening at the level of an individual. It is possible that some patients stopped visiting their doctors because they moved further away from the clinic or changed doctors. However, these reasons cannot account for the vast majority of participants who have not seen a doctor for at least a year and did not obtain laboratory monitoring in that time.

Populations and Individuals

The NA-ACCORD's findings suggest that some people who injected street drugs were more likely than others to have intermittent care. This may indicate that barriers to care exist for this population. People with low incomes also likely face barriers to care.

Examples of barriers faced by drug users and people with low incomes may include the following:

• difficulty interacting with a complex medical-health system
• costs associated with clinic visits (such as transportation)
• fees associated with the cost of insurance for drugs
• fees associated with the dispensing of prescription medicines

Most people who inject street drugs need comprehensive assistance to (initially) stabilize their addiction and, later, to overcome it. Support for their overall mental health is also likely needed. Such interventions at the individual level require commitment and building trusting relationships and they take time. At the level of a clinic, interventions with drug users often are most successful when the help of a multidisciplinary team is involved.

The NA-ACCORD's findings can be used by individual clinics to search their own databases for patients, particularly people who inject drugs, who do not see their doctor at least once a year and therefore do not get sufficient care. Such clinics can then embark on efforts to recall such individuals to the clinic for care and treatment and to investigate the reasons for insufficient contact with the medical-health system.

Clinics Need More Resources

If each clinic had only a handful of people who received irregular care, recalling such patients and interviewing them about their issues would not be a major problem. However, if the number of patients not in regular care becomes large, clinics will need additional funds to not only re-engage patients but also to provide the services that are needed by people trying to recover from substance use.

Furthermore, in different parts of Canada and the U.S., clinic populations are different, so there may be a need for the creation of new services, intensification of existing services, and outreach. For instance, Canadian research has found that in the Prairie and Pacific regions, Aboriginal people who are HIV positive may also inject street drugs. Care and engagement of Aboriginal people and getting them to trust the medical-health system will require cooperation with local Aboriginal organizations as well as groups and agencies that provide services for drug users.

Not Just About Care

If healthcare authorities put more funding toward engaging a significant portion of HIV-positive people in regular care and treatment and addressing issues such as substance use, patients can be helped onto the path of not only improving their immune systems but also their psychological sense of well-being. Keeping people on treatment and in care also has other benefits, such as the following:

• It helps to prevent patients from developing life-threatening infections. Such infections are extremely costly for the emergency and infectious disease departments of hospitals to treat.
• It helps Canada and other high-income countries move toward the goal of reducing the onward spread of HIV. At the level of a large population, such as in a region, there are likely to be fewer HIV transmissions from people taking ART. Moreover, people who are in care and on treatment can be counselled about taking steps to further lower transmission risks to their partners. This also helps to reduce future costs to the system.

Looking ahead, funding agencies and regional authorities should be aware that research will need to be targeted at specific regions in Canada and in the U.S. in order to understand the needs of different clinic populations and how to retain them in care.

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