Service Delivery and Patient Outcomes in Ryan White HIV/AIDS Program-Funded and -Nonfunded Health Care Facilities in the United States

A National Behavioral and Clinical Surveillance System of Adults With Diagnosed HIV (The Medical Monitoring Project): Protocol for an Annual Cross-Sectional Interview and Medical Record Abstraction Survey

BACKGROUND

The Medical Monitoring Project (MMP) is a national population-based behavioral and clinical surveillance system of adults with diagnosed HIV in the United States, and it is sponsored by the Centers for Disease Control and Prevention (CDC). Its purpose is to provide locally and nationally representative estimates of factors affecting HIV transmission risk and clinical outcomes.

OBJECTIVE

This study aimed to describe the rationale for and methodology of the MMP, in addition to its contribution to evaluating and monitoring HIV prevention, care, and treatment efforts in the United States.

METHODS

MMP employs a stratified 2-stage sample design to select annual samples of persons living with diagnosed HIV from the National HIV Surveillance System and conducts interviews and medical record abstractions with participating persons.

RESULTS

MMP data are published routinely via annual reports, conference presentations, and scientific publications. Data may be accessed upon request from the CDC, contingent on the guidelines established for the security and confidentiality of HIV surveillance data.

CONCLUSIONS

MMP is the only source of annual population-based data on the behaviors and clinical care of persons with diagnosed HIV in the United States. It provides essential information for monitoring progress toward national treatment and prevention goals and guiding efforts to improve the health of persons with diagnosed HIV and prevent HIV transmission.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/15453.

The Association of Unmet Needs With Subsequent Retention in Care and HIV Suppression Among Hospitalized Patients With HIV Who Are Out of Care

BACKGROUND

Unmet needs among hospitalized patients with HIV may prevent engagement in HIV care leading to worse clinical outcomes. Our aim was to examine the role of unmet subsistence needs (eg, housing, transportation, and food) and medical needs (eg, mental health and substance abuse treatment) as barriers for retention in HIV care and viral load (VL) suppression.

METHODS

We used data from the Mentor Approach for Promoting Patients' Self-Care intervention study, the enrolled hospitalized HIV patients at a large publicly funded hospital between 2010 and 2013, who were out-of-care. We examined the effect of unmet needs on retention in HIV care (attended HIV appointments within 0-30 days and 30-180 days) and VL suppression, 6 months after discharge.

RESULTS

Four hundred seventeen participants were enrolled, 78% reported having ≥1 unmet need at baseline, most commonly dental care (55%), financial (43%), or housing needs (34%). Participants with unmet needs at baseline, compared to those with no needs, were more likely to be African American, have an existing HIV diagnosis and be insured. An unmet need for transportation was associated with lower odds of retention in care [odds ratio (OR): 0.5; 95% confidence interval (CI): 0.34 to 0.94, P = 0.03], even after adjusting for other factors. Compared to participants with no need, those who reported ≥3 unmet subsistence needs were less likely to demonstrate VL improvement (OR: 0.51; 95% CI: 0.28 to 0.92; P = 0.03) and to be retained in care (OR: 0.52; 95% CI: 0.28 to 0.95; P = 0.03).

CONCLUSION

Broader access to programs that can assist in meeting subsistence needs among hospitalized patients could have significant individual and public health benefits.

Reducing Health Care Disparities in Sickle Cell Disease: A Review

Sickle cell disease (SCD) is an inherited blood disorder most common among African American and Hispanic American persons. The disease can cause substantial, long-term, and costly health problems, including infections, stroke, and kidney failure, many of which can reduce life expectancy. Disparities in receiving health care among African Americans and other racial/ethnic minority groups in the United States are well known and directly related to poor outcomes associated with SCD. As an orphan disease-one that affects <200 000 persons nationwide-SCD does not receive the research funding and pharmaceutical investment directed to other orphan diseases. For example, cystic fibrosis affects fewer than half the number of persons but receives 3.5 times the funding from the National Institutes of Health and 440 times the funding from national foundations. In this review, we discuss the health inequities affecting persons with SCD, describe programs intended to improve their care, and identify actions that could be taken to further reduce these inequities, improve care, control treatment costs, and ease the burden of disease.

Factors Associated With Gaps in Medicaid Enrollment Among People With HIV and the Effect of Gaps on Viral Suppression

INTRODUCTION

Gaps in Medicaid enrollment may affect HIV outcomes. We evaluated factors associated with Medicaid enrollment gaps and their effect on viral suppression (VS) within the HIV Research Network.

METHODS

We used a combined data set with Medicaid enrollment files from 2006 to 2010 and HIV Research Network demographic and clinical data. A gap was defined as ≥1 month without Medicaid and gap length was determined. We used multivariable logistic regression to determine factors associated with a gap and multivariable logistic regression with generalized estimated equations to evaluate factors associated with VS after gap.

RESULTS

Of 5836 participants, the majority were male, of black race, and aged 25-50 years. More than half had a gap in Medicaid. Factors associated with a gap included male sex [adjusted odds ratio (aOR) 1.79, (1.53, 2.08)] and younger age (aORs ranging from 1.50 to 4.13 comparing younger age groups to age >50, P < 0.05 for all). About a quarter of gaps had VS information before and after gap. Of those, 53.7% had VS both before and after gap and 25.8% were unsuppressed both before and after gap. The strongest association with VS after gap was VS before gap [aOR 15.76 (10.48, 23.69)]. Transition into Ryan White HIV/AIDS Program coverage during Medicaid gaps was common (28% of all transitions).

CONCLUSIONS

Gaps in Medicaid enrollment were common and many individuals with pre-gap VS maintained VS after gap, possibly due to accessing other sources of antiretroviral therapy coverage. Implementing initiatives to maintain Medicaid enrollment and to expedite Medicaid reenrollment and having alternate resources available in gaps are important to ensure continuous antiretroviral therapy to optimize HIV outcomes.

Racial and Ethnic Differences in Viral Suppression Among HIV-Positive Women in Care

BACKGROUND

Women with HIV diagnoses are less likely to be virally suppressed than men. Women of different racial/ethnic groups may be differentially affected by sociodemographic factors. We examined differences in viral suppression among women by race/ethnicity and associated variables to inform prevention interventions.

METHODS

We used data from the 2010-2014 cycles of the Medical Monitoring Project, a cross-sectional survey of HIV-positive adults in care. We limited analyses to black, Hispanic, and white women. We calculated weighted prevalences of recent viral suppression (undetectable or <200 copies/mL) and sustained viral suppression (consistent viral suppression during the past 12 months) among women by race/ethnicity. We computed adjusted prevalence differences (aPDs) and 95% confidence intervals (CIs) for viral suppression by racial/ethnic group, controlling for selected variables, including available social determinants of health variables.

RESULTS

Among women, 62.9% were black, 19.8% Hispanic, and 17.3% white. Overall, 74.3% had recent viral suppression, and 62.3% had sustained viral suppression. Compared with white women (79.7%, CI: 77.2 to 82.2), black (72.5%, CI: 70.3 to 74.7; PD: 7.2) and Hispanic (75.4%, CI: 72.6 to 78.3; PD: 4.3) women were less likely to have recent viral suppression. In multivariable analyses, after adjusting for antiretroviral therapy adherence, HIV disease stage, age, homelessness, and education, black-white aPDs remained significant for recent (aPD: 4.8, CI: 1.6 to 8.1) and sustained (aPD: 5.0, CI: 1.1 to 9.0) viral suppression.

CONCLUSION

Viral suppression was suboptimal for all women, but more for black and Hispanic women. Differences between black, Hispanic, and white women may be partially due to antiretroviral therapy adherence, HIV disease stage, and social determinants of health factors.

Discrimination in healthcare settings among adults with recent HIV diagnoses

The prevalence of discrimination in healthcare settings among HIV patients in the United States is unknown. The Medical Monitoring Project (MMP) is a complex sample survey of adults receiving HIV medical care in the United States. We analyzed nationally representative MMP data collected 2011-2015. We assessed the prevalence of self-reported healthcare discrimination, perceived reasons for discrimination, and factors associated with discrimination among persons with HIV diagnoses ≤5 years before interview (n = 3,770). Overall, 14.1% of patients living with HIV (PLWH) experienced discrimination, of whom 82.2% attributed the discrimination to HIV. PLWH reporting poverty, homelessness, or attending a non-Ryan White HIV/AIDS Program (RWHAP) facility were more likely to report discrimination compared with other groups. Of patients attending non-RWHAP facilities, discrimination was higher among those in poverty (27.5%) vs. not in poverty (15.1%). Discrimination was associated with homelessness regardless of facility type, and was highest among homeless persons attending non-RWHAP facilities. Healthcare discrimination was commonly reported among PLWH, and was most often attributed to HIV status. Discrimination was higher among those reporting poverty or homelessness, particularly those attending non-RWHAP facilities. Incorporating practices, such as anti-discrimination training, in facilities may reduce healthcare discrimination.

Predicting Retention in HIV Primary Care: Is There a Missed Visits Continuum Based on Patient Characteristics?

Missing 3 + scheduled HIV primary care visits over a 1-year period increases mortality risk for people living with HIV (PLWH). We used electronic health data from PLWH (≥ 18 years old) at a southeastern US HIV clinic in 2016 to examine differences across patient-level characteristics and number of missed visits (1-2 vs. 0, 3 + vs. 0, 3 + vs. 1-2). In multivariable multinomial logistic regression analyses, poverty, lack of Ryan White HIV/AIDS Program support services, being uninsured, not having a high school degree, and being younger were significantly associated with 1-2 or 3 + missed visits (vs. 0 missed). Only poverty remained predictive of missing 3 + versus 1-2 visits (RR = 2.70, 95% CI 1.49-4.88). Patients at risk for missing 3 + visits present similar characteristics to patients who miss 1-2 visits. Interventions aimed at poverty reduction and increased access to education, health insurance, and support services may improve retention and, therefore, decrease mortality risk.

Generalized anxiety disorder symptoms among persons with diagnosed HIV in the United States

OBJECTIVE

To estimate the prevalence of generalized anxiety disorder (GAD) symptoms among adults with diagnosed HIV (PWH) in the United States in order to inform effective HIV prevention and care efforts.

DESIGN

The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV in the United States.

METHODS

We used MMP data collected during June 2015 to May 2016 to calculate the weighted prevalence of GAD symptoms among PWH (N = 3654) and prevalence ratios with predicted marginal means to evaluate significant differences between groups.

RESULTS

The estimated prevalence of GAD symptoms among PWH was 19%. GAD symptoms were associated with significantly lower antiretroviral therapy prescription and adherence, medical HIV care engagement, and sustained viral suppression. Persons with GAD symptoms were over three times as likely to have an unmet need for mental health services (23 vs. 7%) and had significantly more emergency room visits and hospitalizations than those without these symptoms. GAD symptoms were associated with significantly higher prevalence of condomless sex while not sustainably virally suppressed with a person not known to be taking preexposure prophylaxis (9 vs. 6%).

CONCLUSION

GAD symptom prevalence among PWH was considerably higher than among the US general adult population, indicating an excess burden of anxiety among PWH. Outcomes along the HIV care continuum were poorer, and risk for HIV transmission was higher, among persons with symptoms. Incorporating routine screening for GAD in HIV clinical settings may help improve health outcomes, reduce HIV transmission, and save healthcare costs.

The Ryan White HIV/AIDS Program after the Patient Protection and Affordable Care Act full implementation: a critical review of predictions, evidence, and future directions

The Ryan White HIV/AIDS Program (RWHAP) has been effective in serving people living with HIV (PLWH). Our goal was to examine the impact of the implementation of the Affordable Care Act (ACA) on the program's role in HIV care and its clients. We utilized critical review to synthesize the literature on the anticipated effects of the ACA, and assess the evidence regarding the early effects of the ACA on the program and on PLWH who receive RWHAP services. To date, research on the impact of ACA on RWHAP has been fragmented. Despite the expected benefits of the ACA to PLWH, access and linkage to care, reducing inequity in HIV risk and access to care, and coping with comorbidities remain pressing challenges. There are additional gaps following ACA implementation related to immigrant care. RWHAP's proven success in addressing these challenges, and the political threats to ACA, highlight the need for maintaining the program to meet HIV care needs. More evidence on the role and impact of RWHAP in this new era is needed to guide policy and practice of care for PLWH. Additional research is needed to explore RWHAP care and its clients' health outcomes following ACA implementation, with a focus on at-risk groups such as immigrants, transgender women, homeless individuals, and PLWH struggling with mental health problems.

Trends in medication adherence in HIV patients in the US, 2001 to 2012: an observational cohort study

INTRODUCTION

Adherence to antiretroviral therapy (ART) is essential to reduce HIV-related morbidity and mortality as well as the risk of virological failure and HIV transmission. We determined the trends in ART adherence during the periods of therapeutic advances, wider use of ART and greater attention to ART adherence. To understand the general trends in medication adherence, we compared ART adherence with medications for other common chronic conditions.

METHODS

A retrospective cohort study using Medicaid claims between 2001 and 2012 from 14 US states with the highest HIV prevalence. Medicaid is the largest source of care for HIV patients in the US. We identified Medicaid beneficiaries with HIV who initiated ART between 2001 and 2010 (n=23,343). Comparison groups included (1) HIV- persons who initiated a statin, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB), or metformin and (2) HIV+ persons who initiated these control medications while on and not on ART. We estimated adjusted odds of >90% medication implementation during the two years following initiation.

RESULTS

The proportion of HIV+ persons with >90% ART implementation increased from 33.5% in those who initiated in 2001 to 46.4% in 2005 and 52.4% in 2010. ART initiators in 2007 to 2010 had 53% increased odds of >90% implementation compared to those in 2001 to 2003 (adjusted OR 1.53, 99% CI: 1.34 to 1.75). Older age, male, White race, newer ART regimens and absence of substance use indicators were also associated with increased odds of >90% ART implementation. No or minimal improvements were found in the implementation of control medications in HIV- persons. For HIV- persons, the adjusted ORs comparing 2007-2010 to 2001-2003 were 1.06, 1.01 and 1.19 for statins, ACEI/ARB, metformin respectively. HIV+ persons who were on ART had, on average, 15.0 (SD: 4.2) and 16.1 (SD: 3.4) percentage points higher >90% implementation rates of concurrent statins, ACEI/ARB or metformin compared to HIV- persons and HIV+ persons who were not on ART respectively.

CONCLUSIONS

Adherence to ART substantially improved between 2001 and 2012. Nevertheless, the absolute rates of >90% implementation were low for all groups examined. Substantial disparities by age, sex and race were present, drawing attention to the need to continue to enhance medication adherence. Further studies are required to examine whether these trends and disparities persist in the most recent period.

The Ryan White HIV/AIDS Program: Supplementary Service Provision Post-Affordable Care Act

The Ryan White HIV/AIDS program (RWHAP) provides essential primary and supplementary health services to people living with HIV (PLWH). We examined the relationship between supplementary RWHAP services (Part B) and two outcomes: viral suppression (VS) and two separate measures of retention in care (RiC) based on kept- and missed-visits. We used purposive sampling to identify adult patients who received primary medical care at an academically-affiliated HIV/AIDS clinic in the southeastern United States (N = 1159) and who attended at least one scheduled HIV primary care appointment at the study site during 2015. Unadjusted and adjusted logistic regression models were fit, in which RWHAP supplementary services were the primary independent variables of interest. Age, race, gender, education level, and income were control variables. Among 1159 PLWH, 45.3% received RWHAP supplementary services in addition to public insurance, private insurance, or primary RWHAP. Among participants, 91.4% were virally suppressed, 87.4% were retained in care using the Institute of Medicine (IOM) kept-visits measure, and 60% were retained in care using the missed-visits measure. In multivariable models, patients with RWHAP supplementary services had significantly higher odds of (1) VS [adjusted odds ratio (AOR) = 1.91], (2) RiC using the IOM kept-visits measure (AOR = 2.56), and (3) RiC using the missed-visits measure (AOR = 1.58). Receipt of supplementary RWHAP services is associated with increased odds of VS and two measures of RiC when adjusting for key sociodemographic variables. Policymakers should consider the vital role of RWHAP as continued funding is uncertain.

Sustaining the HIV care provider workforce: Medical Monitoring Project HIV Provider Survey, 2013-2014

OBJECTIVE

To describe delivery of recommended HIV care and work satisfaction among infectious disease (ID) physicians, non-ID physicians, nurse practitioners (NPs), and physician assistants (PAs).

DATA SOURCES

Medical Monitoring Project 2013-2014 HIV Provider Survey.

STUDY DESIGN

Population-based complex sample survey.

DATA COLLECTION/ANALYSIS METHODS

We surveyed 2208 HIV care providers at 505 US HIV care facilities and computed weighted percentages of provider characteristics, stratified by provider type. Rao-Scott chi-square tests and logistic regression used to compare characteristics of ID physicians with each other provider type.

PRINCIPAL FINDINGS

The adjusted provider response rate was 64 percent. Among US HIV care providers, 45 percent were ID physicians, 35 percent non-ID physicians, 15 percent NPs, and 5 percent PAs. Satisfaction with administrative burden was lowest among non-ID physicians (27 percent). Compared with ID physicians, satisfaction with remuneration was lower among non-ID physicians and higher among NPs (37, 28, and 51 percent, respectively). NPs were more likely than ID physicians to report performing four of six services that are key to providing comprehensive HIV care, but more NPs planned to leave clinical practice within 5 years (19 vs 7 percent).

CONCLUSION

Addressing physician dissatisfaction with remuneration and administrative burden could help prevent a provider shortage. Strengthening the role of NPs may help sustain a high-quality workforce.

The Impact Of Medicaid Expansion On People Living With HIV And Seeking Behavioral Health Services

While Medicaid eligibility expansion created health care access for millions in California, its impact on people living with HIV has been more nuanced. Newly covered people living with HIV who have behavioral health care needs now must navigate separate mental health and substance use care systems, instead of receiving them in integrated care settings as they had under the Ryan White HIV/AIDS Program. We conducted forty-seven interviews in the period April 2015-June 2016 to examine the impact of Medicaid expansion on people living with HIV in California who had behavioral health care needs. California's historical division in its Medicaid funding streams created challenges in determining which payer should cover clients' behavioral health care. Compounding these challenges were a perceived lack of cultural competence for serving this population, insufficient infrastructure to facilitate continuity of care, and unmet need for nonmedical supportive services. The multipayer model under health reform has compromised the administrative simplicity and integrated delivery of HIV and behavioral health services previously available to uninsured patients through the Ryan White HIV/AIDS Program.

Systematic monitoring of retention in care in U.S.-based HIV care facilities

National guidelines recommend that HIV providers systematically monitor retention in care to identify and re-engage persons suboptimally in care. We described (1) U.S.-based outpatient HIV care facilities that systematically monitor retention in care, and (2) characteristics of patients attending facilities that monitored retention in care. We used data collected during 6/2014-5/2015 from the Medical Monitoring Project, an annual, cross-sectional survey that produces nationally representative estimates of characteristics of HIV-positive persons in medical care. We described systematic monitoring of retention in care among facilities and patients attending facilities providing this service using weighted percentages and 95% confidence intervals, and used Rao-Scott chi-square tests (p < .05) to assess differences by selected characteristics. Overall, 67% of facilities systematically monitored retention in care, and 81% of patients attended these facilities. Federally qualified health centers, community-based organizations, health departments, non-private practices, and Ryan White HIV/AIDS Program (RWHAP)-funded facilities were more likely to systematically monitor retention in care. Persons living in poverty, and those who were homeless or incarcerated, or injected drugs were more likely to attend facilities with this service. Although systematic monitoring of retention in care is accessible for many patients, improvements at other, non-RWHAP-funded facilities may help in reaching national prevention goals.

Identifying causes of persistent HIV viremia in adult patients at an academic medical center

Objectives:

Despite many advances in medicine, not all individuals with HIV are able to achieve complete virologic suppression. This retrospective study identifies variables associated with persistent HIV viremia in an academic clinic.

Methods:

We studied 66 HIV-infected patients with a viral load of >200 copies/mL over 1 year, with controls matched 1:1 via a propensity score utilizing age at diagnosis, era of diagnosis, gender, and initial CD4 count. We collected data on multiple variables including medications, adherence, comorbidities, hospitalizations, and insurance status. Conditional logistic regression was used for unadjusted and adjusted analyses.

Results:

A total of 66 viremic cases/matched controls were included. Fewer viremic patients were on antiretroviral therapy for all 12 months (45% vs 77%; odds ratio: 0.33, p = .018) and fewer were of white race (52% vs 70%; odds ratio: 0.49, p = .053). Hospitalization (11% vs 3%; odds ratio: 10, p = .028), underinsurance (20% vs 1%; odds ratio: 5.87, p = .022), and conflicting personal beliefs about their disease (17% vs 3%; odds ratio: 5.5, p = .027) were more common in viremic patients. Psychiatric illness increased the odds of viremia in patients who had four or more visits (odds ratio: 1.63/6.64 with four/five clinic visits, respectively).

Conclusion:

Psychiatric illness is an important contributor to the presence of persistent viremia in HIV-infected patients and deserves further study.

Accelerating Improvement in Children's Healthcare Through Quality Improvement Collaboratives: A Synthesis of Recent Efforts

Purpose of review

Quality improvement collaboratives can accelerate quality improvement and patient safety efforts. We reviewed major pediatric quality improvement collaboratives that have published results in the past five years and discussed common success factors and barriers encountered by these collaboratives.

Recent Findings

Many pediatric quality improvement collaboratives are active in neonatal, cystic fibrosis, congenital heart disease, hematology/oncoogy, chronic kidney disease, rheumatology, critical care, and general pediatric care.

Summary

Factors important to the success of these pediatric quality improvement collaboratives include data sharing and communication, trust among institutions, financial support, support from national organizations, use of a theoretical framework to guide collaboration, patient and family involvement, and incentives for participation at both the individual and institutional levels. Common barriers encountered by these collaboratives include insufficient funding or resources, legal concerns, difficulty coming to consensus on best practices and outcome measures, and overcoming cultural barriers to change. Learning from the successes and challenges encountered by these collaboratives will enable the pediatric healthcare quality improvement community to continue to evolve this approach to maximize benefits to children.

Viremia Trajectories of HIV in HIV-Positive Women in the United States, 1994-2017

IMPORTANCE

Viral suppression of HIV is an important treatment goal to decrease morbidity, mortality, and risk of transmission to others.

OBJECTIVE

To characterize longitudinal HIV viral load outcomes among women enrolled in the Women's Interagency HIV Study (WIHS).

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort study of HIV-positive women with semiannual study visits and a minimum of 5 follow-up visits was conducted from 1994 to 2017. The WIHS sites included in this analysis are in Brooklyn and Bronx, New York; Chicago, Illinois; San Francisco, California; and Washington, DC.

MAIN OUTCOMES AND MEASURES

Women were categorized into groups based on their probability of achieving viral load suppression below 200 copies/mL using logistic trajectory modeling. Multinomial regression analysis was used to identify factors associated with placement in the group with the highest probability of viremia.

RESULTS

At baseline, the mean (SD) age of the 1989 women was 36.9 (8.0) years, mean CD4+ T-lymphocyte count was 467/mm3, median (interquartile range) HIV RNA was 6200.0 (384.5-41 678.0) copies/mL, and 1305 women (65.6%) were African American. Three trajectory groups were identified with low (568 [28.6%]), intermediate (784 [39.4%]), and high (637 [32.0%]) probability of viremia above 200 copies/mL. The mean (SD) cumulative years of viral suppression were 18.7 (4.0) years, 12.2 (3.1) years, and 5.8 (2.9) years in the respective groups. Factors associated with high probability of viremia included younger age (odds ratio [OR]. 0.99; 95% CI, 0.98-0.99; P = .03), African American race (odds ratio [OR], 2.43; 95% CI, 1.75-3.37), P < .001), Hispanic race/ethnicity (OR, 1.50; 95% CI, 1.03-2.19; P = .04), increased levels of depressive symptoms (OR, 1.17; 95% CI, 1.01-1.36; P = .03), drug use (OR, 1.23; 95% CI, 1.01-1.51; P = .04), lower CD4+ T-lymphocyte counts (OR, 95% CI, 0.82; 0.80-0.85; P < .001), and unstable housing (OR, 1.25, 95% CI, 1.03-1.50; P = .02). Between 2015 and 2017, 71.2% of women demonstrated sustained viral suppression: 89.6% (310 of 346) of those with low viremia, 83.4% (346 of 415) with intermediate, and 35.2% (112 of 318) with high probability of viremia.

CONCLUSIONS AND RELEVANCE

This longitudinal approach suggested that the probability of viremia decreased substantially over time for most participants, including among women with earlier histories of incomplete viral suppression. The findings from this study suggest that continued efforts are needed to address mental health, social, behavioral and structural factors that were identified as associated with high probability of HIV viremia over time.

Brief Report: Clinical Outcomes of Young Black Men Receiving HIV Medical Care in the United States, 2009-2014

BACKGROUND

More than one-quarter of 2016 HIV diagnoses among blacks in the United States occurred among persons aged 15-24 years, and three-quarters were among men. Although the prevalence of viral suppression in all tests in the past 12 months (durable viral suppression) among persons receiving HIV care increased from 58% to 68% during 2009-2013, we do not know whether this same improvement was observed among young black men receiving care.

METHODS

We analyzed the 2009-2014 Medical Monitoring Project data collected from 336 black men aged 18-24 years. We estimated the proportion of young black men receiving HIV care who were prescribed antiretroviral therapy (ART), adherent to ART, and durably virally suppressed. We assessed changes in clinical outcomes over time and their association with patient characteristics, health behaviors, and depression.

RESULTS

During 2009-2014, 80% of young black men receiving HIV care were prescribed ART, 73% were adherent to ART, and 36% had durable viral suppression. There was no significant change in viral suppression over this period. ART prescription and durable viral suppression were significantly higher among those receiving the Ryan White HIV/AIDS Program assistance compared with those who did not. Durable viral suppression was significantly lower among those who used drugs compared with those who did not.

CONCLUSIONS

Viral suppression among young black men during 2009-2014 was lower than that among the overall population receiving HIV care in 2013 (36% vs. 68%). Increasing viral suppression is essential to improve health and reduce HIV transmissions in this key population.

Syphilis Testing Among Sexually Active Men Who Have Sex With Men and Who Are Receiving Medical Care for Human Immunodeficiency Virus in the United States: Medical Monitoring Project, 2013-2014

BACKGROUND

Guidelines recommend that sexually active men who have sex with men (MSM) including human immunodeficiency virus (HIV)-positive MSM be tested at least annually for syphilis, with testing every 3-6 months for MSM at elevated risk. We examined the proportion of HIV-positive MSM tested for syphilis in the past 3, 6, and 12 months by their HIV care provider during 2013-2014.

METHODS

Using data from the Medical Monitoring Project, a population-based HIV surveillance system, we evaluated the proportion of MSM who had documentation of being tested for syphilis by their HIV care provider in the past 3, 6, and 12 months.

RESULTS

During 2013-2014, 71% (95% confidence interval [CI]: 69%-73%) of sexually active HIV-positive MSM were tested for syphilis in the past year. This proportion was higher among MSM reporting condomless sex: (75%; 95% CI: 72%-78%), and among MSM reporting ≥ 2 sex partners (77%; 95% CI: 74%-79%), in the past 12 months. Among MSM reporting condomless sex, 49% (95% CI: 45%-53%) were tested in the past 6 months, and 26% (95% CI: 22%-30%) in the past 3 months. Among MSM reporting ≥ 2 sex partners, 49% (95% CI: 44%-54%) were tested in the past 6 months and 26% (95% CI: 22%-29%) in the past 3 months.

CONCLUSIONS

Nearly one-third of sexually active HIV-positive MSM were not tested annually, and many at increased risk were not tested at recommended frequencies. Efforts to improve compliance with screening guidelines for high-risk HIV-positive MSM are warranted.

Data-Driven Goals for Curbing the U.S. HIV Epidemic by 2030

Progress in reducing HIV infections has been suboptimal despite availability of effective prevention and treatment interventions and national strategies to bring them to scale. As part of a community-driven process, we expanded previous epidemiologic models using updated surveillance data from the Centers for Disease Control and Prevention to estimate quantitative parameters for ambitious but attainable national HIV prevention goals. We estimated new HIV infections could be reduced by up to 67% and prevalence could begin to decline by 2030 if 95% targets for diagnosis, care retention, and viral suppression are met by 2025 and an additional 20% of transmissions are averted through targeted interventions such as pre-exposure prophylaxis. Notably, this would require the percentage of diagnosed persons retained in HIV care to increase by more than 35 percentage points, which would necessitate innovative models and a substantial expansion of supportive services. Although the HIV incidence reduction goal of 90% as unveiled in the 2019 State of the Union Address is likely unachievable with the current intervention toolkit, it is possible to begin to substantially reduce HIV prevalence in the next decade with sufficient investments and innovation.

Ancillary service needs among persons new to HIV care and the relationship between needs and late presentation to care

Ancillary service needs likely influence time to diagnosis and presentation for HIV care. The effect of both met and unmet needs on late presentation to HIV care is not well understood. We used baseline data from 348 people with HIV (PWH) with no prior HIV care who enrolled in iENGAGE (a randomized controlled trial (RCT) of an intervention to support retention in care) at one of four HIV clinics in the US. A standardized baseline questionnaire collected information on ancillary service needs, and whether each need was presently unmet. We examined covariates known to be associated with disease stage at presentation to care and their association with needs. We subsequently assessed the relationship of needs with CD4 accounting for those other covariates by estimating prevalence ratios (PR) using inverse probability weights. Most patients enrolling in the RCT were male (79%) and the majority were Black (62%); median age was 34 years. Prevalence of any reported individual need was 69%. One-third of the sample had a baseline CD4 cell count <200, 42% between 200 and 499 and 27% ≥500. There was no statistically significant association between need or unmet need and baseline CD4. In general, psychiatric health and SU issues (depression, anxiety, and drug use) were consistently associated with higher prevalence of need (met and unmet). Additionally, the Black race was associated with higher basic resource needs (housing: PR 1.67, 95%CI 1.08-2.59; transportation: PR 1.65, 95% CI 1.12-2.45). Ancillary service needs (met and unmet) were common among patients new to HIV care and impacted vulnerable subgroups. However, we found no evidence that reporting a specific individual need, whether met or unmet, was associated with a timely presentation to HIV care. The impact of needs on subsequent steps of the HIV care continuum will be examined with longitudinal data.

Year 2 of Affordable Care Act Qualified Health Plans (QHPs) in a Medicaid Nonexpansion State: QHPs Associated With Viral Suppression for Virginia AIDS Drug Assistance Program Clients

Background

For year 1 of the Affordable Care Act (ACA), Virginia AIDS Drug Assistance Program (ADAP) clients with Qualified Health Plans (QHPs) achieved a higher rate of viral suppression. This study characterizes the demographic and health care delivery factors associated with QHP enrollment in year 2 and assesses the relationship between 2015 QHP coverage and HIV viral suppression.

Methods

The cohort included Virginia ADAP clients who were eligible for ADAP-funded QHPs. Data were collected from 2014 to 2015. Multivariable binary logistic regression was conducted to assess the association of demographic and health care delivery factors with QHP enrollment and viral suppression.

Results

In year 2, 63% of the cohort (n = 4631) enrolled in QHPs; 2015 ADAP-funded QHP enrollment was associated with 2014 ADAP-funded QHP (adjusted odds ratio [aOR], 111.11; 95% confidence interval [CI], 90.91–166.67), 2014 engagement in care (aOR, 2.16; 95% CI, 1.65–2.82), age (P < .001), race/ethnicity (P = .03), financial status (P < .001), and region (P < .001). For clients engaged in care (n = 2501), viral suppression was higher (83.3%) for those with ADAP-funded QHP coverage than for those who received medications from ADAP (79.9%). In multivariable binary logistic regression, achieving viral suppression was associated with 2015 QHP coverage (aOR, 1.27; 95% CI, 1.01–1.60), an initially undetectable viral load (aOR, 2.69; 95% CI, 2.13–3.39), gender (P = .03), age (P = .01), no AIDS diagnosis (aOR, 1.41; 95% CI, 1.12–1.78), financial status (P = .004), and region (P < .001).

Conclusions

Virginia ADAP client 2015 QHP enrollment increased compared with year 1 and varied based on demographic and health care delivery factors. QHP coverage was again associated with viral suppression, an essential outcome for individuals and for public health.

HIV Infection-Related Care Outcomes among U.S.-Born and Non-U.S.-Born Blacks with Diagnosed HIV in 40 U.S. Areas: The National HIV Surveillance System, 2016

HIV care outcomes must be improved to reduce new human immunodeficiency virus (HIV) infections and health disparities. HIV infection-related care outcome measures were examined for U.S.-born and non-U.S.-born black persons aged ≥13 years by using National HIV Surveillance System data from 40 U.S. areas. These measures include late-stage HIV diagnosis, timing of linkage to medical care after HIV diagnosis, retention in care, and viral suppression. Ninety-five percent of non-U.S.-born blacks had been born in Africa or the Caribbean. Compared with U.S.-born blacks, higher percentages of non-U.S.-born blacks with HIV infection diagnosed during 2016 received a late-stage diagnoses (28.3% versus 19.1%) and were linked to care in ≤1 month after HIV infection diagnosis (76.8% versus 71.3%). Among persons with HIV diagnosed in 2014 and who were alive at year-end 2015, a higher percentage of non-U.S.-born blacks were retained in care (67.8% versus 61.1%) and achieved viral suppression (68.7% versus 57.8%). Care outcomes varied between African- and Caribbean-born blacks. Non-U.S.-born blacks achieved higher care outcomes than U.S.-born blacks, despite delayed entry to care. Possible explanations include a late-stage presentation that requires immediate linkage and optimal treatment and care provided through government-funded programs.

Differences in Characteristics and Clinical Outcomes Among Hispanic/Latino Men and Women Receiving HIV Medical Care - United States, 2013-2014

The prevalence of diagnosed human immunodeficiency virus (HIV) infection among Hispanics/Latinos in the United States is approximately twice that of non-Hispanic whites (1). Barriers to, and experiences with, medical care have been found to vary by sex (2). Describing characteristics of Hispanics/Latinos in care by sex can help identify disparities and inform delivery of tailored services to this underserved population. Data from the 2013 and 2014 cycles of the Medical Monitoring Project (MMP) were analyzed to describe demographic, behavioral, and clinical characteristics among Hispanics/Latinos by sex. MMP is an annual cross-sectional, nationally representative surveillance system that, during 2013-2014, collected information about behaviors, medical care, and clinical outcomes among adults receiving outpatient HIV care. Hispanic/Latina women were significantly more likely than were men to live in poverty (78% versus 54%), report not speaking English well (38% versus 21%), and receive interpreter (27% versus 16%), transportation (35% versus 21%), and meal (44% versus 26%) services. There were no significant differences between Hispanic/Latino women and men in prescription of antiretroviral therapy (ART) (95% versus 96%) or sustained viral suppression (68% versus 73%). Although women faced greater socioeconomic and language-related challenges, the clinical outcomes among Hispanic/Latina women were similar to those among men, perhaps reflecting their higher use of ancillary services. Levels of viral suppression for Hispanics/Latinos are lower than those found among non-Hispanic whites (3) and lower than the national prevention goal of at least 80% of persons with diagnosed HIV infection. Providers should be cognizant of the challenges faced by Hispanics/Latinos with HIV infection in care and provide referrals to needed ancillary services.

Hepatitis C Within a Single Health System: Progression Along the Cascade to Cure Is Higher for Those With Substance Misuse When Linked to a Clinic With Embedded Support Services

Background

Hepatitis C is now curable for most individuals, and national goals for elimination have been established. Transmission persists, however, particularly in nonurban regions affected by the opioid epidemic. To reach goals of elimination, barriers to treatment must be identified.

Methods

In this open cohort of all individuals diagnosed with active hepatitis C from 2010 to 2016 at a large medical center, we identified patient and clinic characteristics associated with our primary outcome, sustained virologic response (SVR). We performed a subgroup analysis for those with documented substance misuse.

Results

SVR was achieved in 1544 (41%) of 3790 people with active hepatitis C. In a multivariable Poisson regression model, SVR was more likely in individuals diagnosed outpatient (incident rate ratio [IRR], 1.7; 95% confidence interval [CI], 1.5-2.0), living in close proximity to the medical center (IRR, 1.2; 95% CI, 1.1-1.3), with private insurance (IRR, 1.1; 95% CI, 1.0-1.3), and with cirrhosis (IRR, 1.4; 95% CI, 1.3-1.5). Achieving SVR was less likely in those qualifying as indigent (IRR, 0.8; 95% CI, 0.8-0.9) and those with substance misuse (IRR, 0.8; 95% CI, 0.7-0.9). In the subgroup analysis of those with substance misuse, SVR rates were higher in those linked to the infectious diseases clinic, which has embedded support services, than those linked to the gastroenterology clinic, which does not (IRR, 1.4; 95% CI, 1.1-1.9).

Conclusions

Social determinants of health including proximity to care and poverty impacted achievement of SVR. Those with substance misuse, a high-priority population for treatment of hepatitis C, had better outcomes when receiving care in a clinic with embedded support services.

Hepatitis A virus immunity and vaccination among at-risk persons receiving HIV medical care

United States guidelines recommend hepatitis A virus (HAV) vaccination for persons living with HIV (PLWH) who are at increased risk for HAV infection, including men who have sex with men (MSM) and persons who inject drugs (PWID). However, nationally representative estimates of vaccine coverage and immunity for this population are lacking. We used medical record and interview data from the 2009-2012 cycles of the Medical Monitoring Project, a nationally representative surveillance system of PLWH receiving HIV medical care in the United States, to estimate the prevalence of HAV immunity, defined as receipt of at least one dose of vaccine or laboratory documentation of anti-HAV antibodies, among 8695 MSM and PWID. Among HAV-nonimmune PLWH, we then examined factors associated with HAV vaccination during the 12-month retrospective observation period using Rao-Scott chi-square tests. Among MSM and PWID receiving HIV medical care, 64% had evidence of HAV immunity. Among those who were nonimmune, 10% were vaccinated during the 12-month retrospective observation period. Factors associated with vaccination during follow-up included younger age (i.e., 18-29 years), self-reported black non-Hispanic race/ethnicity, having detectable HIV RNA, and having been diagnosed with HIV within the past 5 years. Over one third of MSM and PWID receiving HIV medical care during 2009-2012 cycles were not immune to HAV. This analysis suggests that a sizeable proportion of at risk MSM and PWID receiving HIV medical care do not receive HAV vaccination, which is currently recommended.

The Evolution of HIV Prevention Programming: Moving From Intervention to System

Accelerating the fight against HIV globally and achieving the goals of the U.S. National HIV/AIDS Strategy will require an integrated health system that addresses all dimensions of wellness and is not limited to disease diagnosis and treatment or to monolithic prevention strategies. Since the HIV/AIDS epidemic was first recognized in 1981, HIV prevention strategies have evolved from early, information-based efforts to theory-informed and evidence-based approaches. More recently, the growing recognition that social and economic factors play a major role in shaping population health outcomes has driven HIV prevention and care programs in the direction of "people-centered health systems," as called for in the 2016 United Nations General Assembly declaration to end AIDS by 2030. This commentary examines recent innovations in HIV program design and implementation (e.g., using data in novel ways to improve HIV health outcomes, providing incentives to promote integrated HIV prevention and care, and developing mechanisms to proactively address the social determinants affecting health) that embrace a comprehensive vision of health that is much broader than the absence of detectable virus.

For Many Served By The Ryan White HIV/AIDS Program, Disparities In Viral Suppression Decreased, 2010-14

For twenty-five years, the Ryan White HIV/AIDS Program has supported a comprehensive system of health services for vulnerable and under- or uninsured people living with HIV. Using data from the Health Resources and Services Administration about people living with HIV and served by the Ryan White HIV/AIDS Program, we found reductions in disparities in viral suppression rates between 2010 and 2014-with rates for Blacks/African Americans, adolescents and young adults, and people living in the South becoming more similar to rates for Whites, older adults, and people in other regions of the United States, respectively. Although absolute viral suppression rates for people without stable housing and transgender people improved during the same time period, disparities were not reduced between these groups and those with stable housing and nontransgender people, respectively. Addressing persistent disparities through the effective use of this program will be one of the key ways to meet the goals of the National HIV/AIDS Strategy.

Low Prevalence of Hepatitis B Vaccination Among Patients Receiving Medical Care for HIV Infection in the United States, 2009 to 2012

BACKGROUND

Persons with HIV infection are at increased risk for hepatitis B virus infection. In 2016, the World Health Organization resolved to eliminate hepatitis B as a public health threat by 2030.

OBJECTIVE

To estimate the prevalence of hepatitis B vaccination among U.S. patients receiving medical care for HIV infection ("HIV patients").

DESIGN

Nationally representative cross-sectional survey.

SETTING

United States.

PARTICIPANTS

18 089 adults receiving HIV medical care who participated in the Medical Monitoring Project during 2009 to 2012.

MEASUREMENTS

Primary outcomes were prevalence of 1) no documentation of hepatitis B vaccination or laboratory evidence of immunity or infection (candidates to initiate vaccination), and 2) initiation of vaccination among candidates, defined as documentation of at least 1 vaccine dose in a 1-year surveillance period during which patients received ongoing HIV medical care.

RESULTS

At the beginning of the surveillance period, 44.2% (95% CI, 42.2% to 46.2%) of U.S. HIV patients were candidates to initiate vaccination. By the end of the surveillance period, 9.6% (CI, 8.4% to 10.8%) of candidates were vaccinated, 7.5% (CI, 6.4% to 8.6%) had no documented vaccination but had documented infection or immunity, and 82.9% (CI, 81.1% to 84.7%) remained candidates. Among patients at facilities funded by the Ryan White HIV/AIDS Program (RWHAP), 12.5% (CI, 11.1% to 13.9%) were vaccinated during the surveillance period versus 3.7% (CI, 2.6% to 4.7%) at facilities not funded by RWHAP. At the end of surveillance, 36.7% (CI, 34.4% to 38.9%) of HIV patients were candidates to initiate vaccination.

LIMITATION

The study was not designed to describe vaccine series completion or actual prevalence of immunity.

CONCLUSION

More than one third of U.S. HIV patients had missed opportunities to initiate hepatitis B vaccination. Meeting goals for hepatitis B elimination will require increased vaccination of HIV patients in all practice settings, particularly at facilities not funded by RWHAP.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Trends of racial and ethnic disparities in virologic suppression among women in the HIV Outpatient Study, USA, 2010-2015

In the United States, women accounted for 19% of new HIV diagnoses in 2015 and were less likely to reach virologic suppression when compared to men. We assessed trends and disparities in virologic suppression among HIV-positive women to inform HIV treatment strategies. Data were from a prospective cohort of the HIV Outpatient Study and collected at nine United States HIV clinics. We included women aged ≥18 years, with ≥1 visit, who were prescribed antiretroviral therapy, and had ≥1 viral load test performed between 2010 and 2015. We defined virologic suppression as viral load <50 copies/mL and calculated adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) for virologic suppression by race/ethnicity and year of measure. Generalized estimating equations were used for multivariable analyses to assess factors associated with virologic suppression. Among 809 women (median age = 44 years), 482 (60%) were black, 177 (22%) white, 150 (19%) Hispanic/Latina. Virologic suppression was less prevalent among black women (73%) compared with Hispanic/Latina women (83%) and white women (91%). In multivariable analyses, not achieving virologic suppression was more likely among black women (aPR = 2.13; CI = 1.50–3.02) or Hispanic/Latina women (aPR = 1.66; CI = 1.08–2.56) compared with white women, and among women who attended public clinics (aPR = 1.42; CI = 1.07–1.87) compared with those who attended a private clinic. Between 2010 and 2015, virologic suppression among HIV-positive women increased from 68% to 83%, but racial/ethnic disparities persisted. Black and Hispanic/Latina women had significantly lower rates of virologic suppression than white women. Interventions targeting virologic suppression improvement among HIV-positive women of color, especially those who attend public clinics, are warranted.

Short article: Alcohol and substance use, race, and insurance status predict nontreatment for hepatitis C virus in the era of direct acting antivirals: a retrospective study in a large urban tertiary center

OBJECTIVE

Direct acting antivirals (DAAs) have overcome many long-standing medical barriers to hepatitis C virus (HCV) treatment (i.e. host characteristics and medical contraindications) and treatment outcome disparities that were associated with interferon regimens. The public health and clinical benefit of current and forthcoming DAA discoveries will be limited if efforts are not made to examine racial, psychological, and socioeconomic factors associated with being treated with DAAs. This study examined racial, psychological, and socioeconomic factors that facilitate and inhibit patients receiving DAAs for HCV.

PATIENTS AND METHODS

This was a single-center retrospective cohort study at a large urban tertiary center of patients (n=747) who were referred for evaluation and treatment of HCV.

RESULTS

Sixty-eight percent of patients were non-Hispanic White, 31% were African American, and 1% were of other ethnicities. The majority of patients received treatment, but 29% (218/747) did not. Patients who were older [odds ratio (OR)=1.02, 95% confidence interval (CI): 1.01-1.04] and insured (OR=2.73, 95% CI: 1.12-6.97) were more likely to receive HCV treatment. Patients who were African American (OR=0.46, 95% CI: 0.46-1.06), used drugs (OR=0.09, 95% CI: 0.04-0.17), smoked (OR=0.55, 95% CI: 0.37-0.81), and used alcohol (OR=0.11, 95% CI: 0.06-0.20) were less likely to receive HCV treatment.

CONCLUSION

Though DAAs have eliminated many historically, long-standing medical barriers to HCV treatment, several racial, psychological and socioeconomic barriers, and disparities remain. Consequently, patients who are African American, uninsured, and actively use drugs and alcohol will suffer from increased HCV-related morbidity and mortality in the coming years if deliberate public health and clinical efforts are not made to facilitate access to DAAs.

Financial Barriers and Lapses in Treatment and Care of HIV-Infected Adults in a Southern State in the United States

Antiretroviral (ARV) adherence has largely been considered from the perspective of an individual's behavior with less attention given to potential structural causes for lapses in treatment, such as the cost of medications and care. HIV medication expense is typically covered by third party payers. However, private insurance premiums and deductibles may rise, or policies terminated such as with a change in employment. Likewise, a patient's eligibility for publicly funded coverage like state AIDS Drug Assistance Programs (ADAP) or Medicaid can also be lost. We conducted a one-time survey of a sample of 300 patients receiving HIV care at a single large academic center in the south of United States to examine lapses in HIV therapy due to financial reasons. We found that during the prior year, financial issues including medication cost or coverage led to a lapse in ARVs in 10% (n = 31) of participants. However, of the 42% (n = 125) participants who had been enrolled in ADAP at any time during the prior year, 21% (n = 26) reported an ARV lapse due to problems with ADAP or medication cost. Respondents cited ADAP's required semi-annual renewal process and other administrative issues as the cause of ARV lapses. The median duration of missed ARVs was 2 weeks (range of <1-23 weeks). Non-HIV medication and transportation to and from clinic costs were also identified as financial burdens to care by respondents. In conclusion, although conducted at a single medical center and one state, this study suggests that a significant minority of HIV-infected patients encounter financial barriers to ARV access, and this is paradoxically more common among those enrolled in the state ADAP. Streamlining, supporting, and simplifying ADAP renewal procedures will likely reduce lapses in ARV adherence and persistence.

Antiretroviral Prescription and Viral Suppression in a Representative Sample of HIV-Infected Persons in Care in 4 Large Metropolitan Areas of the United States, Medical Monitoring Project, 2011-2013

BACKGROUND

Comparisons of antiretroviral therapy (ART) prescription and viral suppression among people in HIV care across US metropolitan areas are limited. Medical Monitoring Project, 2011-2013, data were used to describe and compare associations between sociodemographics and ART prescription and viral suppression for persons receiving HIV care.

SETTING

Chicago, Los Angeles County (LAC), Philadelphia, and San Francisco in the United States.

METHODS

Bivariate and multivariable methods were used.

RESULTS

The proportion of patients prescribed ART (91%-93%) and virally suppressed (79%-88%) was consistent although more persons were virally suppressed in San Francisco compared with the other areas, and a smaller proportion was virally suppressed in Philadelphia compared with Chicago. In the combined cohort, persons aged 30-49 years were less likely than persons 50+ (adjusted prevalence ratio (aPR) -0.97, confidence interval (CI): 0.94 to 0.99); persons reporting non-injection drug use were less likely than non-users (aPR = 0.94, CI: 0.90 to 0.98); and Hispanics were more likely than whites (aPR - 1.04, CI: 1.01 to 1.08) to be prescribed ART. Blacks (aPR = 0.93; CI: 0.87 to 0.99) and homeless persons (aPR = 0.87; CI: 0.80 to 0.95) were less likely to be virally suppressed in the combined cohort. In LAC, persons aged 30-49 years were less likely than those 50+ to be prescribed ART (aPR = 0.94, CI: 0.90 to 0.98). Younger persons (18-29) (aPR = 0.77; CI: 0.60 to 0.99) and persons with less than a high school education (aPR = 0.80; CI: 0.67 to 0.95) in Philadelphia, blacks (aPR = 0.90; CI: 0.83 to 0.99) and men who have sex with women only (aPR = 0.89; CI: 0.80 to 0.99) in Chicago, and homeless individuals in LAC (aPR = 0.80; CI: 0.67 to 0.94) were less likely to be virally suppressed.

CONCLUSION

Data highlight the need to increase ART prescription to achieve viral suppression among younger persons, noninjection drug users, blacks, and homeless persons in US metropolitan areas and underscores the importance of region-specific strategies for affected subgroups.

Delivery of HIV Antiretroviral Therapy Adherence Support Services by HIV Care Providers in the United States, 2013 to 2014

BACKGROUND

Little is known about clinicians' adoption of recommendations of the International Association of Providers of AIDS Care and others for supporting adherence to antiretroviral therapy (ART).

METHODS

We surveyed a probability sample of US HIV care providers to estimate the percentage offering 3 ART adherence support services to most or all patients and assessed the characteristics of providers offering all 3 services (comprehensive support) to most or all patients.

RESULTS

Almost all providers (95.5%) discussed ART adherence at every visit, 60.1% offered advice about tools to increase adherence, 53.5% referred nonadherent patients for supportive services, and 42.8% provided comprehensive support. Nurse practitioners were more likely to offer comprehensive support as were providers who practiced at Ryan White HIV/AIDS Program-funded facilities, provided primary care, or started caring for HIV-infected patients within 10 years.

CONCLUSION

Less than half of HIV care providers offered comprehensive ART adherence support. Certain subgroups may benefit from interventions to increase delivery of adherence support.

Do Persons Living with HIV Continue to Fill Prescriptions for Antiretroviral Drugs during a Gap in Care? Analysis of a Large Commercial Claims Database

The significance of a gap in HIV care depends, at least partially, on whether patients continue to fill prescriptions for antiretroviral (ARV) drugs during the gap in care. We used a billing claims database to determine the proportion of persons who filled ≥1 prescription for ARV drugs during a gap in care (no clinic visit in >6 months). Persons were stratified into 3 groups: "never" (prescriptions never filled), "sometimes" (prescriptions filled >0%-<100% of months), and "always" (prescriptions filled monthly). Logistic regression analyses were conducted to determine factors associated with "never" filling ARV drugs. Of 14 308 persons, 69% (n = 9817), 13% (n = 1928), and 18% (n = 2563) "never," "sometimes," and "always" filled ARV drugs during the gap in care. Persons aged 18 to 29 years (odds ratio [OR] = 1.56, 95% confidence interval [CI] 1.39-1.74), women (OR = 1.67, CI 1.52-1.83), and persons from the Northeast region of the United States (OR = 1.86, CI 1.69-2.03) were more likely to never fill ARV drugs than persons aged ≥30 years, men, and persons outside the Northeast, respectively. Efforts should be made to minimize gaps in care, emphasize importance of therapy, and provide adherence support.

Comprehensive Ryan White Assistance and Human Immunodeficiency Virus Clinical Outcomes: Retention in Care and Viral Suppression in a Medicaid Nonexpansion State

Background

Knowledge gaps remain about how the Ryan White human immunodeficiency virus (HIV)/AIDS Program (RW) contributes to health outcomes. We examined the association between different RW service classes and retention in care (RiC) or viral suppression (VS).

Methods

We identified Virginians engaged in any HIV care between 1 January and 31 December 2014. RW beneficiaries were classified by receipt of ≥1 service from 3 classes: Core medical, Support, and insurance and/or direct medication assistance through the AIDS Drug Assistance Program (ADAP). Receipt of all RW classes was defined as comprehensive assistance. We used multivariable logistic regression to compare the odds of RiC and of VS by comprehensive assistance and by RW classes alone and in combination.

Results

Among 13104 individuals, 58% received any RW service and 17% comprehensive assistance. Comprehensive assistance is significantly associated with RiC (adjusted odds ratio [aOR], 8.8 [95% confidence interval {CI}, 7.2-10.8]) and viral suppression (aOR, 3.3 [95% CI, 2.9-3.8]). Receiving any 2 RW classes or Core alone is significantly associated with RiC and VS, with the strength of association decreasing as the number of classes decreases. Recipients of Support alone are significantly less likely to have VS (aOR, 0.75 [95% CI, .59-.96]). For ADAP recipients also receiving Core and/or Support, insurance assistance is significantly associated with VS compared to receiving direct medication only (aOR, 1.6 [95% CI, 1.3-1.9]); this relationship is not significant for those who receive ADAP alone.

Conclusions

Receiving more classes of RW-funded services is associated with improved HIV outcomes. For some populations with insurance, RW-funded services may still be required for optimal health outcomes.

Retention in Care Services Reported by HIV Care Providers in the United States, 2013 to 2014

OBJECTIVES

Evidence-based guidelines recommend that HIV care providers offer retention-in-care services, but data are needed to assess service provision.

METHODS

We surveyed a probability sample of 1234 HIV care providers to estimate the percentage of providers whose practices offered 5 recommended retention services and describe providers' perceptions of barriers to care among patients.

RESULTS

An estimated 21% of providers' practices offered all 5 retention services. Providers at smaller (<50 versus >400 patients), private, and non-Ryan White HIV/AIDS Program (RWHAP)-funded practices, and practices without on-site case management were significantly less likely to provide patient navigation services or do systematic monitoring of retention. Providers' most commonly perceived barriers to care among patients were mental health (40%), substance abuse (36%), and transportation (34%) issues.

CONCLUSION

Deficiencies in the provision of key retention services are substantial. New strategies may be needed to increase the delivery of recommended retention services, especially among private, non-RWHAP-funded, and smaller facilities.

Ten-year trends in antiretroviral therapy persistence among US Medicaid beneficiaries

OBJECTIVE

Whether the rate of HIV antiretroviral therapy (ART) persistence has improved over time in the United States is unknown. We examined ART persistence trends between 2001 and 2010, using non-HIV medications as a comparator.

METHODS

We conducted a retrospective cohort study using Medicaid claims. We defined persistence as the duration of treatment from the first to the last fill date before a 90-day permissible gap and used Kaplan-Meier curves and Cox proportional hazard models to assess crude and adjusted nonpersistence. The secular trends of ART persistence in 43 598 HIV patients were compared with the secular trends of persistence with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACEI/ARB), statins, and metformin in non-HIV-infected patients and subgroups of HIV patients who started these control medications while using ART.

RESULTS

Median time to ART nonpersistence increased from 23.9 months in 2001-2003 to 35.4 months in 2004-2006 and was not reached for those starting ART in 2007-2010. In adjusted models, ART initiators in 2007-2010 had 11% decreased hazard of nonpersistence compared with those who initiated in 2001-2003 (P < 0.001). For non-HIV patients initiating angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB), statins, and metformin, the hazard ratios for nonpersistence comparing 2007-2010 to 2001-2003 were 1.07, 0.94, and 1.02, respectively (all P < 0.001). For HIV patients initiating the three control medications, the hazard ratios of nonpersistence comparing 2007-2010 to 2001-2003 were 0.71, 0.65, and 0.63, respectively (all P < 0.001).

CONCLUSION

Persistence with ART improved between 2001 and 2010. Persistence with control medications improved at a higher rate among HIV patients using ART than HIV-negative controls.

Barriers to Universal Prescribing of Antiretroviral Therapy by HIV Care Providers in the United States, 2013-2014

INTRODUCTION

HIV treatment guidelines recommend initiating antiretroviral therapy (ART) regardless of CD4 cell (CD4) count, barring contraindications or barriers to treatment. An estimated 6% of persons receiving HIV care in 2013 were not prescribed ART. We examined reasons for this gap in the care continuum.

METHODS

During 2013-2014, we surveyed a probability sample of HIV care providers, of whom 1234 returned surveys (64.0% adjusted response rate). We estimated percentages of providers who followed guidelines and their characteristics, and who deferred ART prescribing for any reason.

RESULTS

Barring contraindications, 71.2% of providers initiated ART regardless of CD4 count. Providers less likely to initiate had caseloads ≤20 vs. >200 patients [adjusted prevalence ratios (aPR) 0.69, 95% confidence interval (CI): 0.47 to 1.02, P = 0.03], practiced at non-Ryan White HIV/AIDS Program-funded facilities (aPR 0.85, 95% CI: 0.74 to 0.98, P = 0.02), or reported pharmaceutical assistance programs provided insufficient medication to meet patients' needs (aPR 0.79, 95% CI: 0.65 to 0.98, P = 0.02). In all, 17.0% never deferred prescribing ART, 69.6% deferred for 1%-10% of patients, and 13.3% deferred for >10%. Among providers who had deferred ART, 59.4% cited patient refusal as a reason in >50% of cases, 31.1% reported adherence concerns because of mental health disorders or substance abuse, and 21.4% reported adherence concerns because of social problems, eg, homelessness, as factors in >50% of cases when deferring ART.

CONCLUSIONS

An estimated 29% of HIV care providers had not adopted recommendations to initiate ART regardless of CD4 count, barring contraindications, or barriers to treatment. Low-volume providers and those at non-Ryan White HIV/AIDS Program-funded facilities were less likely to follow this guideline. Among all providers, leading reasons for deferring ART included patient refusal and adherence concerns.

Increased Sexually Transmitted Disease Testing Among Sexually Active Persons Receiving Medical Care for Human Immunodeficiency Virus Infection in the United States, 2009-2013

Background

Current guidelines recommend that all sexually active human immunodeficiency virus (HIV)-infected persons be tested at least annually for syphilis, chlamydia, and gonorrhea. We examined temporal trends in syphilis, chlamydia, and gonorrhea testing among sexually active HIV-infected adults receiving medical care in the United States during 2009-2013.

Methods

Using medical record data from the Medical Monitoring Project, a population-based HIV surveillance system, we assessed the proportion of adults receiving HIV medical care who were tested for syphilis, chlamydia, and gonorrhea in the past 12 months by year and stratified by sex and sexual behavior, age, and race/ethnicity.

Results

During 2009-2013, the proportion of sexually active HIV-infected adults receiving medical care who were tested in the past year for all 3 examined sexually transmitted diseases (STDs) increased from 20% to 36% (PTREND < .01). Overall testing for syphilis increased from 55% to 65% (PTREND < .01), and significant increases were noted for the following subgroups: men who have sex with men (58% to 69%), non-Hispanic whites (48% to 64%), and all age groups with the exception of persons aged 18-29 year. Overall testing for chlamydia and gonorrhea increased from 22% to 42% (PTREND < .01), and significant increases were noted for most subgroups.

Conclusions

STD testing significantly increased among sexually active HIV-infected adults receiving medical care; however, the majority of persons were not tested for all 3 STDs in 2013. While increased testing indicates progress, testing remained far below recommended guidelines. Our findings suggest enhanced efforts may be warranted to screen all sexually active HIV-infected adults for syphilis, chlamydia, and gonorrhea.

Outcome of Sentinel Hospital-based and CDC-based ART Service Delivery: A Prospective Open Cohort of People Living with HIV in China

The primary objective of this study was to obtain insights into the outcomes of people living with HIV who accessed services through HIV/AIDS sentinel hospital-based and ART service delivery in China. Post-hoc analyses of an open cohort from an observational database of 22 qualified HIV/AIDS sentinel hospital-based and two CDC-based drug delivery facilities (DDFs) in Guangdong Province was completed. Linkage to care, mortality and survival rates were calculated according to WHO criteria. 12,966 individuals received ART from HIV/AIDS sentinel hospitals and 1,919 from DDFs, with linkage to care rates of 80.7% and 79.9%, respectively (P > 0.05). Retention rates were 94.1% and 84.0% in sentinel hospitals and DDFs, respectively (P < 0.01). Excess mortality was 1.4 deaths/100 person-years (95% CI: 1.1, 1.8) in DDFs compared to 0.4 deaths/100 person-years (95% CI: 0.3, 0.5) in hospitals (P < 0.01). A Cox-regression analysis revealed that mortality was much higher in patients receiving ART from the DDFs than sentinel hospitals, with an adjusted HR of 3.3 (95% CI: 2.3, 4.6). A crude HR of treatment termination in DDFs was 7.5 fold higher (95% CI: 6.3, 9.0) compared to sentinel hospitals. HIV/AIDS sentinel hospital had better retention, and substantially lower mortality compared to DDFs.

Prescribing of Human Immunodeficiency Virus (HIV) Pre-exposure Prophylaxis by HIV Medical Providers in the United States, 2013-2014

BACKGROUND

Clinical trials have demonstrated the effectiveness of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) for reducing HIV acquisition. Understanding how HIV care providers are prescribing PrEP is necessary to ensure success of this prevention strategy.

METHODS

During 2013-2014, we surveyed US HIV care providers who also provided care to HIV-negative patients. We estimated percentages who had prescribed PrEP and assessed associations between provider characteristics and PrEP prescribing.

RESULTS

An estimated 26% (95% confidence interval [CI], 20-31) had ever prescribed PrEP. Of these, 74% (95% CI, 61-87) prescribed for men who have sex with men (MSM), 30% (95% CI, 21-39) for women who have sex with men, 23% (95% CI, 9-37) for men who have sex with women, 23% (95% CI, 15-30) for uninfected partners in HIV-discordant couples trying to conceive, and 1% (95% CI, 0-2) for persons who inject drugs. The following provider characteristics were significantly associated with having prescribed PrEP: male vs female (32% vs 16%; adjusted prevalence ratio [aPR], 1.5; 95% CI, 1.0-2.2), lesbian/gay/bisexual vs heterosexual orientation (50% vs 21%; aPR, 2.0; 95% CI, 1.3-2.9), and HIV caseload (>200, 51-200, and ≤50 patients, 39%, 29%, and 14%, respectively; >200 vs ≤50 patients, aPR 2.4, 95% CI 1.1-5.2, and 51-200 vs ≤50 patients, aPR 2.2, 95% CI 1.2-4.0).

CONCLUSIONS

In 2013-2014, one quarter of HIV care providers reported having prescribed PrEP, most commonly for MSM and rarely for persons who inject drugs. Lesbian/gay/bisexual providers and male providers were more likely than others to have prescribed PrEP. Additional efforts may enable more providers to prescribe PrEP to underserved clients needing the service.

Trends in Racial and Ethnic Disparities in Antiretroviral Therapy Prescription and Viral Suppression in the United States, 2009-2013

OBJECTIVES

To examine trends in racial/ethnic disparities in antiretroviral therapy (ART) prescription and viral suppression among HIV-infected persons in care, overall and among men who have sex with men (MSM), from 2009 to 2013.

DESIGN

The Medical Monitoring Project (MMP) is a complex sample survey of HIV-infected adults receiving medical care in the United States.

METHODS

We used weighted interview and medical record data collected June 2009-May 2014 to estimate the prevalence of ART prescription and viral suppression among racial/ethnic groups overall and among MSM.

RESULTS

We found significant increases in ART prescription and viral suppression among all racial/ethnic groups from 2009 to 2013, both overall and among MSM. By 2013, overall and among MSM, the Hispanic-white disparity in ART prescription was nonexistent, and the black-white disparity was not significant after accounting for differences between blacks and whites in age and length of HIV diagnosis. Despite reductions in racial/ethnic disparities in viral suppression over the time period, significant disparities remained among the total population, even after adjusting for differences in racial/ethnic group characteristics. Encouragingly, however, there was no significant Hispanic-white disparity in viral suppression among MSM by 2013.

CONCLUSIONS

Despite significant improvements in ART prescription and viral suppression in recent years, racial and ethnic disparities persist, particularly for black persons. If the United States is to achieve the National HIV/AIDS Strategy goal of reducing HIV-related health disparities, continued efforts to accelerate the rate of improvement in ART prescription and viral suppression among Hispanic and black persons may need to be prioritized.

Social and Structural Determinants of Cervical Health among Women Engaged in HIV Care

Cervical cancer prevention/control efforts among women living with HIV/AIDS (WLH) are socially and structurally challenging. Healthcare access and perceived HIV stigma and discrimination are factors that may challenge risk reduction efforts. This study examined socio-structural determinants of cervical cancer screening among women engaged in HIV care. One hundred forty-five WLH seeking health/social services from AIDS Service Organizations in the southeastern US completed a questionnaire assessing factors related to cervical cancer prevention/control. Ninety percent were African American, mean age 46.15 ± 10.65 years. Eighty-one percent had a Pap test <1 year ago. Low healthcare access was positively associated with having a Pap test <1 year ago, (Odds ratio [OR] 3.80; 95 % Confidence interval [CI] 1.34-10.78). About 36 % reported ≥2 Pap tests during the first year after HIV diagnosis. Lower educational attainment was positively associated with having ≥2 Pap tests, OR 3.22; CI 1.08-9.62. Thirty-five percent reported more frequent Pap tests after diagnosis. Lower income was moderately associated with more frequent Pap tests post-diagnosis, OR 2.47; CI .98-6.23. Findings highlight the successes of HIV initiatives targeting socio-economically disadvantaged women and provide evidence that health policy aimed at providing and expanding healthcare access for vulnerable WLH has beneficial health implications.

Durable Viral Suppression and Transmission Risk Potential Among Persons With Diagnosed HIV Infection: United States, 2012-2013

BACKGROUND

We examined durable viral suppression, cumulative viral load (VL) burden, and transmission risk potential among human immunodeficiency virus (HIV)-diagnosed persons in care.

METHODS

Using data from the National HIV Surveillance System from 17 jurisdictions with complete reporting of VL test results, we determined the percentage of persons in HIV care who achieved durable viral suppression (all VL results <200 copies/mL) and examined viremia copy-years and time spent above VL levels that increase the risk of HIV transmission during 2012-2013.

RESULTS

Of 265 264 persons in HIV care in 2011, 238 641 had at least 2 VLs in 2012-2013. The median number of VLs per individual during the 2-year period was 5. Approximately 62% had durable viral suppression. The remaining 38% had high VL burden (geometric mean of viremia copy-years, 7261) and spent an average of 438 days, 316 days, and 215 days (60%, 43.2%, and 29.5% of the 2-year period) above 200, 1500, and 10 000 copies/mL. Women, blacks/African Americans, Hispanics/Latinos, persons with HIV infection attributed to transmission other than male-to-male sexual contact, younger age groups, and persons with gaps in care had higher viral burden and transmission risk potential.

CONCLUSIONS

Two-thirds of persons in HIV care had durable viral suppression during a 2-year period. One-third had high VL burden and spent substantial time above VL levels with increased risk of onward transmission. More intervention efforts are needed to improve retention in care and medication adherence so that more persons in HIV care achieve durable viral suppression.

Qualifications, Demographics, Satisfaction, and Future Capacity of the HIV Care Provider Workforce in the United States, 2013-2014

BACKGROUND

The human immunodeficiency virus (HIV)-infected population in the United States is increasing by about 30 000 annually (new infections minus deaths). With improvements in diagnosis and engagement in care, additional qualified HIV care providers may be needed.

METHODS

We surveyed a probability sample of 2023 US HIV care providers in 2013-2014, including those at Ryan White HIV/AIDS Program (RWHAP)-funded facilities and in private practices. We estimated future patient care capacity by comparing counts of providers entering and planning to leave practice within 5 years, and the number of patients under their care.

RESULTS

Of surveyed providers, 1234 responded (adjusted response rate, 64%): 63% were white, 11% black, 11% Hispanic, and 16% other race/ethnicity; 37% were satisfied/very satisfied with salary/reimbursement, and 33% were satisfied/very satisfied with administrative time. Compared with providers in private practice, more providers at RWHAP-funded facilities were HIV specialists (71% vs 43%; P < .0001) and planned to leave HIV practice within 5 years (11% vs 4%; P = .0004). An estimated 190 more full-time equivalent providers (defined as 40 HIV clinical care hours per week) entered practice in the past 5 years than are expected to leave in the next 5 years. If these rates continue, by 2019 patient care capacity will increase by 65 000, compared with an increased requirement of at least 100 000.

CONCLUSIONS

Projected workforce growth by 2019 will not accommodate the increased number of HIV-infected persons requiring care. RWHAP-funded facilities may face attrition of highly qualified providers. Dissatisfaction with salary/reimbursement and administrative burden is substantial, and black and Hispanic providers are underrepresented relative to HIV patients.

Socioeconomic status and response to antiretroviral therapy in high-income countries: a literature review

It has been shown that socioeconomic factors are associated with the prognosis of several chronic diseases; however, there is no recent systematic review of their effect on HIV treatment outcomes. We aimed to review the evidence regarding the existence of an association of socioeconomic status with virological and immunological response to antiretroviral therapy (ART). We systematically searched the current literature using the database PubMed. We identified and summarized original research studies in high-income countries that assessed the association between socioeconomic factors (education, employment, income/financial status, housing, health insurance, and neighbourhood-level socioeconomic factors) and virological response, immunological response, and ART nonadherence among people with HIV-prescribed ART. A total of 48 studies met the inclusion criteria (26 from the United States, six Canadian, 13 European, and one Australian), of which 14, six, and 35 analysed virological, immunological, and ART nonadherence outcomes, respectively. Ten (71%), four (67%), and 23 (66%) of these studies found a significant association between lower socioeconomic status and poorer response, and none found a significant association with improved response. Several studies showed that adjustment for nonadherence attenuated the association between socioeconomic status and ART response. Our review provides strong support that socioeconomic disadvantage is associated with poorer response to ART. However, most studies have been conducted in settings such as the United States without universal free healthcare access. Further study in settings with free access to ART could help assess the impact of socioeconomic status on ART outcomes and the mechanisms by which it operates.