GA
The HIV Telehealth Collaborative Care program (HIV TCC) was developed by the Veterans Health Administration (VA) Office of Rural Health to provide HIV care via telehealth to veterans living in rural areas. Through partnerships between HIV specialty clinics in large, mainly urban VA hospitals, and rural primary care clinics, veterans attend appointments with HIV specialists via telehealth at primary care clinics close to their homes. An evaluation of the intervention in the Atlanta metropolitan area and surrounding rural counties showed that the availability of telehealth led to increases in rates of viral suppression and retention in care. Based on this success, HIV TCC has been expanded to multiple sites in 16 other states as of 2024.
The VA health care system is the single largest medical provider for individuals with HIV in the United States.1 However, many VA HIV clinics are in large urban areas, and veterans living in rural areas must often travel to receive HIV care, with some traveling as far as 90 minutes each way. This type of travel is not sustainable for many rural veterans and can lead to them falling out of care. However, through telehealth appointments, veterans can receive the same quality of care closer to home; thus, removing the travel barrier can lead to improved HIV outcomes.
Veterans visit a primary care clinic close to their home and connect via video telehealth conference with an HIV specialist at the VA hospital-based HIV specialty clinic. Clinicians at the primary care clinic facilitate the appointment and conduct many of the care elements typical of an in-person visit.1 Telehealth technicians assist patients with the use of the videoconferencing technology and technology for limited physical exams (e.g., remote stethoscopes and high-resolution cameras).2 Technicians also help facilitate the appointment with the HIV specialist by obtaining vital signs. In some cases, primary care clinics have laboratory and basic radiology facilities and share results with the HIV specialist, if relevant. A national pharmacy formulary program integrated into VHA telehealth services also serves as an important lifeline for timely antiretroviral therapy (ART) distribution.
In addition to providing a venue for the clinical telehealth services, the local primary care clinic provides “shared-care” with the infectious disease/HIV specialist that focuses on general primary care relevant to HIV. These focus areas include collaborative care on reduction of cardiovascular risk by treating hyperlipidemia, hypertension, diabetes, tobacco/substance use, as well as checking for latent tuberculosis, bone density status, and renal function—all integral to comprehensive HIV care. The infectious disease/HIV specialist ensures that immunizations and HIV-related cancer screenings are up to date. A care manager at the VA HIV specialty clinic helps patients navigate the shared-care model, enabling successful continuation of telehealth provision for veterans with HIV—all within the VA system.
The Veterans Rural Health Resource Center–Iowa City conducted an evaluation of the HIV TCC intervention from 2015 to 2016 in the Atlanta metropolitan area and surrounding rural counties. Evaluators conducted both an intention-to-treat (ITT) analysis and a complier average causal effects (CACE) analysis for retention in care and viral suppression. The ITT analyses compared 925 patients in 13 telehealth-enabled clinics to 745 patients in control clinics. The CACE analyses compared telehealth users with patients in control areas with equal propensity to use telehealth. Both analyses found that patients in the telehealth intervention group had higher rates of viral suppression and retention in care.
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Source: Ohl ME, Richardson K, Rodriguez-Barradas MC, et al. Impact of availability of telehealth programs on documented HIV viral suppression: A cluster-randomized program evaluation in the Veterans Health Administration. Open Forum Infect Dis. 2019;6(6)
Specialty and primary care team collaboration via telehealth. The VA-based infectious disease HIV specialty clinic team includes a program coordinator, HIV specialist physician, HIV care nurse or pharmacy manager, and facility telehealth coordinator. The VA team partners with rural primary care clinics to provide the technology necessary for veterans to receive HIV care via telehealth closer to home, or in many cases, direct to home via VA Video Connect (VVC).
Implementation in phases. In the pre-implementation phase (the first six months), the focus was on building rapport and sharing knowledge with primary care clinics, as well as connecting them with the HIV care team at the VA HIV specialty clinic. Additionally, this time was used for outreach to potential patients to determine eligibility and interest. The implementation phase occurred during months 7-12 and revolved around delivering HIV care via telehealth to patients. The sustainment phase in months 13-24 included evaluating patient outcome data and conducting interviews with patients, physicians, and support staff. The year-long evaluation of the intervention was used to inform adjustments to the intervention and to support the case for continued expansion.
Use of VA databases. The HIV TCC program utilizes a data-to-care model, in which national VHA data compendiums are securely utilized via dashboards to identify patients who may need linkage to care, as evidenced by an elevated HIV viral load or lapse of laboratory monitoring or clinical visit. At that point, the patient care navigation team identifies and relinks the veteran to HIV care and prevention services by offering a clinic-based or home telehealth appointment with an HIV specialist.
Funding continues to be provided by the VA’s Office of Rural Health. HIV TCC has expanded beyond the original 2011 pilot in Iowa City, Iowa, to include 22 other sites, with locations in Texas, Georgia, Indiana, Maine, Tennessee, Ohio, Missouri, Mississippi, Washington, Oregon, California, North Carolina, Arizona, and Minnesota. The most recent expansion in 2023-2024 included the VA Pacific Health Care System based in Hawaii, and the Central Alabama VA Health Care System located in Birmingham, AL. In 2020, HIV pre-exposure prophylaxis (PrEP) was formally integrated into this program, solidifying the first nationally integrated PrEP telehealth program in the United States.
Telehealth improves quality and continuity of care for HIV. For Veterans with HIV living in rural areas, having a knowledgeable HIV specialist as well as a comprehensive primary care provider is key to successful outcomes. The VA continues to establish robust telehealth infrastructure nationally to link primary care clinics to specialty care services, thus maintaining continuity of care for veterans with HIV.
Primary care clinics may need support to set up telehealth services. Rural primary care clinics have competing demands and limited access to internet or cellular capabilities. Therefore, the VA provides intensive support to the primary care clinics. The VA helped primary care clinics set up their telehealth capabilities and provided solutions for improving their internet capabilities. HIV care managers are hired to work with VA HIV specialty clinic teams to help primary care clinics work with patients and navigate the shared-care model.
Confidentiality is still important in HIV care via telehealth. Telehealth patients who are concerned with privacy may choose a primary care clinic slightly further from home but still closer than the VA HIV specialty clinic to avoid these concerns.
The VA population is unique. Findings from the intervention’s evaluation may be difficult to extrapolate to other populations with HIV. Veterans with HIV tend to be older and more likely to be male than the general population with HIV. Additionally, the intervention was funded by the VA, which paid for the technology necessary to establish the telehealth sites.
- Ohl ME, Richardson K, Rodriguez-Barradas MC, et al. Impact of availability of telehealth programs on documented HIV viral suppression: A cluster-randomized program evaluation in the Veterans Health Administration. Open Forum Infect Dis. 2019;6(6):ofz206. doi:10.1093/ofid/ofz206
- Ohl ME, Dillon D, Goss T, Kaboli P. Telehealth collaborative care for rural veterans with HIV infection. Rural Health Promising Practices. U.S. Department of Veterans Affairs Office of Rural Health. 2016 1(1).