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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. The Health Resources Services Administration defines telehealth as:

“the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration”

Telehealth is a broader term encompassing more comprehensive care than telemedicine, which specifically refers to providing remote clinical services.

Telehealth can be a key component of delivering HIV/AIDS specialty care in rural communities because it connects people living with HIV/AIDS 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.

Increasingly, technology is also being used to deliver training and support to providers serving patients 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.

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 to patients, 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 patients' care and appointments and will automatically send a message to the providers when a patient 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 patients during visits and facilitates communication and tracking of patients living with or at high risk for HIV. In a pilot phase of LaPHIE, over 80% of patients 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 HIV/AIDS patients in care.
  • Clinical decision support systems such as Virology FastTrack have shown promise in reducing the length of time it takes for HIV/AIDS patients to follow up with clinical care visits and keeping patients engaged in care. When this support software was tested in one urban hospital, the patient population 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 patients 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. A report released in 2016 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 an estimated 40% of people living in rural regions and in designated tribal areas did not have access to internet 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 an 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 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, most 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 patients 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.

Resources to Learn More

Barriers to Care for Rural People Living with HIV: A Review of Domestic Research and Health Care Models
A systematic review conducted to explore barriers to care for rural people living with HIV. Barriers include 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 (JANAC), 24(5), 422-437
Date: 2013

Improving Access to HIV/AIDS Care in the Rural South: Alleviating Structural Barriers Using Telemedicine
Part 1 of a four-part series of video presentations that describe how telehealth can effectively be used to improve access to and quality of HIV/AIDS care.
Organization(s): Southern AIDS Coalition
Date: 1/2013

Mapping Broadband Health in America
Mapping tool that provides a visual representation of broadband data access as well as specific types of health data, such as preventable hospitalizations. Users can explore the map to see how broadband data access may be related to certain health outcomes on the national, state, or county level. The mapping tool also has a feature which can identify rural counties and identifies the top 100 priority rural counties in terms of broadband connectivity.
Organization(s): Federal Communications Commission

Mixed-Methods Evaluation of a Telehealth Collaborative Care Program for Persons with HIV Infection in Rural Settings
Issue brief summarizing the evaluation of the Veterans Affairs Telehealth Collaborative Care Program and its implementation effectiveness in rural areas. Explains the program, its own evaluation, and key findings on program barriers and successes.
Author(s): Ohl, M., Dillon, D., Moeckli, J., et al.
Organization(s): U.S. Department of Veterans Affairs
Date: 2013

Recent Advances (2011-2012) in Technology-Delivered Interventions for People Living with HIV
Systematic review of identified interventions for people living with HIV/AIDS that were delivered using technology. The authors identified twelve studies for inclusion in the review and found that the majority of studies identified targeted the use of technology for medication adherence. The article highlights several gaps in research focused on engaging and retaining patients in care.
Author(s): Pellowski, J.A., & Kalichman, S.C.
Citation: Current HIV/AIDS Reports, 9(4), 326-334
Date: 12/2012

Current State Laws and Reimbursement Policies Telehealth
Explains state laws and policies for reimbursement for telehealth services. These regulations vary by state and by Medicaid regulations. Policies can be sorted by specific state or type of legislation.
Organization(s): Center for Connected Health Policy