HIV: Managing a Complex, Chronic Condition

High drug costs, social stigma, complications, comorbidities, and complexity of the prescribed regimen, make human immunodeficiency virus (HIV) a challenging disease for patients, providers, and payors, and may prevent some patients from getting effective care.

Medication side effects can be particularly daunting. Short-term side effects of HIV medications include fever, nausea, and fatigue, while long-term side effects can include diabetes, liver damage, heart disease, depression (including suicidal thoughts), kidney problems, and even kidney failure.

A whole-patient management approach is vital. The CVS Specialty HIV Care Management program offers dedicated support through Accordant rare-disease care management nurses specially trained in HIV care.* This differentiated model proactively engages plan members to help close gaps that can exist within the traditional specialty pharmacy model. Providing members with comprehensive, continuous care helps promote adherence, improve outcomes, and reduce overall health costs. The Care Management program recently received NCQA Patient and Practitioner Oriented Disease Management (DM) accreditation for a range of conditions including HIV. The accreditation is an indication that a DM program is dedicated to giving patients and/or practitioners the support, education, and other help necessary to facilitate good outcomes and good care.

Using this Care Management model, CVS Health has seen up to 13 times greater engagement from members, including following prescribed steps to improve lifestyle or effectively address health issues.^**

Complex Disease, Comprehensive Care

Antiretroviral therapy (ART), which began in the 1990s, transformed HIV from a fatal infection to a chronic condition that must be managed for a lifetime. Although more single-tablet regimens (STRs) have been introduced in recent years, which can reduce the number of pills to manage, treatment is becoming more expensive and there are still many hurdles that too often go unaddressed. Only about 55 percent of patients prescribed ART are adherent, and non-adherence can lead to drug resistance.

About 63 percent of patients experience at least one gap in care, which can be dangerous. Gaps in care are associated with poorer outcomes, such as increased hospitalizations and a higher mortality rate.

Another significant factor in patients delaying or stopping treatment is the high prevalence of comorbidities. About 25 percent of those with HIV have hepatitis C as well, 30 percent may have kidney disease, and people with HIV are at much higher risk for some cancers.

Although there is no simple HIV case, the degree of complexity depends on several factors, such as gender, age, financial situation, geographical location, and whether the patient belongs to a particular high-risk group. Effectively managing these challenges can help improve health outcomes and lower costs, for patients and payors.

Specially trained Accordant rare-disease care management nurses conduct a total health assessment of patients and regularly engage with patients throughout the course of treatment. Patient support is available 365 days a year. We are also utilizing technology tools including a cell phone app, website, and email to make it easier for patients to engage with us through a channel of their choosing.

In our effort to continually expand the plan designs we can support, we’ve modified the Exclusive Specialty Network to offer members greater access and flexibility when filling their HIV prescriptions. A plan with Exclusive Specialty can choose to provide members with HIV the ability to fill their prescriptions at any retail pharmacy that participates in their plan’s network.

Improved Adherence, Outcomes

Holistic Care Management helps improve outcomes and the overall patient experience. By collaborating with a patient’s other providers, assessing all of their needs, and giving them the tools to stay healthy, CVS Health offers a tailored, holistic approach to a complex disease. And it works.

Patients with access to our care management program saw a 5 percentage point improvement in medication possession ratio and reduced gaps between fills by five days, compared to retail patients.*** Care management also led to an 11 percent reduction in total health care costs for managed conditions, based on a 7 percent drop in emergency room visits and a 23 percent reduction in hospital admissions.****

By focusing on building and reinforcing patients’ understanding of their disease, helping them generate their own motivation, and supporting the creation of positive health behaviors, we can help achieve better outpatient care and disease management, and fewer complications and costs, benefits members, their providers, and payors.