Telehealth and Use of Technology to Improve Access to Care for People Living with HIV/AIDS

This model uses technology to provide access to health and human services, education, and clinical training across distance.

Telehealth can be a key component of delivering HIV/AIDS specialty care in rural communities because it connects people living with HIV to providers and specialists and makes it possible for them to receive services without having to travel (sometimes across multiple counties or out of state) to a clinical setting. Telemedicine, a form of telehealth that specifically refers to providing remote clinical services, has been shown to be effective at increasing medication adherence for people with HIV. Text message-based health interventions can make education and self-management assistance more accessible for people living with HIV.

Increasingly, technology is also being used to deliver training and support to providers serving people in rural and remote areas. HIV specialists and researchers from academic medical centers or urban clinics can use video conferencing technology to provide real-time clinical expertise to rural providers with small or complex HIV/AIDS caseloads.

For more information about telehealth approaches and implementation of rural programs that use technology to improve access to care, see the Rural Telehealth Toolkit.

Examples of Programs that use Telehealth and Technology to Improve Access to Quality Care for People Living with HIV/AIDS:

Medical Advocacy and Outreach (MAO) is a community-based organization that provides care to residents of rural Alabama and offers telemedicine services to deliver care in a manner that overcomes some of the challenges of living in a rural area with a shortage of HIV providers. MAO offers a variety of services, including HIV testing and prevention education, secure video chats with primary care doctors, and food bank and translation services. MAO has worked with several partners to expand the reach of the program and to increase the number of patients included in the program.
Telehealth Collaborative Care for Rural HIV Patients is a U.S. Department of Veterans Affairs (VA) program that targets rural veterans living with HIV/AIDS to connect them virtually with HIV/AIDS care teams to provide healthcare services. The VA care teams work with the local VA outpatient clinics in addition to the telehealth services. Both of these enable veterans to access HIV specialty care closer to home. An evaluation of this program explored the experiences of HIV-positive veterans in rural Illinois and Iowa and found that the program provided increased access to comprehensive care for people living with HIV/AIDS.
Louisiana Public Health Information Exchange (LaPHIE) is a public health information exchange that healthcare providers and organizations are using in Louisiana to access and share health information on a secure network. The network links providers' electronic medical record data with state health surveillance data. It is used to diagnose, monitor, and treat a variety of different chronic conditions, including HIV/AIDS and hepatitis C. The system monitors people's care and appointments and will automatically send a message to the providers when a person has not received HIV care in over a year, has a change in status, or has upcoming appointments. This message can prompt the provider to discuss the importance of continuous treatment and medication adherence with people during visits and facilitates communication and tracking of people living with or at high risk for HIV. In a pilot phase of LaPHIE, over 80% of people returned for a follow-up visit during the pilot period after their provider engaged them in a discussion about the importance of care. The Georgia Department of Public Health has also received funding to develop a similar health information exchange to help retain people receiving care for HIV/AIDS.
Clinical decision support systems such as Virology FastTrack have shown promise in reducing the length of time it takes for people living with HIV/AIDS to follow up with clinical care visits and keeping them engaged in care. When this support software was tested in one urban hospital, the people also showed improvements in CD4 counts, suggesting improvements in immune function. While this specific software has not been tested in a rural clinic setting, clinical decision support systems show promise for improving care for people in non-urban environments as well.

Considerations for Implementation

Reliable, high-speed internet access is essential to successfully implement telehealth programs and other interventions that rely on technology. Additionally, some telehealth interventions require people to have access to internet in their homes or data-enabled mobile devices so that they can take full advantage of the services available. The Fourteenth Broadband Deployment Report, published by the Federal Communications Commission (FCC) highlights the persistent gaps around the country in access to broadband internet at speeds considered to be adequate by the FCC. This report found that approximately 17% of people living in rural regions did not have access to fixed terrestrial broadband at sufficient speeds.

Financial implications are also important to consider as new technology can be expensive; program implementers should consider the kinds of upfront and maintenance costs the technology will require for both the implementation site and program participants.

As with any program, resources are a key consideration for implementation. In addition to needing specific technology to implement and maintain the program, other resources may be required, such as trained clinical staff and community partnerships to help ensure the program runs effectively.

Medicare, Medicaid, and state funding mechanisms have different rules about the type of telehealth services eligible for reimbursement. In a semi-annual survey about Medicaid and state policies related to telehealth, the Center for Connected Health Policy found that every state has a different reimbursement policy for telehealth services. These policies can complicate implementation of telehealth programs since an organization in a rural area, assuming proper licensure of its providers, may serve residents from surrounding states that have different reimbursement policies. For people with private insurance, there are no federal laws that require private health plans to cover telehealth services and, as a result, many insurance plans do not cover them. Identifying alternative funding streams may be an important consideration when reimbursement is not an option. Additional resources below explain the different state policies in place and describe how they can influence reimbursement.

Information exchanges such as the LaPHIE can be useful mechanisms for following up on people who miss appointments and have trouble with medication adherence because it can alert providers to these issues. These types of models involve statewide investment, resources, and infrastructure that could also be challenging to implement in certain locations.

For more information about implementation strategies for rural telehealth programs, see Implementation Strategies for Rural Community Telehealth Programs.

Resources to Learn More

Barriers to Care for Rural People Living with HIV: A Review of Domestic Research and Health Care Models
Document
A systematic review conducted to explore barriers to care for rural people living with HIV. Discusses limited transportation, community stigma, and concerns about patient confidentiality and financial considerations.
Author(s): Pellowski, J.A.
Citation: The Journal of the Association of Nurses in AIDS Care, 24(5), 422-437
Date: 2013

Improving Access to HIV/AIDS Care in the Rural South: Alleviating Structural Barriers Using Telemedicine
Video/Multimedia
Webinar demonstrating how telehealth can effectively be used to improve access to and quality of HIV/AIDS care.
Organization(s): Alabama Department of Public Health (ADPH), Southern AIDS Coalition
Date: 1/2013

Mapping Broadband Health in America
Website
A tool providing a visual representation of broadband access data and specific types of health data, such as preventable hospitalizations. Users can explore the map to see how broadband access may be related to certain health outcomes on the national, state, or county level. The tool identifies rural counties and ranks the top 100 priority rural counties in terms of critical need for broadband connectivity.
Organization(s): Federal Communications Commission (FCC)

State Telehealth Laws and Reimbursement Policies Report
Webpage
Explains state laws and policies for reimbursement for telehealth services. Reimbursement policies vary by state and by Medicaid regulations and this report provides updates on any changes to policies made in the last several months.
Organization(s): Center for Connected Health Policy

Getting Started with Telehealth in Rural Communities to Improve Access to Care for People with HIV
Video/Multimedia
Presentation given at the 2020 National Ryan White Conference on HIV Care & Treatment highlighting the opportunities telemedicine provides to extend health services to rural communities. Offers participants strategies for starting and maintaining a telehealth program to improve access.
Organization(s): HRSA and Ryan White HIV/AIDS Program
Year: 2020

Successful Use of Telehealth in Rural Communities: An Emerging Model of Care for HIV Providers
Video/Multimedia
Presentation given at the 2020 National Ryan White Conference on HIV Care & Treatment highlighting the successes and challenges in the implementation of telehealth by providers in primary healthcare, behavioral health, and dentistry settings.
Organization(s): HRSA and Ryan White HIV/AIDS Program
Date: 2020