Impact of Availability of Telehealth Programs on Documented HIV Viral Suppression: A Cluster-Randomized Program Evaluation in the Veterans Health Administration

Abstract

Background: Telehealth may improve care for people with HIV who live far from HIV specialty clinics. We conducted a cluster-randomized evaluation to determine the impact of availability of HIV telehealth programs on documented viral suppression in Veterans Administration clinics.

Methods: In 2015-2016, people who previously traveled to HIV specialty clinics were offered telehealth visits in nearby primary care clinics. Patients were cluster-randomized to immediate telehealth availability (n = 925 patients in service areas of 13 primary care clinics offering telehealth) or availability 1 year later (n = 745 patients in 12 clinics). Measures during the evaluation year included telehealth use among patients in areas where telehealth was available and documented HIV viral suppression (viral load performed and <200 copies/mL). Impact of telehealth availability was determined using intention-to-treat (ITT) analyses that compared outcomes for patients in areas where telehealth was available with outcomes for patients where telehealth was not available, regardless of telehealth use. Complier average causal effects (CACEs) compared outcomes for telehealth users with outcomes for control patients with equal propensity to use telehealth, when available.

Results: Overall, 120 (13.0%) patients utilized telehealth when it was available. Availability of telehealth programs led to small improvements in viral suppression in ITT analyses (78.3% vs 74.1%; relative risk [RR], 1.06; 95% confidence interval [CI], 1.01 to 1.11) and large improvements among telehealth users in CACE analyses (91.5% vs 80.0%; RR, 1.14; 95% CI, 1.01 to 1.30).

Conclusions: Availability of telehealth programs improved documented viral suppression. HIV clinics should offer telehealth visits for patients facing travel burdens.

Keywords: HIV; randomized trial; telehealth; veterans.

Figure 1.

Map showing geographic service areas of 9 primary care clinics in the Atlanta VA network based on existing road drive times. Service areas are irregularly shaped due to variation in road networks. In the baseline year, patients traveled to the HIV specialty care clinic (see map legend) in the main facility for care. In the evaluation year, patients were offered telehealth if they resided in the service area of clinics randomized to host HIV telehealth visits (shaded areas). Patients in these areas were given the option of using telehealth visits in the nearest primary care clinic or continuing to travel to the HIV specialty clinic. Patients in service areas of control clinics (unshaded areas) were offered telehealth at the end of the evaluation year. Patients living closer to the HIV specialty clinic than to a primary care clinic were not offered telehealth and not included in analyses. See the “Methods” section for details.

Figure 2.

Flowchart showing assignment of 25 primary care clinics and associated patients to telehealth and control status. Primary care clinics were affiliated with 3 HIV specialty care clinics in 3 networks.