The use of combination anti-viral drugs has led to successful treatment and care of those who have HIV and AIDS, to the point where many individuals are able to live relatively healthy lives with normal lifespans.

But that success depends greatly on strict adherence to a sometimes complex medication and follow-up care regimen, something that not all HIV patients can attain. In fact, hospitalized HIV patients are among those with the highest readmission rates, meaning they are readmitted into the hospital within 30 days of discharge. Healthcare experts say various medical and social factors account for that high rate.

An innovative project at Parkland Health & Hospital System that focuses on both the inpatient and outpatient care of HIV patients has led to significant reductions, as much as 40 percent, in the rate of readmissions. Parkland’s HIV Transitional Care Project, a three-year effort that began in fiscal year 2014, uses a multidisciplinary team of HIV specialists that includes physicians, mid-level providers such as nurse practitioners or physician assistants, transition nurses, pharmacists and social workers to care for and instruct inpatients to help them make the transition to outpatient care.

“HIV patients need to have specialty care and they need far more coordinated care, not just for medical issues but also social needs,” said Ank Nijhawan, MD, one of the HIV specialists involved with the Parkland project. Dr. Nijhawan also is an Assistant Professor of Internal Medicine at UT Southwestern Medical Center. “For HIV inpatients, that kind of care is vital. But some patients, for whatever reason, do not follow up with their medication or plan of care, and that leads to them being hospitalized again or even dying. We have patients, many in their 20s and 30s, who still die from this disease.”

According to John Raish, Parkland’s Vice President of Transformational Initiatives, the HIV Transitional Care Project is one of the system’s 1115 waiver projects that provide state funding for uncompensated care and for programs that increase healthcare access to underserved populations.

“We feel the HIV Project has been a great success and is a great example of why the 1115 Waiver programs are crucial for improving healthcare in Texas. We have actually far exceeded our goals in terms of number of patients served,” Raish said. “Realistically, we have reduced the number of HIV patients we would have expected to readmit by about 40 percent.”

The HIV Transitional Care Project is important, Dr. Nijhawan added, because of the great difference medicines can make in a patient’s life. Medication can often effectively lower a patient’s viral load (the amount of HIV in the blood) to levels that cannot be detected by most common testing. While the person is still infected with HIV, their risk of developing a serious opportunistic infection is greatly reduced.

Mamta Jain, MD, who also works on the Parkland HIV Project and is an Associate Professor of Internal Medicine at UT Southwestern, said readmissions had been high at Parkland because of the vulnerable populations that the hospital system treats. “Through this waiver project, Parkland was able to hire the dedicated staff who can make a difference in those HIV readmissions.”

Dr. Nijhawan previously worked on an HIV readmissions study that showed HIV patients had readmission rates of about 25 percent, higher than other diseases such as heart disease and pneumonia. The study, conducted in conjunction with the Parkland Center for Clinical Innovation (PCCI), was published in 2012 in the Journal of Acquired Immune Deficiency Syndrome.

The study confirmed that in addition to medical issues, such as the severity of opportunistic infections and access to medicines, social factors such as housing instability, lack of insurance, distance to healthcare facilities and poverty contributed to readmission rates.

As a result of the HIV Project, Dr. Nijhawan said, many HIV patients are enjoying a better quality of life.

“Many of our patients have spoken about the great improvements they’ve experienced. They’ve had fewer illnesses and are able to live more normal lives,” Dr. Nijhawan said.