Comparing different measures of retention in outpatient HIV care

Survival functions for defining a clinical management Lost To Follow-Up (LTFU) cut-off in Antiretroviral Therapy (ART) program in Zomba, Malawi

BACKGROUND

While, lost to follow-up (LTFU) from antiretroviral therapy (ART) can be considered a catch-all category for patients who miss scheduled visits or medication pick-ups, operational definitions and methods for defining LTFU vary making comparisons across programs challenging. Using weekly cut-offs, we sought to determine the probability that an individual would return to clinic given that they had not yet returned in order to identify the LTFU cut-off that could be used to inform clinical management and tracing procedures.

METHODS

Individuals who initiated ART with Dignitas International supported sites (n = 22) in Zomba, Malawi between January 1 2007-June 30 2010 and were ≥ 1 week late for a follow-up visit were included. Lateness was categorized using weekly cut-offs from ≥1 to ≥26 weeks late. At each weekly cut-off, the proportion of patients who returned for a subsequent follow-up visit were identified. Cumulative Distribution Functions (CDFs) were plotted to determine the probability of returning as a function of lateness. Hazard functions were plotted to demonstrate the proportion of patients who returned each weekly interval relative to those who had yet to return.

RESULTS

In total, n = 4484 patients with n = 7316 follow-up visits were included. The number of included follow-up visits per patient ranged from 1-10 (median: 1). Both the CDF and hazard function demonstrated that after being ≥9 weeks late, the proportion of new patients who returned relative to those who had yet to return decreased substantially.

CONCLUSIONS

We identified a LTFU definition useful for clinical management. The simple functions plotted here did not require advanced statistical expertise and were created using Microsoft Excel, making it a particularly practical method for HIV programs in resource-constrained settings.

Retention in Early Care at an HIV Outpatient Clinic in Rio de Janeiro, Brazil, 2000-2013

Retention in early HIV care has been associated with virologic suppression and improved survival, but remains understudied in Brazil. We estimated retention in early HIV care for the period 2000-2013, and identified socio-demographic and clinical factors associated with good retention in an urban cohort from Rio de Janeiro, Brazil. Antiretroviral therapy-naïve, HIV-infected persons ≥18 years old linked to care between 2000 and 2011 were included. Retention in the first 2 years post-linkage (i.e. early care) was defined by the proportion of 6-month intervals with ≥1 HIV laboratory result. "Good" retention was defined as ≥1 HIV laboratory result recorded in at least three intervals. Overall, 80 % of participants met criteria for good retention and retention significantly improved over the study period. Older age, higher education level and early antiretroviral therapy initiation were associated with good retention. Efforts to improve retention in early care in this population should target younger and less-educated HIV-infected persons.

Antiretroviral Refill Adherence Correlates with, But Poorly Predicts Retention in HIV Care

If antiretroviral refill adherence could predict non-retention in care, it could be clinically useful. In a retrospective cohort study of HIV-infected adults in Philadelphia between October 2012 and April 2013, retention in care was measured by show versus no-show at an index visit. Three measures of adherence were defined per person: (1) percent of doses taken for two refills nearest index visit, (2) days late for last refill before index visit, and (3) longest gap between any two refills. Of 393 patients, 108 (27.4 %) no-showed. Adherence was higher in the show group on all measures with longest gap having the greatest difference: 40 days (IQR 33-56) in the show versus 47 days (IQR 38-69) in the no-show group, p < 0.001. Yet, no cut-points of adherence adequately predicted show versus no-show. Antiretroviral adherence being associated, but a poor predictor of retention suggests that these two behaviors are related but distinct phenomena.

The Impact of Youth-Friendly Structures of Care on Retention Among HIV-Infected Youth

Limited data exist on how structures of care impact retention among youth living with HIV (YLHIV). We describe the availability of youth-friendly structures of care within HIV Research Network (HIVRN) clinics and examine their association with retention in HIV care. Data from 680 15- to 24-year-old YLHIV receiving care at 7 adult and 5 pediatric clinics in 2011 were included in the analysis. The primary outcome was retention in care, defined as completing ≥2 primary HIV care visits ≥90 days apart in a 12-month period. Sites were surveyed to assess the availability of clinic structures defined a priori as 'youth-friendly'. Univariate and multivariable logistic regression models assessed structures associated with retention in care. Among 680 YLHIV, 85% were retained. Nearly half (48%) of the 680 YLHIV attended clinics with youth-friendly waiting areas, 36% attended clinics with evening hours, 73% attended clinics with adolescent health-trained providers, 87% could email or text message providers, and 73% could schedule a routine appointment within 2 weeks. Adjusting for demographic and clinical factors, YLHIV were more likely to be retained in care at clinics with a youth-friendly waiting area (AOR 2.47, 95% CI [1.11-5.52]), evening clinic hours (AOR 1.94; 95% CI [1.13-3.33]), and providers with adolescent health training (AOR 1.98; 95% CI [1.01-3.86]). Youth-friendly structures of care impact retention in care among YLHIV. Further investigations are needed to determine how to effectively implement youth-friendly strategies across clinical settings where YLHIV receive care.

Factors Associated With Retention Among Non-Perinatally HIV-Infected Youth in the HIV Research Network

BACKGROUND

The transmission of human immunodeficiency virus (HIV) among youth through high-risk behaviors continues to increase. Retention in Care is associated with positive clinical outcomes and a decrease in HIV transmission risk behaviors. We evaluated the clinical and demographic characteristics of non-perinatally HIV (nPHIV)-infected youth associated with retention 1 year after initiating care and in the 2 years thereafter. We also assessed the impact retention in year 1 had on retention in years 2 and 3.

METHODS

This was a retrospective analysis of treatment-naive nPHIV-infected 12- to 24-year-old youth presenting for care in 16 US HIV clinical sites within the HIV Research Network between 2002 and 2008. Multivariate logistic regression identified factors associated with retention.

RESULTS

Of 1160 nPHIV-infected youth, 44.6% were retained in care during the first year, and 22.4% were retained in all 3 years. Retention in the first year was associated with starting antiretroviral therapy in the first year (adjusted odds ratio [AOR], 3.47 [95% confidence interval (CI), 2.57-4.67]), Hispanic ethnicity (AOR, 1.66 [95% CI, 1.08-2.56]), men who have sex with men (AOR, 1.59 [95% CI, 1.07-2.36]), and receiving care at a pediatric site (AOR, 5.37 [95% CI, 3.20-9.01]). Retention in years 2 and 3 was associated with being retained 1 year after initiating care (AOR, 7.44 [95% CI, 5.11-10.83]).

CONCLUSION

A high proportion of newly enrolled nPHIV-infected youth were not retained for 1 year, and only 1 in 4 were retained for 3 years. Patients who were Hispanic, were men who have sex with men, or were seen at pediatric clinics were more likely to be retained in care. Interventions that target those at risk of being lost to follow up are essential for this high-risk population.

The Scale of Self-Efficacy Expectations of Adherence to Antiretroviral Treatment: A Tool for Identifying Risk for Non-Adherence to Treatment for HIV

Background

Identification of risk for non-adherence to treatment is a challenge for personalized care for people living with HIV. Standardized questionnaires of patients’ expectations of their capability to overcome obstacles for treatment adherence may be used as a pre-screening for risk identification. A scale of self-efficacy expectations of adherence to antiretroviral treatment (SEA-ART scale) was previously developed. This study assesses the scale validity in predicting non-adherence to ART in adults living with HIV.

Methods and Findings

A prospective cohort study applied a 21-item SEA-ART scale to 275 adults in ART treatment at an outpatient public service for HIV in Southern Brazil. ART medications taken were assessed at one-month follow-up; ART adherence was devised as an intake of 95% and more of the prescribed medication. A SEA-ART score was calculated by adding up the scores of all items. Multivariable logistic regression and the Area Under the Receiver-Operating-Characteristic Curve (AUROC) were applied to examine the ability of the SEA-ART score to predict non-adherence at follow-up. The SEA-ART score varied from 21 to 105; mean 93.9; median 103.0. Non-adherence was 30.3% (n = 81/267). The odds of non-adherence was 8% lower for each unit increase of the SEA-ART score; after adjustment for age, sex, formal education and time in treatment (OR = 0.92; 95%CI 0.90–0.95; LRT for linear trend, p = 0.002). The AUROC was 0.80 (95%CI 0.73–0.87; p<0.001). The SEA-ART optimal cut-off value was 101, providing a sensitivity of 76.5%, a specificity of 73.1%, a positive predictive value of 55.4% and a negative predictive value of 87.7%. There was no evidence of difference in sensitivity, and specificity among groups organized by age, gender, formal education and time in treatment.

Conclusions

The SEA-ART scale appears to have a good capacity to discriminate between adherents and non-adherents at one-month follow-up. Further studies should confirm these results in other populations.

Continuous Retention and Viral Suppression Provide Further Insights Into the HIV Care Continuum Compared to the Cross-sectional HIV Care Cascade

BACKGROUND

The human immunodeficiency virus (HIV) care continuum has become an important tool for evaluating HIV care. Current depictions of the care continuum are often cross-sectional and evaluate retention and viral suppression (VS) in a single year, yet the National HIV/AIDS Strategy calls for programs with long-lasting outcomes.

METHODS

Retrospective chart review of HIV-infected patients enrolled in a large, urban clinic in 2010 followed longitudinally for 36 months. McNemar comparisons and logistic regression analyses were conducted to evaluate covariate association with continuous retention and VS. Generalized estimating equation log-linear models were used to integrate time into the model.

RESULTS

Among 655 patients (77% male, 83% black, 54% men who have sex with men (MSM), 78% uninsured) continuous retention/VS at 12 months (84%/64%), 24 months (60%/48%), and 36 months (49%/39%) showed significant attrition (P < .0001) over time. Continuous retention was associated with prevalent VS at the end of 36 months (adjusted prevalence ratio 3.12; 95% confidence interval [CI], 2.40, 4.07). 12-month retention for black (84%) and nonblack (85%) patients was equivalent, yet fewer blacks (46%) than nonblacks (63%) achieved 36-month continuous retention due to a significant interaction between race and time (aOR 0.75, 95% CI, .59, .95).

CONCLUSIONS

Continuous retention is a critically important measure of long-term success in HIV treatment and the crucial component of successful treatment-as-prevention but is infrequently evaluated. Single cross-sections may overestimate successful retention and virologic outcomes. A longitudinal HIV care continuum provides greater insight into long-term outcomes and exposes disparities not evident with traditional cross-sectional care continua.

IAPAC Guidelines for Optimizing the HIV Care Continuum for Adults and Adolescents

BACKGROUND

An estimated 50% of people living with HIV (PLHIV) globally are unaware of their status. Among those who know their HIV status, many do not receive antiretroviral therapy (ART) in a timely manner, fail to remain engaged in care, or do not achieve sustained viral suppression. Barriers across the HIV care continuum prevent PLHIV from achieving the therapeutic and preventive effects of ART.

METHODS

A systematic literature search was conducted, and 6132 articles, including randomized controlled trials, observational studies with or without comparators, cross-sectional studies, and descriptive documents, met the inclusion criteria. Of these, 1047 articles were used to generate 36 recommendations to optimize the HIV care continuum for adults and adolescents.

RECOMMENDATIONS

Recommendations are provided for interventions to optimize the HIV care environment; increase HIV testing and linkage to care, treatment coverage, retention in care, and viral suppression; and monitor the HIV care continuum.

Retention in care and medication adherence: current challenges to antiretroviral therapy success

Health behaviors such as retention in HIV medical care and adherence to antiretroviral therapy (ART) pose major challenges to reducing new HIV infections, addressing health disparities, and improving health outcomes. Andersen's Behavioral Model of Health Service Use provides a conceptual framework for understanding how patient and environmental factors affect health behaviors and outcomes, which can inform the design of intervention strategies. Factors affecting retention and adherence among persons with HIV include patient predisposing factors (e.g., mental illness, substance abuse), patient-enabling factors (e.g., social support, reminder strategies, medication characteristics, transportation, housing, insurance), and healthcare environment factors (e.g., pharmacy services, clinic experiences, provider characteristics). Evidence-based recommendations for improving retention and adherence include (1) systematic monitoring of clinic attendance and ART adherence; (2) use of peer or paraprofessional navigators to re-engage patients in care and help them remain in care; (3) optimization of ART regimens and pharmaceutical supply chain management systems; (4) provision of reminder devices and tools; (5) general education and counseling; (6) engagement of peer, family, and community support groups; (7) case management; and (8) targeting patients with substance abuse and mental illness. Further research is needed on effective monitoring strategies and interventions that focus on improving retention and adherence, with specific attention to the healthcare environment.

Benefits of a routine opt-out HIV testing and linkage to care program for previously diagnosed patients in publicly funded emergency departments in Houston, TX

BACKGROUND

The Routine Universal Screening for HIV program provides opt-out HIV testing and linkage to care for emergency department (ED) patients in Harris Health System, Houston, TX. Seventy-five percent of patients testing positive in this program have been previously diagnosed. Whether linkage to care is increased among these patients is unknown.

METHODS

We conducted a retrospective cohort study of persons tested for HIV in the ED between 2008 and 2012 but had a previously documented positive HIV test ≥1 year prior. Outcomes were engagement in care (≥1 HIV outpatient visits in 6 months), retention in care (≥2 HIV outpatient visits in 12 months, at least 3 months apart), and virologic suppression (<200 copies/mL in 12 months) compared before and after the ED visit. Analysis was conducted using McNemar test and multivariate conditional logistic regression.

RESULTS

A total of 202,767 HIV tests identified 2068 previously diagnosed patients. The mean age was 43 years with 65% male and 87% racial and ethnic minorities. Engagement in care increased from 41.3% previsit to 58.8% postvisit (P < 0.001). Retention in care increased from 32.6% previsit to 47.1% postvisit (P < 0.001). Virologic suppression increased from 22.8% previsit to 34.0% postvisit (P < 0.001). Analyses revealed that engagement in care after visit improved most among younger participants (ages 16-24 years), retention improved across all groups, and virologic suppression improved most among participants aged 25-34 years.

CONCLUSIONS

Routine opt-out HIV testing in an ED paired with standardized service linkage improves engagement, retention, and virologic suppression in previously diagnosed patients.

Barriers and facilitators to patient retention in HIV care

Background

Retention in HIV care improves survival and reduces the risk of HIV transmission to others. Multiple quantitative studies have described demographic and clinical characteristics associated with retention in HIV care. However, qualitative studies are needed to better understand barriers and facilitators.

Methods

Semi-structured interviews were conducted with 51 HIV-infected individuals, 25 who were retained in care and 26 not retained in care, from 3 urban clinics. Interview data were analyzed for themes using a modified grounded theory approach. Identified themes were compared between the two groups of interest: patients retained in care and those not retained in care.

Results

Overall, participants identified 12 barriers and 5 facilitators to retention in HIV care. On average, retained individuals provided 3 barriers, while persons not retained in care provided 5 barriers. Both groups commonly discussed depression/mental illness, feeling sick, and competing life activities as barriers. In addition, individuals not retained in care commonly reported expensive and unreliable transportation, stigma, and insufficient insurance as barriers. On average, participants in both groups referenced 2 facilitators, including the presence of social support, patient-friendly clinic services (transportation, co-location of services, scheduling/reminders), and positive relationships with providers and clinic staff.

Conclusions

In our study, patients not retained in care faced more barriers, particularly social and structural barriers, than those retained in care. Developing care models where social and financial barriers are addressed, mental health and substance abuse treatment is integrated, and patient-friendly services are offered is important to keeping HIV-infected individuals engaged in care.

The HIV Care Continuum: Changes over Time in Retention in Care and Viral Suppression

BACKGROUND

The HIV care continuum (diagnosis, linkage to care, retention in care, receipt of antiretroviral therapy (ART), viral suppression) has been used to identify opportunities for improving the delivery of HIV care. Continuum steps are typically calculated in a conditional manner, with the number of persons completing the prior step serving as the base population for the next step. This approach may underestimate the prevalence of viral suppression by excluding patients who are suppressed but do not meet standard definitions of retention in care. Understanding how retention in care and viral suppression interact and change over time may improve our ability to intervene on these steps in the continuum.

METHODS

We followed 17,140 patients at 11 U.S. HIV clinics between 2010-2012. For each calendar year, patients were classified into one of five categories: (1) retained/suppressed, (2) retained/not-suppressed, (3) not-retained/suppressed, (4) not-retained/not-suppressed, and (5) lost to follow-up (for calendar years 2011 and 2012 only). Retained individuals were those completing ≥ 2 HIV medical visits separated by ≥ 90 days in the year. Persons not retained completed ≥ 1 HIV medical visit during the year, but did not meet the retention definition. Persons lost to follow-up had no HIV medical visits in the year. HIV viral suppression was defined as HIV-1 RNA ≤ 200 copies/mL at the last measure in the year. Multinomial logistic regression was used to determine the probability of patients' transitioning between retention/suppression categories from 2010 to 2011 and 2010 to 2012, adjusting for age, sex, race/ethnicity, HIV risk factor, insurance status, CD4 count, and use of ART.

RESULTS

Overall, 65.8% of patients were retained/suppressed, 17.4% retained/not-suppressed, 10.0% not-retained/suppressed, and 6.8% not-retained/not-suppressed in 2010. 59.5% of patients maintained the same status in 2011 (kappa=0.458) and 53.3% maintained the same status in 2012 (kappa=0.437).

CONCLUSIONS

Not counting patients not-retained/suppressed as virally suppressed, as is commonly done in the HIV care continuum, underestimated the proportion suppressed by 13%. Applying the care continuum in a longitudinal manner will enhance its utility.

Sorting through the lost and found: are patient perceptions of engagement in care consistent with standard continuum of care measures?

BACKGROUND

Indicators for determining one's status on the HIV care continuum are often measured using clinical and surveillance data but do not typically assess patient perspectives. We assessed patient-reported care status along the care continuum and whether it differed from medical records and surveillance data.

METHODS

Between June 2013 and October 2014, a convenience sample of clinic-attending HIV-infected persons was surveyed regarding care-seeking behaviors and self-perceived status along the care continuum. Participant responses were matched to DC Department of Health surveillance data and clinic records. Participants' care patterns were classified using Health Resources Services Administration-defined care status: in care (IC), sporadic care (SC), or out of care (OOC). Semistructured qualitative interviews were analyzed using an open coding process to elucidate relevant themes regarding participants' perceptions of engagement in care.

RESULTS

Of 169 participants, most were male participants (64%) and black (72%), with a mean age of 50.7 years. Using self-reported visit patterns, 115 participants (68%) were consistent with being IC, 33 (20%) SC, and 21 (12%) OOC. Among OOC participants, 52% perceived themselves to be fully engaged in HIV care. In the previous year, among OOC participants, 71% reported having a non-HIV-related medical visit and 90% reported current antiretroviral use. Qualitatively, most SC and OOC persons did not see their HIV providers regularly because they felt healthy.

CONCLUSIONS

Participants' perceptions of HIV care engagement differed from actual care receipt as measured by surveillance and clinical records. Measures of care engagement may need to be reconsidered as persons not receiving regular HIV care maybe accessing other health care and HIV medications elsewhere.

Impact of age on retention in care and viral suppression

BACKGROUND

Retention in care is important for all HIV-infected persons and is strongly associated with initiation of antiretroviral therapy and viral suppression. However, it is unclear how retention in care and age interact to affect viral suppression. We evaluated whether the association between retention and viral suppression differed by age at entry into care.

METHODS

Cross-sectional analysis (2006-2010) involving 17,044 HIV-infected adults in 14 clinical cohorts across the United States and Canada. Patients contributed 1 year of data during their first full-calendar year of clinical observation. Poisson regression examined associations between retention measures [US National HIV/AIDS Strategy (NHAS), US Department of Health and Human Services (DHHS), 6-month gap, and 3-month visit constancy] and viral suppression (HIV RNA ≤200 copies/mL) by age group: 18-29 years, 30-39 years, 40-49 years, 50-59 years, and 60 years or older.

RESULTS

Overall, 89% of patients were retained in care using the NHAS measure, 74% with the DHHS indicator, 85% did not have a 6-month gap, and 62% had visits in 3-4 quarters of the year; 54% achieved viral suppression. For each retention measure, the association with viral suppression was significant for only the younger age groups (18-29 and 30-39 years): 18-29 years [adjusted prevalence ratio (APR) = 1.33, 95% confidence interval (CI): 1.03 to 1.70]; 30-39 years (APR = 1.23, 95% CI: 1.01 to 1.49); 40-49 years (APR = 1.06, 95% CI: 0.90 to 1.22); 50-59 (APR = 0.92, 95% CI: 0.75 to 1.13); ≥60 years (APR = 0.99, 95% CI: 0.63 to 1.56) using the NHAS measure as a representative example.

CONCLUSIONS

These results have important implications for improving viral control among younger adults, emphasizing the crucial role retention in care plays in supporting viral suppression in this population.

Retention in HIV care among female sex workers in the Dominican Republic: implications for research, policy and programming

There are clear benefits of retention in HIV care, yet millions of people living with HIV are sub-optimally retained. This study described factors from Andersen's behavioral model that were associated with retention in HIV care among 268 female sex workers (FSWs) living with HIV in the Dominican Republic using two measures of retention: a 6-month measure of HIV clinic attendance and a measure that combined clinic attendance and missed visits. FSWs who ever attended HIV care reported high rates (92 %) of 6-month attendance, but 37 % reported missed visits. Using the combined retention measure, the odds of being retained in HIV care were higher among FSWs with more positive perceptions of HIV service providers [adjusted odds ratio (AOR) 1.17; 95 % confidence interval (CI) 01.09, 1.25] and lower among women who reported recent alcohol consumption (AOR 0.50; 95 % CI 0.28, 0.92) and self-stigmatizing beliefs related to sex work (AOR 0.93; 95 % CI 0.88, 0.98). These findings support the hypothesis that retention in HIV care may be best determined through a combined measure as missed visits are an important mechanism to identify in-care patients who require additional support.

Patterns of HIV service use and HIV viral suppression among patients treated in an academic infectious diseases clinic in North Carolina

Irregular participation in HIV medical care hinders HIV RNA suppression and impacts health among people living with HIV. Cluster analysis of clinical data from 1,748 patients attending a large academic medical center yielded three HIV service usage patterns, namely: 'engaged in care', 'sporadic care', and 'frequent use'. Patients 'engaged in care' exhibited most consistent retention (on average, >88 % of each patient's observation years had ≥2 visits 90 days apart), annualized visit use (2.9 mean visits/year) and viral suppression (>73 % HIV RNA tests <400 c/mL). Patients in 'sporadic care' demonstrated lower retention (46-52 %), visit use (1.7 visits/year) and viral suppression (56 % <400 c/mL). Patients with 'frequent use' (5.2 visits/year) had more inpatient and emergency visits. Female, out-of-state residence, low attendance during the first observation year and detectable first-observed HIV RNA were early predictors of subsequent service usage. Patients 'engaged in care' were more likely to have HIV RNA <400 than those receiving sporadic care. Results confirm earlier findings that under-utilization of services predicts poorer viral suppression and health outcomes and support recommendations for 2-3 visits/year.

Comparative value of four measures of retention in expert care in predicting clinical outcomes and health care utilization in HIV patients

This study compared the ability of four measures of patient retention in HIV expert care to predict clinical outcomes. This retrospective study examined Veterans Health Administration (VHA) beneficiaries with HIV (ICD-9-CM codes 042 or V08) receiving expert care (defined as HIV-1 RNA viral load and CD4 cell count tests occurring within one week of each other) at VHA facilities from October 1, 2006, to September 30, 2008. Patients were ≥18 years old and continuous VHA users for at least 24 months after entry into expert care. Retention measures included: Annual Appointments (≥2 appointments annually at least 60 days apart), Missed Appointments (missed ≥25% of appointments), Infrequent Appointments (>6 months without an appointment), and Missed or Infrequent Appointments (missed ≥25% of appointments or >6 months without an appointment). Multivariable nominal logistic regression models were used to determine associations between retention measures and outcomes. Overall, 8,845 patients met study criteria. At baseline, 64% of patients were virologically suppressed and 37% had a CD4 cell count >500 cells/mm³. At 24 months, 82% were virologically suppressed and 46% had a CD4 cell count >500 cells/mm³. During follow-up, 13% progressed to AIDS, 48% visited the emergency department (ED), 28% were hospitalized, and 0.3% died. All four retention measures were associated with virologic suppression and antiretroviral therapy initiation at 24 months follow-up. Annual Appointments correlated positively with CD4 cell count >500 cells/mm³. Missed Appointments was predictive of all primary and secondary outcomes, including CD4 cell count ≤500 cells/mm³, progression to AIDS, ED visit, and hospitalization. Missed Appointments was the only measure to predict all primary and secondary outcomes. This finding could be useful to health care providers and public health organizations as they seek ways to optimize the health of HIV patients.

Ten-year Survival by Race/Ethnicity and Sex Among Treated, HIV-infected Adults in the United States

BACKGROUND

Ensuring equal access to antiretroviral therapy (henceforth therapy) should alleviate disparities in health outcomes among persons infected with human immunodeficiency virus (HIV). However, evidence supporting the persistence of disparities in survival following therapy initiation is mixed.

METHODS

Patients initiating therapy in eight academic medical centers in the Centers for AIDS Research Network of Integrated Clinical Systems between 1 January 1998 and 30 December 2011. Patients (n = 10 017) were followed from therapy initiation until death from any cause, administrative censoring at 10 years after therapy initiation or the end of follow-up on 31 December 2011. The 10-year risk of all-cause mortality was calculated from standardized Kaplan-Meier survival curves.

RESULTS

Patients were followed for a median of 4.7 years (interquartile range: 2.2, 8.2). During 51 121 person-years of follow-up, 1224 of the 10 017 patients died. The overall 10-year mortality risk was 20.2% (95% confidence interval [CI], 19.2%, 21.3%). Black men and women experienced standardized 10-year all-cause mortality risks that were 7.2% (95% CI, 4.3%, 10.1%) and 7.9% (95% CI, 3.9%, 12.0%) larger (absolute difference) than white men. White women, Hispanic men, and Hispanic women all had lower 10-year mortality than white men.

CONCLUSIONS

These data serve as a call to action to identify modifiable mechanisms leading to these observed mortality disparities among HIV-infected black patients. Effective interventions are needed to ensure that the goal of the National HIV/AIDS Strategy to overcome health disparities becomes a reality.

Aging and loss to follow-up among youth living with human immunodeficiency virus in the HIV Research Network

PURPOSE

In the United States, 21 years is a critical age of legal and social transition, with changes in social programs such as public insurance coverage. Human immunodeficiency virus (HIV)-infected youth have lower adherence to care and medications and may be at risk of loss to follow-up (LTFU) at this benchmark age. We evaluated LTFU after the 22nd birthday for HIV-infected youth engaged in care. LTFU was defined as having no primary HIV visits in the year after the 22nd birthday.

METHODS

All HIV-infected 21-year-olds engaged in care (2002-2011) at the HIV Research Network clinics were included. We assessed the proportion LTFU and used multivariable logistic regression to evaluate demographic and clinical characteristics associated with LTFU after the 22nd birthday. We compared LTFU at other age transitions during the adolescent/young adult years.

RESULTS

Six hundred forty-seven 21-year-olds were engaged in care; 91 (19.8%) were LTFU in the year after turning 22 years. Receiving care at an adult versus pediatric HIV clinic (adjusted odds ratio [AOR], 2.91; 95% confidence interval [CI], 1.42-5.93), having fewer than four primary HIV visits/year (AOR, 2.72; 95% CI, 1.67-4.42), and antiretroviral therapy prescription (AOR, .50; 95% CI, .41-.60) were independently associated with LTFU. LTFU was prevalent at each age transition, with factors associated with LTFU similar to that identified for 21-year-olds.

CONCLUSIONS

Although 19.8% of 21-year-olds at the HIV Research Network sites were LTFU after their 22nd birthday, significant proportions of youth of all ages were LTFU. Fewer than four primary HIV care visits/year, receiving care at adult clinics and not prescribed antiretroviral therapy, were associated with LTFU and may inform targeted interventions to reduce LTFU for these vulnerable patients.

HIV viral suppression among persons with varying levels of engagement in HIV medical care, 19 US jurisdictions

BACKGROUND

Ongoing HIV medical care is vital in achieving and maintaining viral suppression. We examined viral suppression applying retention in care definitions used by various federal agencies.

METHODS

Using National HIV Surveillance System data from 19 US jurisdictions with complete CD4 and viral load reporting, we determined viral suppression among persons who met the National HIV/AIDS Strategy retention in care definition (≥2 visits ≥3 months apart; "retained in continuous care") and among those who had evidence of care but did not meet the definition ("engaged in care"). We also examined viral suppression among persons who met the Health and Human Services Core Indicator definition for retention.

RESULTS

Of 338,959 persons living with diagnosed HIV infection in 19 areas in 2010, 63.7% received any care; of these, 19.7% were "engaged in care" and 80.3% were "retained in continuous care." Of those "engaged in care," 47.7% achieved viral suppression compared with 73.6% of persons "retained in continuous care." Significant differences were evident for all subpopulations within each care category; younger persons and blacks/African Americans had lower levels of viral suppression than their counterparts. Persons "engaged in care," regardless of sex, age, race/ethnicity, and transmission category, had significantly lower percentages of viral suppression than persons "retained in continuous care." Similar patterns of viral suppression were found for persons meeting the Health and Human Services definition compared with persons "retained in continuous care."

CONCLUSIONS

Higher levels of engagement in care, including more frequent monitoring of CD4 and viral load, were associated with viral suppression.

Examining the relationship between multiple comorbidities and retention in HIV medical care: a retrospective analysis

Retention in medical care among people living with HIV (PLWH) is a major component in properly managing the disease. As PLWH age, diagnoses of comorbid conditions become common and it may be important to understand how these conditions may impact engagement in care, in particular retention in HIV medical care. A secondary data analysis was conducted to determine the relationship between multiple comorbid conditions and retention in HIV care among patients who sought HIV care between 2003 and 2011. Retention in care was defined as having two clinic visits separated by ≥3 months within a 12-month period. Logistic regression was conducted to determine if multiple comorbid conditions were associated with optimal retention (100%) versus suboptimal retention (<100%). There were 1261 patients included in the analysis, 47% had ≥1 comorbid condition, and approximately 55%, were optimally retained in care. In the regression model, those with one comorbid condition (odds ratio [OR]: 2.47; 95% confidence interval [CI]: 1.81-3.39) and ≥2 comorbid conditions (OR: 4.08; 95% CI: 2.59-6.45) were at significantly higher odds of being optimally retained in care. The results of the study suggest that those living with both HIV and multiple comorbid conditions are better engaged in care compared to those without any comorbid conditions, and this may not present a barrier to care as suggested by other researchers. The results of this study may shed light on the development of tailored interventions to improve retention in care.

Mapping patient-identified barriers and facilitators to retention in HIV care and antiretroviral therapy adherence to Andersen's Behavioral Model

Andersen's Behavioral Model (ABM) provides a framework for understanding how patient and environmental factors impact health behaviors and outcomes. We compared patient-identified barriers/facilitators to retention in care and antiretroviral therapy (ART) adherence and evaluated how they mapped to ABM. Qualitative semi-structured interviews with 51 HIV-infected adults at HIV clinics in Philadelphia, PA, in 2013 were used to explore patients' experiences with HIV care and treatment. Interview data were analyzed for themes using a grounded theory approach. Among those interviewed, 53% were male and 88% were nonwhite; 49% were retained in care, 96% were on ART, and 57% were virally suppressed. Patients discussed 18 barriers/facilitators to retention in care and ART adherence: 11 common to both behaviors (stigma, mental illness, substance abuse, social support, reminder strategies, housing, insurance, symptoms, competing life activities, colocation of services, provider factors), 3 distinct to retention (transportation, clinic experiences, appointment scheduling), and 4 distinct to adherence (medication characteristics, pharmacy services, health literacy, health beliefs). Identified barriers/facilitators mapped to all ABM domains. These data support the use of ABM as a framework for classifying factors influencing HIV-specific health behaviors and have the potential to inform the design of interventions to improve retention in care and ART adherence.

Multiple gaps in care common among newly diagnosed HIV patients

The objective of this study was to identify frequency and predictors of gaps in care in a longitudinal cohort of HIV-infected patients in urban New England. We conducted a retrospective cohort study in Providence, RI, of 581 newly diagnosed HIV patients >18 entering into care from 2004 to 2010, and followed their care through the end of 2011. The outcome of interest was gaps in care, defined as an interruption of medical care for >6 months. Time to the first gap was characterized using Kaplan-Meier (KM) curves. Anderson-Gill proportional hazards (AGPH) model was used to identify the risk factors of recurrent gaps in care. During the study period, 368 patients (63%) experienced at least 1 gap in care, 178 (30%) had ≥2 gaps, 84 (14.5%) had ≥3 gaps, and 21 (3.6%) died; 77% of the gaps were followed by a re-linkage with care The KM curves estimate that one-quarter of patients (95% CI = 22-29%) would experience ≥1 gap in care by Year 1; nearly one-half (CI = 45-54%) by Year 2; and 90% (CI = 93-96%) by Year 8. A prior gap was a strong predictor (HR = 2.36; CI = 2.16-2.58) of subsequent gaps; other predictors included age <25 (HR = 1.29; CI = 1.04-1.60), and no prescription of ART in first year of care (HR = 1.23; CI = 1.01-1.50). The results of this study suggest that a significant proportion of newly diagnosed HIV-infected patients will experience multiple gaps in care and yet re-engagement is possible. Interventions should focus on both prevention of gaps as well as re-engaging those lost to follow-up.

Factors associated with retention and viral suppression among a cohort of HIV+ women of color

Access to sustained HIV medical care is critical to achieving viral suppression. However, a variety of factors may impede or facilitate retention in care or becoming virally suppressed. Though retention and suppression are often treated separately, this study examined both in a cohort of 921 HIV+ women of color who participated in eight demonstration programs across the US. For women who met the inclusion criteria, 83% (n = 587) were retained and 73% (n = 357) were virally suppressed. Average age of women retained was 40.9, and 41.9 for those virally suppressed. The majority were African American/Black or Hispanic/Latina, single, and had no children less than 18 years of age, had health insurance, a high school degree or higher, were stably housed, and unemployed. Some factors associated with retention in care were indecision about seeking HIV medical care (AOR = 0.42) and having children under the age of 18 (AOR = 0.59). Some factors associated with being virally suppressed were living with others (AOR = 0.58), current substance abuse (AOR = 0.38), and fair/poor health (AOR = 0.40). The findings suggest different processes and social mechanisms may influence retention and viral suppression. Interventions seeking to improve retention in care may require tailored program components and strategies that focus on improving viral suppression.

Simulating patterns of patient engagement, treatment adherence, and viral suppression: a system dynamics approach to evaluating HIV care management

System dynamics (SD) modeling belongs to the rapidly evolving, interdisciplinary field of system science research. This field adds value to more traditional health research by contributing to the design and testing of complex integrated models of change, to examine health system performance and patient outcomes. Using selected milestones in HIV care management to frame our simulation research, we created a SD model to examine three patient subgroups of women of color (WOC) represented in our multi-site cohort, classified by their health care seeking status at baseline. Asked to reflect on their circumstance 6 months prior to enrollment in the MSE cohort, 53% noted they were receiving some care (In Care, n = 341), 31% that they had been seeking care (Seeking Care, n = 201), and 16% that they were undecided about seeking care (i.e., answered that they may or may not look for care) for treatment of their HIV (May or May Not Seek Care, n = 103). Our SD model compared simulated patterns of patient retention over 24 months in relation to: (1) access to antiretroviral therapy (ART), (2) adherence to ART, and (3) viral suppression. Assessed patterns yielded insights about system capacities and constraints in the context of the SPNS initiative under evaluation.

Beyond core indicators of retention in HIV care: missed clinic visits are independently associated with all-cause mortality

BACKGROUND

The continuum of care is at the forefront of the domestic human immunodeficiency virus (HIV) agenda, with the Institute of Medicine (IOM) and Department of Health and Human Services (DHHS) recently releasing clinical core indicators. Core indicators for retention in care are calculated based on attended HIV care clinic visits. Beyond these retention core indicators, we evaluated the additional prognostic value of missed clinic visits for all-cause mortality.

METHODS

We conducted a multisite cohort study of 3672 antiretroviral-naive patients initiating antiretroviral therapy (ART) during 2000-2010. Retention in care was measured by the IOM and DHHS core indicators (2 attended visits at defined intervals per 12-month period), and also as a count of missed primary HIV care visits (no show) during a 24-month measurement period following ART initiation. All-cause mortality was ascertained by query of the Social Security Death Index and/or National Death Index, with adjusted survival analyses starting at 24 months after ART initiation.

RESULTS

Among participants, 64% and 59% met the IOM and DHHS retention core indicators, respectively, at 24 months. Subsequently, 332 patients died during 16 102 person-years of follow-up. Failure to achieve the IOM and DHHS indicators through 24 months following ART initiation increased mortality (hazard ratio [HR] = 2.23; 95% confidence interval [CI], 1.79-2.80 and HR = 2.36; 95% CI, 1.89-2.96, respectively). Among patients classified as retained by the IOM or DHHS clinical core indicators, >2 missed visits further increased mortality risk (HR = 3.61; 95% CI, 2.35-5.55 and HR = 3.62; 95% CI, 2.30-5.68, respectively).

CONCLUSIONS

Beyond HIV retention core indicators, missed clinic visits were independently associated with all-cause mortality. Caution is warranted in relying solely upon retention in care core indicators for policy, clinical, and programmatic purposes.

Strong agreement of nationally recommended retention measures from the Institute of Medicine and Department of Health and Human Services

Objective

We sought to quantify agreement between Institute of Medicine (IOM) and Department of Health and Human Services (DHHS) retention indicators, which have not been compared in the same population, and assess clinical retention within the largest HIV cohort collaboration in the U.S.

Design

Observational study from 2008–2010, using clinical cohort data in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD).

Methods

Retention definitions used HIV primary care visits. The IOM retention indicator was: ≥2 visits, ≥90 days apart, each calendar year. This was extended to a 2-year period; retention required meeting the definition in both years. The DHHS retention indicator was: ≥1 visit each semester over 2 years, each ≥60 days apart. Kappa statistics detected agreement between indicators and C statistics (areas under Receiver-Operating Characteristic curves) from logistic regression analyses summarized discrimination of the IOM indicator by the DHHS indicator.

Results

Among 36,769 patients in 2008–2009 and 34,017 in 2009–2010, there were higher percentages of participants retained in care under the IOM indicator than the DHHS indicator (80% vs. 75% in 2008–2009; 78% vs. 72% in 2009–2010, respectively) (p<0.01), persisting across all demographic and clinical characteristics (p<0.01). There was high agreement between indicators overall (κ = 0.83 in 2008–2009; κ = 0.79 in 2009–2010, p<0.001), and C statistics revealed a very strong ability to predict retention according to the IOM indicator based on DHHS indicator status, even within characteristic strata.

Conclusions

Although the IOM indicator consistently reported higher retention in care compared with the DHHS indicator, there was strong agreement between IOM and DHHS retention indicators in a cohort demographically similar to persons living with HIV/AIDS in the U.S. Persons with poorer retention represent subgroups of interest for retention improvement programs nationally, particularly in light of the White House Executive Order on the HIV Care Continuum.

Outcomes of HIV-infected patients receiving care at multiple clinics

Receiving care at multiple clinics may compromise the therapeutic patient-provider alliance and adversely affect the treatment of people living with HIV. We evaluated 12,759 HIV-infected adults in Philadelphia, PA between 2008 and 2010 to determine the effects of using multiple clinics for primary HIV care. Using generalized estimating equations with logistic regression, we examined the relationship between receiving care at multiple clinics (≥ 1 visit to two or more clinics during a calendar year) and two outcomes: (1) use of ART and (2) HIV viral load ≤ 200 copies/mL for patients on ART. Overall, 986 patients (8 %) received care at multiple clinics. The likelihood of attending multiple clinics was greater for younger patients, women, blacks, persons with public insurance, and for individuals in their first year of care. Adjusting for sociodemographic factors, patients receiving care at multiple clinics were less likely to use ART (AOR = 0.62, 95 % CI 0.55-0.71) and achieve HIV viral suppression (AOR = 0.78, 95 % CI 0.66-0.94) than individuals using one clinic. Qualitative data are needed to understand the reasons for visiting multiple clinics.

Monitoring retention in care: using multiple laboratory tests as an indicator for HIV medical care

Retention in care is an important strategy for HIV prevention. Unfortunately, surveillance systems were not designed to capture face-to-face visits with HIV health care providers to assess retention in care. Instead, HIV-related laboratory tests are used as a surrogate measure. This study estimated the sensitivity (90%) and specificity (28%) of two HIV-related laboratory tests separated by at least 90 days for two face-to-face visits among people receiving HIV-related health care in Oregon. Overall accuracy of the surrogate was good but slightly overestimated the proportion of people living with HIV/AIDS actually retained in care.

Optimizing the use of surveillance data for monitoring the care status of persons recently diagnosed with HIV in NYC

BACKGROUND

Comprehensive laboratory reporting of CD4 and viral load (VL) tests to surveillance has been used to assess HIV care-related outcomes at the population level, but their validity for this purpose has not been comprehensively evaluated.

OBJECTIVE

Assess performance characteristics and validity of surveillance-based measures of linkage to and establishment of HIV primary care among HIV-infected persons in the first 12 months after diagnosis using medical record (MR) data on outpatient HIV primary care visits as the gold standard.

METHODS

All patients diagnosed with HIV in 2009 at 24 New York City high-volume, HIV diagnostic and treatment facilities who linked to care within 12 months at the same site as defined by the presence of ≥1 CD4/VL report received by surveillance were selected for MR review to confirm linkage to outpatient HIV primary care within the first year. All HIV care visit dates were abstracted and considered associated with a surveillance laboratory report, if within 14 days of a care visit. The proportion linking to care according to the MR was compared with the proportion linking per CD4/VL tests reported to surveillance. Four measures of the establishment of outpatient HIV primary care in the first year were assessed: (1) sustained care (first visit within 3 months; second visit, 3-9 months later), (2) continuous care (2 visits at least 90 days apart), (3) trimester visits (visit in each 4-month period), and (4) visit constancy (visit in each 3-month period). The validity of surveillance data for measuring this outcome was assessed by comparing results for each of the 4 measures calculated using surveillance data to those calculated using MR data.

RESULTS

Of the 782 patients selected, 20% (N = 157) of patients did not link to outpatient HIV primary care at the co-located care facility within 12 months of diagnosis. Half (48.5%) of patients' care visits after linkage did not have an associated CD4/VL reported to surveillance. Of the 4 establishment measures, sustained and continuous care had the highest agreement with MR (86.6% and 88.8%, respectively) as compared with the trimester visits and visit constancy (77.8% and 72.8%, respectively).

CONCLUSIONS

Surveillance data overestimated linkage rates but underestimated the frequency of HIV care in the first year after HIV diagnosis. Of the 4 measures of establishment of HIV care evaluated, "sustained care" is best suited for measurement using surveillance data because of its high level of agreement with MR data and close alignment with national standards for timely linkage and flexible follow-up.

The HIV-Brazil cohort study: design, methods and participant characteristics

Background

The HIV-Brazil Cohort Study was established to analyze the effectiveness of combination antiretroviral therapy (cART) and the impact of this treatment on morbidity, quality of life (QOL) and mortality. The study design, patients’ profiles and characteristics of cART initiation between 2003 and 2010 were described.

Methodology/Principal Findings

Since 2003, the HIV-Brazil Cohort has been following HIV-infected adults receiving cART at 26 public health care facilities, using routine clinical care data and self-reported QOL questionnaires. When not otherwise available, data are obtained from national information systems. The main outcomes of interest are diseases related or unrelated to HIV; suppression of viral replication; adverse events; virological, clinical and immunological failures; changes in the cART; and mortality. For the 5,061 patients who started cART between 2003 and 2010, the median follow-up time was 4.1 years (IQR 2.2–5.9 years) with an 83.4% retention rate. Patient profiles were characterized by a predominance of men (male/female ratio 1.7∶1), with a mean age of 36.9 years (SD 9.9 years); 55.2% had been infected with HIV via heterosexual contact. The majority of patients (53.4%) initiated cART with a CD4⁺ T-cell count ≤200 cells/mm³. The medications most often used in the various treatment regimens were efavirenz (59.7%) and lopinavir/ritonavir (18.2%). The proportion of individuals achieving viral suppression within the first 12 months of cART use was 77.4% (95% CI 76.1–78.6). Nearly half (45.4%) of the patients presented HIV-related clinical manifestations after starting cART, and the AIDS mortality rate was 13.9 per 1,000 person-years.

Conclusions/Significance

Results from cART use in the daily practice of health services remain relatively unknown in low- and middle-income countries, and studies with the characteristics of the HIV-Brazil Cohort contribute to minimizing these shortcomings, given its scope and patient profile, which is similar to that of the AIDS epidemic in the country.

Retention in care is more strongly associated with viral suppression in HIV-infected patients with lower versus higher CD4 counts

BACKGROUND

Retention in care is important for all HIV-infected patients, but may be more important for people with advanced HIV disease. We evaluated whether the association between retention in care and viral suppression differed by HIV disease severity.

METHODS

A repeated cross-sectional analysis (2006-2011) involving 35,433 adults at 18 US HIV clinics. Multivariable logistic regression models examined associations between retention measures [Health Resources and Services Administration (HRSA) retention measure, 6-month gap, and 3-month visit constancy] and viral suppression (HIV-1 RNA ≤ 400 copies/mL) for HIV disease severity groups defined by CD4 counts: ≤ 200, 201-350, 351-500, and >500 cells per cubic millimeter.

RESULTS

Overall, patients met the HRSA measure in 84% of person-years, did not have a 6-month gap in 76%, and had visits in all 4 quarters in 37%; patients achieved viral suppression in 72% of person-years. The association between retention in care and viral suppression differed by disease severity, and was strongest for patients with lower CD4 counts: ≤ 200 [adjusted odds ratio (AOR) = 2.33, 95% confidence interval (CI): 2.16 to 2.51], 201-350 (AOR = 1.96, CI: 1.81 to 2.12), 351-500 (AOR = 1.65, CI: 1.53 to 1.78), and >500 cells per cubic millimeter (AOR = 1.22, CI: 1.14 to 1.30) using the HRSA retention measure as a representative example.

CONCLUSIONS

This is one of the first studies to report the impact of HIV disease severity on retention in care and viral suppression, demonstrating that retention in care is more strongly associated with viral suppression in patients with lower CD4 counts. These results have important implications for improving the health of patients with advanced HIV disease and for test and treat approaches to HIV prevention.

Retention in care within 1 year of initial HIV care visit in a multisite US cohort: who's in and who's out?

Biannual attendance at medical visits is an established measure of retention in HIV care. We examined factors associated with attending at least 2 clinic visits at least 90 days apart among HIV-infected, antiretroviral therapy (ART)-naive HIV Outpatient Study participants entering care during 2000 to 2011. Of 1441 patients, 85% were retained in care during the first year of observation. Starting ART during the year was the strongest correlate of retention (adjusted odds ratio [aOR] 6.4, 95% confidence interval [CI] 4.4-9.4). After adjusting for starting ART, publicly insured patients (aOR 0.6, 95% CI 0.4-1.0), and patients with baseline CD4 counts <200 cells/mm(3) (aOR 0.5, 95% CI 0.3-0.9) or missing CD4 counts (aOR 0.3, 95% CI 0.2-0.6) were less likely to be retained in care. Although most patients had recommended biannual care visits, some ART-naive individuals may require additional interventions to remain in care. Promptly initiating ART may facilitate engagement in care.

Disparities in HIV transmission risk among HIV-infected black and white men who have sex with men, United States, 2009

OBJECTIVE

To better understand why HIV incidence is substantially higher among black than white men who have sex with men (MSM), we present the first nationally representative estimates of factors that contribute to transmission - sexual behavior, antiretroviral therapy (ART) use, and viral suppression - among HIV-infected black and white MSM in the United States.

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 during June 2009 to May 2010 to estimate the prevalence of sexual behaviors, ART use, and viral suppression among sexually active HIV-infected black and white MSM. We used χ tests to assess significant differences between races and logistic regression models to identify factors that mediated the racial differences.

RESULTS

Sexual risk behaviors among black and white MSM were similar. Black MSM were significantly less likely than white MSM to take ART (80 vs. 91%) and be durably virally suppressed (48 vs. 69%). Accounting for mediators (e.g. age, insurance, poverty, education, time since diagnosis, and disease stage) reduced, but did not eliminate, disparities in ART use and rendered differences in viral suppression among those on ART insignificant.

CONCLUSION

Lower levels of ART use and viral suppression among HIV-infected black MSM may increase the likelihood of HIV transmission. Addressing the patient-level factors and structural inequalities that contribute to lower levels of ART use and viral suppression among this group will improve clinical outcomes and might reduce racial disparities in HIV incidence.

Racial/ethnic differences in trust in health care: HIV conspiracy beliefs and vaccine research participation

BACKGROUND

Prior research has documented a high prevalence of conspiracy beliefs about the origin of the human immunodeficiency virus (HIV) and the role of the government in the acquired immunodeficiency syndrome (AIDS) epidemic, particularly among racial and ethnic minorities in the United States. Whether such beliefs are a barrier to participation in HIV prevention research is not known.

OBJECTIVE

To understand the prevalence of HIV conspiracy beliefs and their relationship to willingness to participate in HIV vaccine research among three racial/ethnic groups.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Six hundred and one community-recruited volunteers (33.0 % White, 32.5 % Mexican American, and 34.5 % African American).

MAIN MEASURES

We evaluated the level of agreement with six previously described HIV conspiracy beliefs, trust in medical research, and willingness to participate in HIV vaccine research. Multivariate models were used to compare these parameters among the three racial/ethnic groups while controlling for the potential confounding effects of socioeconomic status, access to health care, and other demographic factors.

RESULTS

African Americans, Mexican Americans, and whites had similar levels of distrust in medical research. African and Mexican Americans were more likely to endorse one or more of six HIV conspiracy beliefs than whites (59.0 % and 58.6 % versus 38.9 %, respectively, P < 0.001), but were significantly more willing to participate in HIV vaccine research (ORs 1.58, CI 1.10-2.25 and 2.53, CI 1.75-3.66, respectively). Among respondents of all racial/ethnic groups, endorsing HIV conspiracy beliefs was not associated with willingness to participate in research.

CONCLUSIONS

HIV conspiracy beliefs, while common among all racial and ethnic groups in the United States, do not preclude willingness to participate in HIV prevention research.

Behind the cascade: analyzing spatial patterns along the HIV care continuum

BACKGROUND

Successful HIV treatment as prevention requires individuals to be tested, aware of their status, linked to and retained in care, and virally suppressed. Spatial analysis may be useful for monitoring HIV care by identifying geographic areas with poor outcomes.

METHODS

Retrospective cohort of 1704 people newly diagnosed with HIV identified from Philadelphia's Enhanced HIV/AIDS Reporting System in 2008-2009, with follow-up to 2011. Outcomes of interest were not linked to care, not linked to care within 90 days, not retained in care, and not virally suppressed. Spatial patterns were analyzed using K-functions to identify "hot spots" for targeted intervention. Geographic components were included in regression analyses along with demographic factors to determine their impact on each outcome.

RESULTS

Overall, 1404 persons (82%) linked to care; 75% (1059/1404) linked within 90 days; 37% (526/1059) were retained in care; and 72% (379/526) achieved viral suppression. Fifty-nine census tracts were in hot spots, with no overlap between outcomes. Persons residing in geographic areas identified by the local K-function analyses were more likely to not link to care [adjusted odds ratio 1.76 (95% confidence interval: 1.30 to 2.40)], not link to care within 90 days (1.49, 1.12-1.99), not be retained in care (1.84, 1.39-2.43), and not be virally suppressed (3.23, 1.87-5.59) than persons not residing in the identified areas.

CONCLUSIONS

This study is the first to identify spatial patterns as a strong independent predictor of linkage to care, retention in care, and viral suppression. Spatial analyses are a valuable tool for characterizing the HIV epidemic and treatment cascade.

Accuracy of definitions for linkage to care in persons living with HIV

OBJECTIVE

To compare the accuracy of linkage to care metrics for patients diagnosed with HIV using retention in care and virological suppression as the gold standards of effective linkage.

DESIGN

A retrospective cohort study of patients aged 18 years and older with newly diagnosed HIV infection in the City of Philadelphia, 2007-2008.

METHODS

Times from diagnosis to clinic visits or laboratory testing were used as linkage measures. Outcome variables included being retained in care and achieving virological suppression, 366-730 days after diagnosis. Positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) for each linkage measure and retention, and virological suppression outcomes are described.

RESULTS

Of the 1781 patients in the study, 503 (28.2%) were retained in care in the Ryan White system and 418 (23.5%) achieved virological suppression 366-730 days after diagnosis. The linkage measure with the highest PPV for retention was having 2 clinic visits within 365 days of diagnosis, separated by 90 days (74.2%). Having a clinic visit between 21 and 365 days after diagnosis had both the highest NPV for retention (94.5%) and the highest adjusted AUC for retention (0.872). Having 2 tests within 365 days of diagnosis, separated by 90 days, had the highest adjusted AUC for virological suppression (0.780).

CONCLUSIONS

Linkage measures associated with clinic visits had higher PPV and NPV for retention, whereas linkage measures associated with laboratory testing had higher PPV and NPV for retention. Linkage measures should be chosen based on the outcome of interest.

A comparison study of methods for measuring retention in HIV medical care

The purpose of this study was to compare multiple measures of retention in HIV medical care by determining their ability to predict viral suppression. Patients who sought care between 2003 and 2011 were eligible. Visit constancy, gaps-in-care, and HRSA measure were the measures compared. Multiple logistic regressions and area under the curve statistics were employed to determine which measure most accurately discerned between patients with or without viral suppression. There were 850 patients included in the study. The mean follow-up time among the cohort was 5.6 years and less than half were consistently retained in care. All three measures had similar area under the curves, but only visit constancy and gaps in care were significantly associated with viral suppression. Retention in care should be defined consistently across studies and interventions should be set in place to increase the number of optimal retainers.

Medication possession ratio predicts antiretroviral regimens persistence in Peru

Objectives

In developing nations, the use of operational parameters (OPs) in the prediction of clinical care represents a missed opportunity to enhance the care process. We modeled the impact of multiple measurements of antiretroviral treatment (ART) adherence on antiretroviral treatment outcomes in Peru.

Design And Methods

Retrospective cohort study including ART naïve, non-pregnant, adults initiating therapy at Hospital Nacional Cayetano Heredia, Lima-Peru (2006-2010). Three OPs were defined: 1) Medication possession ratio (MPR): days with antiretrovirals dispensed/days on first-line therapy; 2) Laboratory monitory constancy (LMC): proportion of 6 months intervals with ≥1 viral load or CD4 reported; 3) Clinic visit constancy (CVC): proportion of 6 months intervals with ≥1 clinic visit.

Three multi-variable Cox proportional hazard (PH) models (one per OP) were fit for (1) time of first-line ART persistence and (2) time to second-line virologic failure. All models were adjusted for socio-demographic, clinical and laboratory variables.

Results

856 patients were included in first-line persistence analyses, median age was 35.6 years [29.4-42.9] and most were male (624; 73%). In multivariable PH models, MPR (per 10% increase HR=0.66; 95%CI=0.61-0.71) and LMC (per 10% increase 0.83; 0.71-0.96) were associated with prolonged time on first-line therapies.

Among 79 individuals included in time to second-line virologic failure analyses, MPR was the only OP independently associated with prolonged time to second-line virologic failure (per 10% increase 0.88; 0.77-0.99).

Conclusions

The capture and utilization of program level parameters such as MPR can provide valuable insight into patient-level treatment outcomes.

Initial Linkage and Subsequent Retention in HIV Care for a Newly Diagnosed HIV-Infected Cohort in Denver, Colorado

This is a retrospective cohort study of 352 newly diagnosed HIV-infected individuals in Denver, from 2005 to 2007. Utilizing data from 3 health care systems, 2 clinical trials units, and statewide Colorado HIV laboratory reporting databases, we tracked initial linkage to HIV care, retention in care, loss to follow-up, and transitions between HIV care providers. After more than 2.6 years of follow-up, 256 (73%) individuals linked to HIV care within 180 days. Of the 301 individuals who eventually linked to care, 168 (56%) had at least one 180-day gap in care, while 49 (16%) had a 360-day gap. Transitions in care were common, with 131 (37%) individuals accessing care from 2 different providers and 15% having evidence of living outside of Colorado. In this newly diagnosed HIV-infected cohort, linkage to care was slow and long-term retention in care was poor. Transitions between HIV care providers were common and may impair engagement in care over time. Out-of-state migration was frequent and may cause an underestimation of engagement in care.

Evolving uses of oral reverse transcriptase inhibitors in the HIV-1 epidemic: from treatment to prevention

The HIV epidemic continues unabated, with no highly effective vaccine and no cure. Each new infection has significant economic, social and human costs and prevention efforts are now as great a priority as global antiretroviral therapy (ART) scale up. Reverse transcriptase inhibitors, the first licensed class of ART, have been at the forefront of treatment and prevention of mother to child transmission over the past two decades. Now, their use in adult prevention is being extensively investigated. We describe two approaches: treatment as prevention (TasP) - the use of combination ART (2NRTI and 1NNRTI) following HIV diagnosis to limit transmission and pre-exposure prophylaxis (PrEP) –the use of single or dual oral agents prior to sexual exposure. Prevention of mother-to-child transmission using NRTI has been highly successful, though does not involve sustained use of NRTI to limit transmission. Despite theoretical and preliminary support for TasP and PrEP, data thus far indicate that adherence, retention in care and late diagnosis are the major barriers to their successful, sustained implementation. Future advances in drug technologies will be needed to overcome the issue of drug adherence, through development of drugs that involve both less frequent dosing as well as reduced toxicity, possibly through specific targeting of infected cells.

Conformity of pediatric/adolescent HIV clinics to the patient-centered medical home care model

The patient-centered medical home (PCMH) has been introduced as a model for providing high-quality, comprehensive, patient-centered care that is both accessible and coordinated, and may provide a framework for optimizing the care of youth living with HIV (YLH). We surveyed six pediatric/adolescent HIV clinics caring for 578 patients (median age 19 years, 51% male, and 82% black) in July 2011 to assess conformity to the PCMH. Clinics completed a 50-item survey covering the six domains of the PCMH: (1) comprehensive care, (2) patient-centered care, (3) coordinated care, (4) accessible services, (5) quality and safety, and (6) health information technology. To determine conformity to the PCMH, a novel point-based scoring system was devised. Points were tabulated across clinics by domain to obtain an aggregate assessment of PCMH conformity. All six clinics responded. Overall, clinics attained a mean 75.8% [95% CI, 63.3-88.3%] on PCMH measures-scoring highest on patient-centered care (94.7%), coordinated care (83.3%), and quality and safety measures (76.7%), and lowest on health information technology (70.0%), accessible services (69.1%), and comprehensive care (61.1%). Clinics moderately conformed to the PCMH model. Areas for improvement include access to care, comprehensive care, and health information technology. Future studies are warranted to determine whether greater clinic PCMH conformity improves clinical outcomes and cost savings for YLH.

Treatment outcomes in undocumented Hispanic immigrants with HIV infection

Objective

Little is known about the treatment outcomes of undocumented Hispanic immigrants with HIV infection. We sought to compare the treatment outcomes of undocumented and documented patients 12-months after entering HIV care.

Methods

We conducted a retrospective cohort study of antiretroviral-naive patients 18 years and older attending their first visit at Thomas Street Health Center in Houston, Texas, between 1/1/2003 and 6/30/2008. The study population of 1,620 HIV-infected adults included 186 undocumented Hispanic, 278 documented Hispanic, 986 Black, and 170 White patients. The main outcome measures were retention in care (quarter years with at least one completed HIV primary care provider visit) and HIV suppression (HIV RNA <400 copies/mL), both measured 12-months after entering HIV care.

Results

Undocumented Hispanic patients had lower median initial CD₄ cell count (132 cells/mm³) than documented Hispanic patients (166 cells/mm³; P = 0.186), Black patients (226 cells/mm³; P<0.001), and White patients (264 cells/mm³; P = 0.001). However, once in care, undocumented Hispanic patients did as well or better than their documented counterparts. One year after entering HIV care, undocumented Hispanics achieved similar rates of retention in care and HIV suppression as documented Hispanic and White patients. Of note, black patients were significantly less likely to have optimal retention in care (adjusted odds ratio [aOR] 0.65, CI = 0.45–0.94) or achieve HIV suppression (aOR 0.32, CI = 0.17–0.61) than undocumented Hispanics.

Conclusions

Undocumented Hispanic persons with HIV infection enter care with more advanced disease than documented persons, suggesting testing and/or linkage to care efforts for this difficult-to-reach population need intensification. Once diagnosed, however, undocumented Hispanics have outcomes as good as or better than other racial/ethnic groups. Safety net providers for undocumented immigrants are vital for maintaining individual and public health.

Measuring retention in HIV care: the elusive gold standard

BACKGROUND

Measuring retention in HIV primary care is complex, as care includes multiple visits scheduled at varying intervals over time. We evaluated 6 commonly used retention measures in predicting viral load (VL) suppression and the correlation among measures.

METHODS

Clinic-wide patient-level data from 6 academic HIV clinics were used for 12 months preceding implementation of the Centers for Disease Control and Prevention/Health Resources and Services Administration (CDC/HRSA) retention in care intervention. Six retention measures were calculated for each patient based on scheduled primary HIV provider visits: count and dichotomous missed visits, visit adherence, 6-month gap, 4-month visit constancy, and the HRSA HIV/AIDS Bureau (HRSA HAB) retention measure. Spearman correlation coefficients and separate unadjusted logistic regression models compared retention measures with one another and with 12-month VL suppression, respectively. The discriminatory capacity of each measure was assessed with the c-statistic.

RESULTS

Among 10,053 patients, 8235 (82%) had 12-month VL measures, with 6304 (77%) achieving suppression (VL <400 copies/mL). All 6 retention measures were significantly associated (P < 0.0001) with VL suppression (odds ratio; 95% CI, c-statistic): missed visit count (0.73; 0.71 to 0.75, 0.67), missed visit dichotomous (3.2; 2.8 to 3.6, 0.62), visit adherence (3.9; 3.5 to 4.3,0.69), gap (3.0; 2.6 to 3.3, 0.61), visit constancy (2.8; 2.5 to 3.0, 0.63), and HRSA HAB (3.8; 3.3 to 4.4, 0.59). Measures incorporating "no-show" visits were highly correlated (Spearman coefficient = 0.83-0.85), as were measures based solely on kept visits (Spearman coefficient = 0.72-0.77). Correlation coefficients were lower across these 2 groups of measures (range = 0.16-0.57).

CONCLUSIONS

Six retention measures displayed a wide range of correlation with one another, yet each measure had significant association and modest discrimination for VL suppression. These data suggest there is no clear gold standard and that selection of a retention measure may be tailored to context.

Establishment, retention, and loss to follow-up in outpatient HIV care

BACKGROUND

For optimal clinical benefit, HIV-infected patients should receive periodic outpatient care indefinitely. However, initially establishing HIV care and subsequent retention in care are problematic. This study examines establishment, retention, and loss to follow-up (LTFU) in a large multi-site cohort over a 2-8 year period.

METHODS

Medical record data were reviewed for 22,984 adult HIV patients receiving care at 12 clinics in the HIV Research Network between 2001 and 2009. Three dichotomous outcome measures were based on each patient's history of outpatient visits. Establishment reflects whether the patient made outpatient visits for longer than 6 months after initial enrollment. The retention measure reflects whether the patient had at least 2 outpatient visits separated by 90 days in each year in care. LTFU reflects whether the patient had no outpatient visits for more than 12 months without returning. Multiple logistic regression examined demographic and clinical correlates of each outcome and the combined outcome of meeting all 3 measures.

RESULTS

Overall, 21.7% of patients never established HIV care after an initial visit. Among established patients, 57.4% did not meet the retention criterion in all years, and 34.9% were LTFU. Only 20.4% of all patients met all 3 criteria. The odds of successfully meeting all 3 criteria were higher for women, for older patients, for Hispanics compared with whites, and for those with CD4 levels ≤50 cells per cubic millimeter.

CONCLUSIONS

These data highlight the need to improve establishment and retention in HIV care.