services and increased viral suppression compared with
nonintegrated HIV clinics in VHA.32,33
A qualitative study of care integration found that in
VHA HIV clinics that were integrated, patients reported
less stigma and more positive relationships with their
providers.34 The VHA Office of Public Health, in collaboration with the Office of Academic Affiliations, has
supported the expansion of a postdoctoral fellowship in
clinical psychology with a specific focus on integrated
HIV and hepatitis C clinical care in an effort to increase
the availability of mental health providers specifically
trained to address MH/SUDs in the HIV-infected population. This national fellowship program has been described in detail elsewhere.11
The HIV care continuum is a useful model to describe
the cascade of HIV care and opportunities for points of
engagement. Although VHA may be performing higher
along the care continuum than national samples, there
is still much work to be done to better understand
the barriers to engagement and interventions that will
boost each step so that more veterans with HIV infec-
tion achieve viral suppression.
Increasing access to mental health and substance use
services, particularly through integrated care models, as
well as addressing issues of HIV-related stigma, may positively impact engagement in HIV clinical care. Given
the use of electronic medical records, the availability of
MH/SUD treatment, and the increasing emphasis on integrated HIV care at multiple facilities across the system,
the VHA is well positioned to address gaps in care, with
a particular focus on the role that MH/SUDs have in HIV
care continuum drop-offs.
The authors report no actual or potential conflicts of interest
with regard to this article.
Figure 2. VA Facility-Level Performance Across the HIV Care Continuum Compared
With National Samples8-10,a
Reprinted with permission from AIDS RESEARCH AND HUMAN RETROVIRUSES, 2014, published by Mary Ann Liebert, Inc., New Rochelle, NY.
Abbreviations: ART, antiretroviral therapy; HIV, human immunodeficiency virus; VL, HIV viral load.
aProportions of people living with HIV and receiving care at the Atlanta VAMC who are engaged in selected stages of the continuum
of HIV care where stages are dependent subsets of upstream stages (dark pink) vs national proportions of HIV-infected individuals engaged in selected
stages of the cascade of HIV care as estimated by Gardner et al9 (pink) and Hall et al10 (light pink).
HIV Infected VL
Atlanta VAMC National (Gardner et al) National (Hall et al)