Integrating Evidence-Based Practice Into QI to Improve Patient Outcomes in HIV:
Viral Load Suppression
Victoria Lieb, ACRN, MPH; Carla Rossi, MD; Jaime Bloss, CRNP, MSN; Christa DeLong, MA; Rebecca Haffner, MA; & Kailly Muthard, MSW
Background & Purpose
Viral load (VL) suppression is key to both
improving patient outcomes in HIV and to
decreasing community viral load.
Patient
adherence to antiretroviral therapy (ART) is
crucial in achieving VL suppression and
preventing viral resistance.
The Easton Community HIV/AIDS Organization
(ECHO), a Ryan White Part C program in eastern
Pennsylvania, began to participate in the
National Quality Center’s In+Care program in
October 2011. Viral Load (VL) Suppression is
defined by In+Care as a VL <200 copies/ml.
• ECHO Baseline VL Suppression Rate: 67%
• National Benchmark Data:
81.9% (top 25%)
86.5% (top 10%).
Results
Evidence-Based Strategies Utilized
• Individualized patient-centered approach
• Adherence assessments by phone or in
person for unsuppressed patients conducted
by RN within 2 weeks
• Motivational interviewing techniques utilized
in adherence counseling
• Adherence tools: alarmed pill boxes, cell
phone alarms, phone call reminders, officebased pill box refills, and frequent phone call
follow-up.
• Brief adherence intervention during yearly
wellness visits.
Easton Community HIV/AIDS Organization
Guideline for Management of Unsuppressed
Viral Load
Viral Load < 200
Goals of ECHO’s quality improvement project:
• Increase the percent of patients with a
suppressed viral load
• Incorporate evidence-based practices into
patient care
• Develop standardized processes for the
management of unsuppressed patients
Adherence
Assessment by
phone or in-person
within 2 weeks
Adherence
Issues
Identified
Formulate &
Implement
Adherence Plan
No
Adherence
Issues



Recheck VL
in 3 months
or less
Methods
We convened a multidisciplinary team (MD,
NP, RN, CM, MA’s) which:
• Conducted a literature search to
determine best practices
• Utilized DHHS guidelines and IAPAC
guidelines
• Completed process flow diagrams for
clinical & non-clinical processes
• Incorporated evidence-based strategies
into an adherence program
• Developed an algorithm for clinical
management of unsuppressed patients

Consider /Do
Genotype
Consider/Do Tropism
& HLAB5701
Evaluate for Drug-Drug
Interactions
Consider/ Make Med 
2nd VL <200
2nd VL >200
Routine VL
Monitoring
Every 3-4
Months
Easton Community HIV Organization
Percent of Patients with Suppressed Viral Load
October 2011 - October 2013
80%
79%
78%
77%
76%
75%
74%
73%
75%
79%
77%
75%
74%
72%
73.00%
70%
69%
68%
66%
67%
64%
62%
60%
Conclusions
Viral Load > 200
Adherence
Assessment at Next
Appointment
No
Adherence
Issues
Viral load suppression increased 19%, from
67% of all patients to 79%.
Ongoing Adherence
Monitoring and VL
Testing at 2-3 Month
Intervals Until
Undetectable
Adherence Counseling Using Motivational Interviewing Techniques (OARS)
Open-Ended Questions:
“It’s hard for many people with HIV to take their medications. So tell me
how you find that it’s going for you.”
Affirmations:
“You’ve done really well over the past year in coming to appointments and
getting your lab work done.”
Reflective Listening:
“It sounds like you’re trying to juggle a lot of things right now and
sometimes it’s hard for you to remember to take your pills.”
Summaries:
“ You’ve had to deal with some unexpected things in your personal life
lately that have kind of taken your focus off of taking good care of yourself.,
But you’re willing to try some new things to help you remember to take your
medicines and to keep in contact with us more frequently over the next
several months until you’re back on track. Let’s check back in a month and
see how it’s going.”
An
individualized,
patient-centered
approach incorporating evidence-based
clinical guidelines is effective in achieving
viral load suppression for many patients.
We developed a clinical management
guideline based on Department of Health
and Human Services (DHHS) guidelines and
adherence guidelines published by the
International Association of Physicians in
AIDS Care (IAPAC) and other published
studies. Our results indicate that a
combination of current clinical practice
guidelines and adherence counseling which
utilizes motivational interviewing techniques
can help patients to improve and maintain
adherence to ART.
References
International Association of Physicians in AIDS Care. (2012). Guidelines for improving entry into and retention in
care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International
Association of Physicians in AIDS Care Panel. Retrieved from Agency for Healthcare Research and Quality website:
http://www.guideline.gov/content.aspx?id=36947&search=iapac
International Association of Physicians in AIDS Care website. (n.d.). http://www.iapac.org/AboutUs01.html
Panel on Antiretroviral Guidelines for Adults and Adolescents. (2012). Guidelines for the use of antiretroviral
agents in HIV-1 infected adults and adolescents. Retrieved from AIDSinfo website:
http://www.aidsinfo.nih.gov/contentfiles/guidelines/adultandadolescentgl.pdf
Rollnick, S., Miller, W., & Butler, C. (2008). Motivational interviewing in health care. New York, NY: Guilford .
Simoni, J. M., Amico, R., Pearson, C., & Malow, R. (2008). Strategies for promoting adherence to antiretroviral
therapy: A review of the literature. Current Infectious Disease Reports, 10, 515-521.