Racial disparities in HIV virologic failure: do missed visits matter?

Missed Initial Medical Visits: Predictors, Timing, and Implications for Retention in HIV Care

HIV disproportionately affects racial/ethnic minorities and individuals living in the southern United States, and missed clinic visits account for much of this disparity. We sought to evaluate: (1) predictors of missed initial HIV medical visits, (2) time to initial visit, and (3) the association between initial visit attendance and retention in HIV care. Chart reviews were conducted for 200 consecutive HIV-infected patients (100 in Dallas, 100 in San Antonio) completing case management (CM) intake. Of these, 52 (26%) missed their initial visit, with 22 (11%) never presenting for care. Mean age was 40 years, 85% were men, >70% were of minority race/ethnicity, and 28% had a new HIV diagnosis. Unemployment (OR [95% CI] = 2.33 [1.04-5.24], p = 0.04) and lower attendance of CM visits (OR = 3.08 [1.43-6.66], p = 0.004) were associated with missing the initial medical visit. A shorter time to visit completion was associated with CD4 ≤ 200 (HR 1.90 [1.25-2.88], p = 0.003), Dallas study site (HR = 1.48 [1.03-2.14], p = 0.04), and recent hospitalization (HR = 2.18 [1.38-3.43], p < 0.001). Patients who did not complete their initial medical visit within 90 days of intake were unlikely to engage in care. Initial medical visit attendance was associated with higher proportion of visits attended (p = 0.04) and fewer gaps in care (p = 0.01). Missed medical visits were common among HIV patients initiating or reinitiating care in Texas. Employment and CM involvement predicted initial medical visit attendance, which was associated with retention in care. New, early engagement strategies are needed to decrease missed visits and reduce HIV health disparities.

Sex, Race, and HIV Risk Disparities in Discontinuity of HIV Care After Antiretroviral Therapy Initiation in the United States and Canada

Disruption of continuous retention in care (discontinuity) is associated with HIV disease progression. We examined sex, race, and HIV risk disparities in discontinuity after antiretroviral therapy (ART) initiation among patients in North America. Adults (≥18 years of age) initiating ART from 2000 to 2010 were included. Discontinuity was defined as first disruption of continuous retention (≥2 visits separated by >90 days in the calendar year). Relative hazard ratio (HR) and times from ART initiation until discontinuity by race, sex, and HIV risk were assessed by modeling of the cumulative incidence function (CIF) in the presence of the competing risk of death. Models were adjusted for cohort site, baseline age, and CD4+ cell count within 1 year before ART initiation; nadir CD4+ cell count after ART, but before a study event, was assessed as a mediator. Among 17,171 adults initiating ART, median follow-up time was 3.97 years, and 49% were observed to have ≥1 discontinuity of care. In adjusted regression models, the hazard of discontinuity for patients was lower for females versus males [HR: 0.84; 95% confidence interval (CI): 0.79-0.89] and higher for blacks versus nonblacks (HR: 1.17; 95% CI: 1.12-1.23) and persons with injection drug use (IDU) versus non-IDU risk (HR: 1.33; 95% CI: 1.25-1.41). Sex, racial, and HIV risk differences in clinical retention exist, even accounting for access to care and known competing risks for discontinuity. These results point to vulnerable populations at greatest risk for discontinuity in need of improved outreach to prevent disruptions of HIV care.

Sociodemographic profile and predictors of outpatient clinic attendance among HIV-positive patients initiating antiretroviral therapy in Selangor, Malaysia

BACKGROUND

Inconsistent literature evidence suggests that sociodemographic, economic, and system- and patient-related factors are associated with clinic attendance among the HIV-positive population receiving antiretroviral therapy (ART) around the world. We examined the factors that predict outpatient clinic attendance among a cohort of HIV-positive patients initiating ART in Selangor, Malaysia.

PATIENTS AND METHODS

This cross-sectional study analyzed secondary data on outpatient clinic attendance and sociodemographic, economic, psychosocial, and patient-related factors among 242 adult Malaysian patients initiating ART in Selangor, Malaysia. Study cohort was enrolled in a parent randomized controlled trial (RCT) in Hospital Sungai Buloh Malaysia between January and December 2014, during which peer counseling, medication, and clinic appointment reminders were provided to the intervention group through short message service (SMS) and telephone calls for 24 consecutive weeks. Data on outpatient clinic attendance were extracted from the hospital electronic medical records system, while other patient-level data were extracted from pre-validated Adult AIDS Clinical Trial Group (AACTG) adherence questionnaires in which primary data were collected. Outpatient clinic attendance was categorized into binary outcome - regular attendee and defaulter categories - based on the number of missed scheduled outpatient clinic appointments within a 6-month period. Multivariate regression models were fitted to examine predictors of outpatient clinic attendance using SPSS version 22 and R software.

RESULTS

A total of 224 (93%) patients who completed 6-month assessment were included in the model. Out of those, 42 (18.7%) defaulted scheduled clinic attendance at least once. Missed appointments were significantly more prevalent among females (n=10, 37.0%), rural residents (n=10, 38.5%), and bisexual respondents (n=8, 47.1%). Multivariate binary logistic regression analysis showed that Indian ethnicity (adjusted odds ratio [AOR] =0.235; 95% CI [0.063-0.869]; P=0.030) and heterosexual orientation (AOR =4.199; 95% CI [1.040-16.957]; P=0.044) were significant predictors of outpatient clinic attendance among HIV-positive patients receiving ART in Malaysia.

CONCLUSION

Ethnicity and sexual orientation of Malaysian patients may play a significant role in their level of adherence to scheduled clinic appointments. These factors should be considered during collaborative adherence strategy planning at ART initiation.

Reengagement in Care After a Gap in HIV Care Among a Population of Privately Insured Persons with HIV in the United States

The HIV care continuum illustrates steps needed to reach HIV viral suppression, including retention in care. The continuum's retention measure does not account for gaps or reengagement in care and thus provides an incomplete picture of long-term engagement. We used a claims database to determine the proportion of privately insured persons with HIV who experienced a gap in care and subsequently reengaged between 2008 and 2012. A gap was defined as no office visit claim in >6 months and reengagement as ≥1 office visit claim after a gap. Cox proportional hazards models were conducted to determine factors associated with time to first gap and time to reengagement. Of 5142 persons in the study, 79% were males and median age was 46 years (range, 19-64 years). No race/ethnicity data were available. Thirty percent (n = 1555) experienced a gap. Median time to first gap was 15 months (IQR: 6-30). Median gap length was 3.2 months. Seventy percent with a gap reengaged; 22% reengaged more than once. Of 1086 patients who reengaged, 224 (21%) eventually had a terminal gap. Residence in the North Central region (HR 0.73, 95% CI 0.62-0.87) and having ≥1 Charlson comorbidities (HR 0.85, 95% CI 0.73-0.99) were associated with shorter time to reengagement. The majority who experienced a gap reengaged within a relatively short period and remained in the cohort at 60 months. However, 21% of those reengaging had a terminal gap by 60 months, which should alert providers to the eventual potential for loss to follow-up. The analysis was limited by inability to distinguish between HIV-specific and non-HIV-specific care visits.

Racial Disparities in HIV Care Extend to Common Comorbidities: Implications for Implementation of Interventions to Reduce Disparities in HIV Care

BACKGROUND

Prior studies have described racial disparities in the quality of care for persons with HIV infection, but it is unknown if these disparities extend to common comorbid conditions. To inform implementation of interventions to reduce disparities in HIV care, we examined racial variation in a set of quality measures for common comorbid conditions among Veterans in care for HIV in the United States.

METHOD

The cohort included 23,974 Veterans in care for HIV in 2013 (53.4% black; 46.6% white). Measures extracted from electronic health record and administrative data were receipt of combination antiretroviral therapy (cART), HIV viral control (serum RNA < 200 copies/ml among those on cART), hypertension control (blood pressure < 140/90 mm Hg among those with hypertension), diabetes control (hemoglobin A1C < 9% among those with diabetes), lipid monitoring, guideline-concordant antidepressant prescribing, and initiation and engagement in substance use disorder (SUD) treatment. Black persons were less likely than their white counterparts to receive cART (90.2% vs. 93.2%, p<.001), and experience viral control (84.6% vs. 91.3%, p<.001), hypertension control (61.9% vs. 68.3%, p<.001), diabetes control (85.5% vs. 89.5%, p<.001), and lipid monitoring (81.5% vs. 85.2%, p<.001). Initiation and engagement in SUD treatment were similar among blacks and whites. Differences remained after adjusting for age, comorbidity, retention in HIV care, and a measure of neighborhood social disadvantage created from census data.

SIGNIFICANCE

Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.

Pilot RCT of bidirectional text messaging for ART adherence among nonurban substance users with HIV

OBJECTIVE

This pilot study tested the preliminary efficacy of a theory-based bidirectional text messaging intervention (TEXT) on antiretroviral (ART) adherence, missed care visits, and substance use among people with HIV.

METHOD

Participants with recent substance use and ART nonadherence from 2 nonurban HIV clinics were randomized to TEXT or to usual care (UC). The TEXT intervention included daily queries of ART adherence, mood, and substance use. The system sent contingent intervention messages created by participants for reports of adherence/nonadherence, good mood/poor mood, and no substance use/use. Assessments were at preintervention, postintervention, and 3-month postintervention follow-up. Objective primary outcomes were adherence, measured by past 3-month pharmacy refill rate, and proportion of missed visits (PMV), measured by medical records. The rate of substance-using days from the timeline follow-back was a secondary outcome.

RESULTS

Sixty-three patients participated, with 33 randomized to TEXT and 30 to UC. At preintervention, adherence was 64.0%, PMV was 26.9%, and proportion of days using substances was 53.0%. At postintervention, adherence in the TEXT condition improved from 66% to 85%, compared with 62% to 71% in UC participants (p = .04). PMV improved from 23% to 9% for TEXT participants and 31% to 28% in UC participants (p = .12). There were no significant differences between conditions in substance-using days at postintervention. At 3-month follow-up, differences were not significant.

CONCLUSIONS

Personalized bidirectional text messaging improved adherence and shows promise to improve visit attendance, but did not reduce substance using days. This intervention merits further testing and may be cost-efficient given its automation.

Clinic Attendance for Antiretroviral Pills Pick-Up among HIV-Positive People in Nepal: Roles of Perceived Family Support and Associated Factors

INTRODUCTION

HIV-positive people's clinic attendance for medication pick-up is critical for successful HIV treatment. However, limited evidence exists on it especially in low-income settings such as Nepal. Moreover, the role of family support in clinic attendance remains under-explored. Therefore, this study was conducted to examine the association between perceived family support and regular clinic attendance and to assess factors associated with regular clinic attendance for antiretroviral pills pick-up among HIV-positive individuals in Nepal.

METHODS

A cross-sectional study was conducted among 423 HIV-positive people in three districts of Nepal. Clinic attendance was assessed retrospectively for the period of 12 months. To assess the factors associated, an interview survey was conducted using a semi-structured questionnaire from July to August, 2015. Multiple logistic regression models were used to assess the factors associated with regular clinic attendance.

RESULTS

Of 423 HIV-positive people, only 32.6% attended the clinics regularly. They were more likely to attend them regularly when they received high family support (AOR = 3.98, 95% CI = 2.29, 6.92), participated in support programs (AOR = 1.68, 95% CI = 1.00, 2.82), and had knowledge on the benefits of antiretroviral therapy (AOR = 2.62, 95% CI = 1.15, 5.99). In contrast, they were less likely to attend them regularly when they commuted more than 60 minutes to the clinics (AOR = 0.53, 95% CI = 0.30, 0.93), when they self-rated their health status as being very good (AOR = 0.13, 95% CI = 0.04, 0.44), good (AOR = 0.14, 95% CI = 0.04, 0.46), and fair (AOR = 0.21, 95% CI = 0.06, 0.70).

CONCLUSION

HIV-positive individuals are more likely to attend the clinics regularly when they receive high family support, know the benefits of antiretroviral therapy, and participate in support programs. To improve clinic attendance, family support should be incorporated with HIV care programs in resource limited settings. Service providers should also consider educating them about the benefits of antiretroviral therapy.

Disparities in achieving and sustaining viral suppression among a large cohort of HIV-infected persons in care - Washington, DC

One goal of the HIV care continuum is achieving viral suppression (VS), yet disparities in suppression exist among subpopulations of HIV-infected persons. We sought to identify disparities in both the ability to achieve and sustain VS among an urban cohort of HIV-infected persons in care. Data from HIV-infected persons enrolled at the 13 DC Cohort study clinical sites between January 2011 and June 2014 were analyzed. Univariate and multivariate logistic regression were conducted to identify factors associated with achieving VS (viral load < 200 copies/ml) at least once, and Kaplan-Meier (KM) curves and Cox proportional hazards models were used to identify factors associated with sustaining VS and time to virologic failure (VL ≥ 200 copies/ml after achievement of VS). Among the 4311 participants, 95.4% were either virally suppressed at study enrollment or able to achieve VS during the follow-up period. In multivariate analyses, achieving VS was significantly associated with age (aOR: 1.04; 95%CI: 1.03-1.06 per five-year increase) and having a higher CD4 (aOR: 1.05, 95% CI 1.04-1.06 per 100 cells/mm(3)). Patients infected through perinatal transmission were less likely to achieve VS compared to MSM patients (aOR: 0.63, 95% CI 0.51-0.79). Once achieved, most participants (74.4%) sustained VS during follow-up. Blacks and perinatally infected persons were less likely to have sustained VS in KM survival analysis (log rank chi-square p ≤ .001 for both) compared to other races and risk groups. Earlier time to failure was observed among females, Blacks, publically insured, perinatally infected, those with longer standing HIV infection, and those with diagnoses of mental health issues or depression. Among this HIV-infected cohort, most people achieved and maintained VS; however, disparities exist with regard to patient age, race, HIV transmission risk, and co-morbid conditions. Identifying populations with disparate outcomes allows for appropriate targeting of resources to improve outcomes along the care continuum.

A qualitative study of barriers to and facilitators of optimal engagement in care among PLWH and substance use/misuse

BACKGROUND

Persons living with HIV (PLWH) and substance use/misuse experience significant barriers to engagement in HIV care at every step of the HIV care continuum including: (1) HIV testing and diagnosis (2) linkage to clinical care (3) retention in care pre-antiretroviral therapy (ART) (4) ART initiation and adherence (5) viral suppression. We qualitatively explored the facilitators of and barriers to participation in the HIV care continuum among PLWH with substance use/misuse.

METHODS

We performed semi-structured in-depth interviews with 34 PLWH in care with recent substance use. The transcripts were analyzed in an iterative process using an editing style analysis. Interviews were conducted until thematic saturation was achieved.

RESULTS

Participants attributed an escalation in drug use at the time of diagnosis to denial of their disease and the belief that their death was inevitable and cited this as a barrier to treatment entry. In contrast, participants reported that experiencing adverse physical effects of uncontrolled HIV infection motivated them to enroll in care. Reported barriers to retention and adherence to care included forgetting medications and appointments because of drug use, prioritizing drug use over HIV treatment and side effects associated with medications. Participants described that progression of illness, development of a medication taking ritual and a positive provider-patient relationship all facilitated engagement and reengagement in care.

CONCLUSIONS

PLWH with substance use engaged in care describe barriers to and facilitators of optimal engagement related to and distinct from substance use. Greater understanding of the biologic, psychological and social factors that promote and impair engagement in care can inform interventions and reduce the increased morbidity and mortality experienced by PLWH with substance use.

Geographic Variations in Retention in Care among HIV-Infected Adults in the United States

Objective

To understand geographic variations in clinical retention, a central component of the HIV care continuum and key to improving individual- and population-level HIV outcomes.

Design

We evaluated retention by US region in a retrospective observational study.

Methods

Adults receiving care from 2000–2010 in 12 clinical cohorts of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) contributed data. Individuals were assigned to Centers for Disease Control and Prevention (CDC)-defined regions by residential data (10 cohorts) and clinic location as proxy (2 cohorts). Retention was ≥2 primary HIV outpatient visits within a calendar year, >90 days apart. Trends and regional differences were analyzed using modified Poisson regression with clustering, adjusting for time in care, age, sex, race/ethnicity, and HIV risk, and stratified by baseline CD4+ count.

Results

Among 78,993 adults with 444,212 person-years of follow-up, median time in care was 7 years (Interquartile Range: 4–9). Retention increased from 2000 to 2010: from 73% (5,000/6,875) to 85% (7,189/8,462) in the Northeast, 75% (1,778/2,356) to 87% (1,630/1,880) in the Midwest, 68% (8,451/12,417) to 80% (9,892/12,304) in the South, and 68% (5,147/7,520) to 72% (6,401/8,895) in the West. In adjusted analyses, retention improved over time in all regions (p<0.01, trend), although the average percent retained lagged in the West and South vs. the Northeast (p<0.01).

Conclusions

In our population, retention improved, though regional differences persisted even after adjusting for demographic and HIV risk factors. These data demonstrate regional differences in the US which may affect patient care, despite national care recommendations.

Predictors of HIV Disclosure in Infected Persons Presenting to Establish Care

Persons receiving effective HIV treatment experience longevity and improvement in quality of life. For those infected, social support is associated with improved medication adherence. Disclosure of infection status is likely a prerequisite for social support. However, little research describes patterns of HIV disclosure by infected persons. We retrospectively evaluated factors associated with disclosure among patients initiating HIV care at a university-based clinic from 2007 to 2012. Of 490 persons initiating care, 13 % had not disclosed their HIV infection to anyone. Black race significantly predicted non-disclosure and persons living with a significant other or friends were more likely to have disclosed their HIV infection versus those living alone. CD4 + T lymphocyte count <200 was associated with nondisclosure and disclosure only to family members. Future research is needed to better understand factors associated with disclosure of HIV infection status, because this could enhance receipt of social support and contribute to improved HIV health outcomes.

Elements of the HIV Care Continuum: Improving Engagement and Retention in Care

The HIV care continuum (or treatment cascade) classifies individuals with HIV infection who are diagnosed, linked to care, retained in care, on antiretroviral therapy, and virally suppressed, to assess the effectiveness of health care and treatment from a population-level health perspective. Initially, it was estimated that only approximately 50% of individuals diagnosed with HIV infection are retained in care, and a lower percentage is virally suppressed. In an HIV clinic, retention in care should be addressed from a system perspective but focus on persons on an individual basis, and success in retention of a high proportion of individuals in care is likely to depend on collaboration with surrounding communities, local health departments, and other agencies. Two initiatives to improve engagement and retention in care undertaken at the University of Alabama at Birmingham 1917 Clinic are discussed. This article summarizes a presentation by Michael J. Mugavero, MD, MHSc, at the Ryan White HIV/AIDS Program Clinical Care Conference held in New Orleans, Louisiana, in December 2015.

Characteristics of HIV patients who missed their scheduled appointments

OBJECTIVE

To analyze whether sociodemographic characteristics, consultations and care in special services are associated with scheduled infectious diseases appointments missed by people living with HIV.

METHODS

This cross-sectional and analytical study included 3,075 people living with HIV who had at least one scheduled appointment with an infectologist at a specialized health unit in 2007. A secondary data base from the Hospital Management & Information System was used. The outcome variable was missing a scheduled medical appointment. The independent variables were sex, age, appointments in specialized and available disciplines, hospitalizations at the Central Institute of the Clinical Hospital at the Faculdade de Medicina of the Universidade de São Paulo, antiretroviral treatment and change of infectologist. Crude and multiple association analysis were performed among the variables, with a statistical significance of p ≤ 0.05.

RESULTS

More than a third (38.9%) of the patients missed at least one of their scheduled infectious diseases appointments; 70.0% of the patients were male. The rate of missed appointments was 13.9%, albeit with no observed association between sex and absences. Age was inversely associated to missed appointment. Not undertaking anti-retroviral treatment, having unscheduled infectious diseases consultations or social services care and being hospitalized at the Central Institute were directly associated to missed appointments.

CONCLUSIONS

The Hospital Management & Information System proved to be a useful tool for developing indicators related to the quality of health care of people living with HIV. Other informational systems, which are often developed for administrative purposes, can also be useful for local and regional management and for evaluating the quality of care provided for patients living with HIV.

Regular clinic attendance in two large San Francisco HIV primary care settings

Although poor clinic attendance is associated with increased morbidity and mortality among HIV-infected individuals, less is known about predictors of retention and the acceptability of targeted interventions to increase regular clinic attendance. To better understand which patients are at risk for irregular clinic attendance and to explore interventions to aid in retention to care, we surveyed patients attending two outpatient HIV clinics affiliated with the University of California, San Francisco. A total of 606 participants were surveyed, and the analysis was restricted to the 523 male respondents. Of this group, 45% (N = 299) reported missing at least one visit a year. Missing a clinic visit was associated with being African American (aOR = 1.99; 95%CI 1.12-3.52), being a man who has sex with both men and women (aOR=2.72; 95%CI 1.16-6.37), and reporting at least weekly methamphetamine use (aOR=5.79; 95%CI 2.47-13.57). Participants who reported a monthly income greater than $2000 were less likely to miss an appointment (aOR = 0.56; 95%CI 0.34-0.93). Regarding possible retention interventions, most patients preferred phone calls over other forms of support. These findings support the need for ongoing engagement support with particular attention to at-risk sub-groups.

Improving access to medicines through centralised dispensing in the public sector: a case study of the Chronic Dispensing Unit in the Western Cape Province, South Africa

BACKGROUND

The Chronic Dispensing Unit (CDU) is an out-sourced, public sector centralised dispensing service that has been operational in the Western Cape Province in South Africa since 2005. The CDU dispenses medicines for stable patients with chronic conditions. The aim is to reduce pharmacists' workload, reduce patient waiting times and decongest healthcare facilities. Our objectives are to describe the intervention's scope, illustrate its interface with the health system and describe its processes and outcomes. Secondly, to quantify the magnitude of missed appointments by enrolled patients and to describe the implications thereof in order to inform a subsequent in-depth empirical study on the underlying causes.

METHODS

We adopted a case study design in order to elicit the programme theory underlying the CDU strategy. We consulted 15 senior and middle managers from the provincial Department of Health who were working closely with the intervention and the contractor using focus group discussions and key informant interviews. In addition, relevant literature, and policy and programme documents were reviewed and analysed.

RESULTS

We found that the CDU scope has significantly expanded over the last 10 years owing to technological advancements. As such, in early 2015, the CDU produced nearly 300,000 parcels monthly. Medicines supply, patient enrollment processes, healthcare professionals' compliance to legislation and policies, mechanisms for medicines distribution, management of non-collected medicines (emanating from patients' missed appointments) and the array of actors involved are all central to the CDU's functioning. Missed appointments by patients are a problem, affecting an estimated 8%-12% of patients each month. However, the causes have not been investigated thoroughly. Implications of missed appointments include a cost to government for services rendered by the contractor, potential losses due to expired medicines, additional workload for the contractor and healthcare facility staff and potential negative therapeutic outcomes for patients.

CONCLUSIONS

The CDU demonstrates innovation in a context of overwhelming demand for dispensing medicines for chronic conditions. However, it is not a panacea to address access-to-medicines related challenges. A multi-level assessment that is currently underway will provide more insights on how existing challenges can be addressed.

Activation of persons living with HIV for treatment, the great study

Background

Patient empowerment represents a potent tool for addressing racial, ethnic and socioeconomic disparities in health care, particularly for chronic conditions such as HIV infection that require active patient engagement. This multimodal intervention, developed in concert with HIV patients and clinicians, aims to provide HIV patients with the knowledge, skills, attitudes and tools to become more activated patients.

Methods/Design

Randomized controlled trial of a multimodal intervention designed to activate persons living with HIV. The intervention includes four components: 1) use of a web-enabled hand-held device (Apple iPod Touch) loaded with a Personal Health Record (ePHR) customized for HIV patients; 2) six 90-minute group-based training sessions in use of the device, internet and the ePHR; 3) a pre-visit coaching session; and 4) clinician education regarding how they can support activated patients. Outcome measures include pre- post changes in patient activation measure score (primary outcome), eHealth literacy, patient involvement in decision-making and care, medication adherence, preventive care, and HIV Viral Load.

Discussion

We hypothesize that participants receiving the intervention will show greater improvement in empowerment and the intervention will reduce disparities in study outcomes. Disparities in these measures will be smaller than those in the usual care group. Findings have implications for activating persons living with HIV and for other marginalized groups living with chronic illness.

Trial registration

ClinicalTrials.gov Identifier: NCT02165735, 6/13/2014.

Obesity is associated with race/sex disparities in diabetes and hypertension prevalence, but not cardiovascular disease, among HIV-infected adults

Race/sex differences are observed in cardiometabolic disease (CMD) risk and prevalence in the context of treated, chronic HIV infection, and these differences could be exacerbated by disparities in obesity prevalence. We sought to determine the effect of obesity on these disparities among people living with HIV. Prevalence of CMD (dyslipidemia, cardiovascular disorders, hypertension, diabetes, chronic kidney disease) was determined for patients seen at the University of Alabama at Birmingham HIV clinic between 7/2010 and 6/2011. Staged logistic regression was used to examine the impact of race/sex on comorbidities adjusting for key confounders including/excluding obesity (body mass index ≥30 kg/m(2)). Of 1,800 participants, 77% were male, 54% were black, and 25% were obese. Obesity prevalence differed by race/sex: black women 49%, black men 24%, white women 24%, white men 15% (p<0.01). Compared to white men, other groups had reduced odds for dyslipidemia and cardiovascular disorders (p<0.01). Black men had increased odds for hypertension and chronic kidney disease, while black women had a nearly 2-fold increased odds for diabetes and hypertension (all at p<0.01). The associations of black women with diabetes and hypertension were attenuated when obesity was included in the models. Other group differences remained significant. Disparities in obesity prevalence do not explain race/sex differences in all CMD among people with HIV. Obesity accounted for associations with diabetes/hypertension for black women, who may benefit from weight reduction to decrease disease risk. Further investigations into the etiology and treatment of CMD in people living with HIV should consider unique race/sex treatment issues.

The Contribution of Missed Clinic Visits to Disparities in HIV Viral Load Outcomes

OBJECTIVES

We explored the contribution of missed primary HIV care visits ("no-show") to observed disparities in virological failure (VF) among Black persons and persons with injection drug use (IDU) history.

METHODS

We used patient-level data from 6 academic clinics, before the Centers for Disease Control and Prevention and Health Resources and Services Administration Retention in Care intervention. We employed staged multivariable logistic regression and multivariable models stratified by no-show visit frequency to evaluate the association of sociodemographic factors with VF. We used multiple imputations to assign missing viral load values.

RESULTS

Among 10 053 patients (mean age = 46 years; 35% female; 64% Black; 15% with IDU history), 31% experienced VF. Although Black patients and patients with IDU history were significantly more likely to experience VF in initial analyses, race and IDU parameter estimates were attenuated after sequential addition of no-show frequency. In stratified models, race and IDU were not statistically significantly associated with VF at any no-show level.

CONCLUSIONS

Because missed clinic visits contributed to observed differences in viral load outcomes among Black and IDU patients, achieving an improved understanding of differential visit attendance is imperative to reducing disparities in HIV.

Antiretroviral treatment use, co-morbidities and clinical outcomes among Aboriginal participants in the Australian HIV Observational Database (AHOD)

Background

There are few data regarding clinical care and outcomes of Indigenous Australians living with HIV and it is unknown if these differ from non-Indigenous HIV-positive Australians.

Methods

AHOD commenced enrolment in 1999 and is a prospective cohort of HIV-positive participants attending HIV outpatient services throughout Australia, of which 20 (74 %) sites report Indigenous status. Data were collected up until March 2013 and compared between Indigenous and non-Indigenous participants. Person-year methods were used to compare death rates, rates of loss to follow-up and rates of laboratory testing during follow-up between Indigenous and non-Indigenous participants. Factors associated with time to first combination antiretroviral therapy (cART) regimen change were assessed using Kaplan Meier and Cox Proportional hazards methods.

Results

Forty-two of 2197 (1.9 %) participants were Indigenous. Follow-up amongst Indigenous and non-Indigenous participants was 332 & 16270 person-years, respectively. HIV virological suppression was achieved in similar proportions of Indigenous and non-Indigenous participants 2 years after initiation of cART (81.0 % vs 76.5 %, p = 0.635). Indigenous status was not independently associated with shorter time to change from first- to second-line cART (aHR 0.95, 95 % CI 0.51-1.76, p = 0.957). Compared with non-Indigenous participants, Indigenous participants had significantly less frequent laboratory monitoring of CD4 count (rate:2.76 tests/year vs 2.97 tests/year, p = 0.025) and HIV viral load (rate:2.53 tests/year vs 2.93 tests/year, p < 0.001), while testing rates for lipids and blood glucose were almost half that of non-indigenous participants (rate:0.43/year vs 0.71 tests/year, p < 0.001). Loss to follow-up (23.8 % vs 29.8 %, p = 0.496) and death (2.4 % vs 7.1 %, p = 0.361) occurred in similar proportions of indigenous and non-Indigenous participants, respectively, although causes of death in both groups were mostly non-HIV-related.

Conclusions

As far as we are aware, these are the first data comparing clinical outcomes between Indigenous and non-Indigenous HIV-positive Australians. The forty-two Indigenous participants represent over 10 % of all Indigenous Australians ever diagnosed with HIV. Although outcomes were not significantly different, Indigenous patients had lower rates of laboratory testing for HIV and lipid/glucose parameters. Given the elevated risk of cardiovascular disease in the general Indigenous community, the additional risk factor of HIV infection warrants further focus on modifiable risk factors to maximise life expectancy in this population.

Uptake and Acceptability of Information and Communication Technology in a Community-Based Cohort of People Who Inject Drugs: Implications for Mobile Health Interventions

Background

Mobile phone and Internet-based technologies are increasingly used to disseminate health information and facilitate delivery of medical care. While these strategies hold promise for reducing barriers to care for medically-underserved populations, their acceptability among marginalized populations such as people who inject drugs is not well-understood.

Objective

To understand patterns of mobile phone ownership, Internet use and willingness to receive health information via mobile devices among people who inject drugs.

Methods

We surveyed current and former drug injectors participating in a longitudinal cohort study in Baltimore, Maryland, USA. Respondents completed a 12-item, interviewer-administered questionnaire during a regular semi-annual study visit that assessed their use of mobile technology and preferred modalities of receiving health information. Using data from the parent study, we used logistic regression to evaluate associations among participants’ demographic and clinical characteristics and their mobile phone and Internet use.

Results

The survey was completed by 845 individuals, who had a median age of 51 years. The sample was 89% African-American, 65% male, and 33% HIV-positive. Participants were generally of low education and income levels. Fewer than half of respondents (40%) indicated they had ever used the Internet. Mobile phones were used by 86% of respondents. Among mobile phone owners, 46% had used their phone for text messaging and 25% had accessed the Internet on their phone. A minority of respondents (42%) indicated they would be interested in receiving health information via phone or Internet. Of those receptive to receiving health information, a mobile phone call was the most favored modality (66%) followed by text messaging (58%) and Internet (51%).

Conclusions

Utilization of information and communication technology among this cohort of people who inject drugs was reported at a lower level than what has been estimated for the general U.S. population. Our findings identify a potential barrier to successful implementation of mobile health and Internet-based interventions for people who inject drugs, particularly those who are older and have lower levels of income and educational attainment. As mobile communication technology continues to expand, future studies should re-examine whether mHealth applications become more accessible and accepted by socioeconomically disadvantaged groups.

Risk Prediction Tool for Medical Appointment Attendance Among HIV-Infected Persons with Unsuppressed Viremia

Successful treatment of HIV infection requires regular clinical follow-up. A previously published risk-prediction tool (RPT) utilizing data from the electronic health record (EHR) including medication adherence, previous appointment attendance, substance abuse, recent CD4+ count, prior antiretroviral therapy (ART) exposure, prior treatment failure, and recent HIV-1 viral load (VL) has been shown to predict virologic failure at 1 year. If this same tool could be used to predict the more immediate event of appointment attendance, high-risk patients could be identified and interventions could be targeted to improve this outcome. We conducted an observational cohort study at the Vanderbilt Comprehensive Care Clinic from August 2013 through March 2014. Patients with routine medical appointments and most recent HIV-1 VL >200 copies/mL were included. Risk scores for a modified RPT were calculated based on data from the EHR. Odds ratios (OR) for missing the next appointment were estimated using multivariable logistic regression. Among 510 persons included, median age was 39 years, 74% were male, 55% were black, median CD4+ count was 327 cells/mm(3) [Interquartile Range (IQR): 142-560], and median HIV-1 VL was 21,818 copies/mL (IQR: 2,030-69,597). Medium [OR 3.95, 95% confidence interval (CI) 2.08-7.50, p-value<0.01] and high (OR 9.55, 95% CI 4.31-21.16, p-value<0.01) vs. low RPT risk scores were independently associated with missing the next appointment. RPT scores, constructed using readily available data, allow for risk-stratification of HIV medical appointment non-attendance and could support targeting limited resources to improve appointment adherence in groups most at-risk of poor HIV outcomes.

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.

What we know and what we do not know about factors associated with and interventions to promote antiretroviral adherence

Antiretroviral therapy (ART) adherence remains critical for achieving successful outcomes. Factors affecting ART adherence can occur at the individual level or be related to the treatment regimen, daily schedule, and/or interpersonal relationships. While treatment-related barriers have diminished with recent simplified ART regimens, guidelines still recommend considering regimen simplicity. ART readiness should be assessed prior to starting ART, with follow-up adherence assessments once ART is initiated, and at all subsequent clinical visits. Adherence interventions work best when multifaceted, targeted for at-risk and nonadherent participants, and tailored to individuals' needs. Successful interventions have included education and counseling, provision of social support, directly observed therapy, and financial incentives. Pillboxes and two-way short-text messaging service (SMS) reminders have been shown to be effective and are widely recommended tools for promoting ART adherence. Further research is needed to determine the optimal combination of adherence interventions, as well as generalizability, implementation, and cost-effectiveness.

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.

Positive coping strategies and HIV-related stigma in south India

Whether perceived or enacted, HIV-related stigma is widespread in India, and has had a crippling effect on People Living with HIV/AIDS (PLHA). Research has shown that a positive attitude towards the illness sets a proactive framework for the individual to cope with his or her infection; therefore, healthy coping mechanisms are essential to combat HIV-related stigma. This qualitative study involving in-depth interviews and focus group discussions with PLHA affiliated with HIV support groups in South India explored positive coping strategies employed by PLHA to deal with HIV-related stigma. Interviews and focus group discussions were translated, transcribed, and analyzed for consistent themes. Taboos surrounding modes of transmission, perceiving sex workers as responsible for the spread of HIV, and avoiding associating with PLHA provided the context of HIV-related stigma. Despite these challenges, PLHA used several positive strategies, classified as Clear Knowledge and Understanding of HIV, Social Support and Family Well-Being, Selective Disclosure, Employment Building Confidence, and Participation in Positive Networks. Poor understanding of HIV and fears of being labeled immoral undermined healthy coping behavior, while improved understanding, affiliation with support groups, family support, presence of children, and financial independence enhanced PLHA confidence. Such positive coping behaviours could inform culturally relevant interventions.

"Keep it simple": older African Americans' preferences for a health literacy intervention in HIV management

PURPOSE

Health literacy is lower in minorities and older adults, and has been associated with nonadherence to medications, treatment, and care in people living with human immunodeficiency virus (HIV). Likewise, African Americans with HIV are more likely to be nonadherent to their HIV medications, less likely to keep their clinic appointments related to HIV treatment and care, and more likely to die during hospitalizations than their ethnic counterparts. The present study explored the preferences of older African Americans with HIV for a health literacy intervention to promote HIV management.

PATIENTS AND METHODS

In this qualitative study, 20 older adult African Americans living with HIV were recruited from an HIV/acquired immunodeficiency syndrome outpatient clinic in the southeastern region of the US. Using patient-centered participatory design methods, semi-structured individual interviews were conducted to determine patient preferences for intervention development and design. Health literacy was also measured using the Rapid Estimate of Adult Literacy in Medicine - Revised (REALM-R).

RESULTS

Four major themes emerged related to intervention development and design: keep health information simple; use a team-based approach for health education; tailor teaching strategies to patients' individual needs; and account for patients' low experience, but high interest, in technology. Forty-five percent of the study population had low health literacy based on the revised Rapid Estimate of Adult Literacy in Medicine.

CONCLUSION

Future interventions that target minorities and older adults living with HIV should consider patients' learning needs, sex-specific and mental health needs, and delivery approaches, in order to increase uptake and improve disease management and health outcomes.

Impact of Poor Retention in HIV Medical Care on Hepatitis B Vaccination

BACKGROUND

We identified factors associated with complete hepatitis B vaccination of patients with HIV.

METHODS

Retrospective analysis of patients undergoing HIV clinic orientation from 2000 to 2010. Vaccine-eligible patients had negative hepatitis B serologies at baseline. Receipt of at least 3 doses was defined as complete vaccination.

RESULTS

Of 1242 patients, 519 (42%) were completely vaccinated. Complete vaccination was positively associated with missing ≤25% of the visits during the first year of care (adjusted odds ratio [aOR] = 2.35, 95% confidence interval [CI]: 1.79-3.09), being naive to care (aOR = 1.50, 95% CI: 1.13-1.99), and living at the clinic's county (aOR = 1.33, 95% CI: 1.02-1.75). Complete vaccination was negatively associated with failure to remain in care >2 years (aOR = 0.18, 95% CI: 0.13-0.24), history of intravenous drug use (aOR = 0.48, 95% CI: 0.27-0.87), and baseline CD4 count <200 cells/mm(3) (aOR = 0.69, 95% CI: 0.53-0.92).

CONCLUSION

Poor retention in HIV care is strongly associated with suboptimal hepatitis B vaccination.

Medical mistrust is related to lower longitudinal medication adherence among African-American males with HIV

African-Americans living with HIV show worse health behaviors (e.g. medication adherence) and outcomes (e.g. viral suppression) than do their White counterparts. In a 6-month longitudinal study, we investigated whether medical mistrust among African-American males with HIV (214 enrolled, 140 with longitudinal data) predicted lower electronically monitored antiretroviral medication adherence. General medical mistrust (e.g. suspicion toward providers), but not racism-related mistrust (e.g. belief that providers treat African-Americans poorly due to race), predicted lower continuous medication adherence over time (b = -.08, standard error = .04, p = .03). Medical mistrust may contribute to poor health outcomes. Intervention efforts that address mistrust may improve adherence among African-Americans with HIV.

Factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension

BACKGROUND

Missed appointments are associated with an increased risk of hospitalization and mortality. Despite its widespread prevalence, little data exists regarding factors related to appointment non-adherence among hypertensive African-Americans.

OBJECTIVE

To investigate factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension.

DESIGN AND PARTICIPANTS

A cross-sectional survey of 185 African-Americans admitted to an urban medical center in Maryland, with severe, poorly controlled hypertension from 1999-2004. Categorical and continuous variables were compared using chi-square and t-tests. Adjusted multivariable logistic regression was used to assess correlates of appointment non-adherence.

MAIN OUTCOME MEASURES

Appointment non-adherence was the primary outcome and was defined as patient-report of missing greater than 3 appointments out of 10 during their lifetime.

RESULTS

Twenty percent of participants (n = 37) reported missing more than 30% of their appointments. Patient characteristics independently associated with a higher odds of appointment non-adherence included not finishing high school (Odds ratio [OR]  = 3.23 95% confidence interval [CI] (1.33-7.69), hypertension knowledge ([OR]  = 1.20 95% CI: 1.01-1.42), lack of insurance ([OR]  = 6.02 95% CI: 1.83-19.88), insurance with no medication coverage ([OR]  = 5.08 95% CI: 1.05-24.63), cost of discharge medications ([OR]  = 1.20 95% CI: 1.01-1.42), belief that anti-hypertensive medications do not work ([OR]  = 3.67 95% CI: 1.16-11.7), experience of side effects ([OR]  = 3.63 95% CI: 1.24-10.62), medication non-adherence ([OR]  = 11.31 95% CI: 3.87-33.10). Substance abuse was not associated with appointment non-adherence ([OR]  = 1.05 95% CI: 0.43-2.57).

CONCLUSIONS

Appointment non-adherence among African-Americans with poorly controlled hypertension was associated with many markers of inadequate access to healthcare, knowledge, attitudes and beliefs.

Factors Associated With Hospitalizations Among HIV-Infected Adults in the United States: Review of the Literature

Although improving health outcomes in human immunodeficiency virus (HIV)-infected persons has been identified as a national priority, little is known about the factors associated with hospitalizations of HIV-infected persons in the highly active antiretroviral therapy (HAART) era. Since the introduction of HAART in 1996, there has been a dramatic increase in the life expectancy of HIV-infected persons. However, aging and the long term use of HIV medications have led to an increased incidence of chronic, non-HIV-related illnesses. To improve patient outcomes, the factors that contribute to co-morbidities in HIV-infected persons need to be identified. As a first step, we will summarize the current literature on causes and contributing factors of hospitalizations in adults infected with HIV in the HAART era.

Risk and protective factors for retention in HIV care

Retention in care for HIV is essential for effective disease management; however, factors that may confer risk or protection for adherence to regular HIV care are less well understood. This study tested whether HIV-associated cognitive impairment (CI) and low health literacy reduced adherence to routine HIV medical and phlebotomy visits and if social support and patient-provider relationship conferred a protective effect. Participants were 210 HIV-infected patients enrolled in outpatient care and followed for 28-weeks. Results showed that those attending >75 % of phlebotomy visits were more likely to be virally suppressed. Health literacy was unassociated with adherence to medical or phlebotomy visits. CI was not directly related to medical or phlebotomy visit adherence; however those with CI and greater use of social support were less likely to miss medical visits. Utilizing social support may be an effective means of managing visit adherence, especially among patients with CI.

Health information technology interventions enhance care completion, engagement in HIV care and treatment, and viral suppression among HIV-infected patients in publicly funded settings

BACKGROUND

The National HIV/AIDS Strategy (NHAS) emphasizes the use of technology to facilitate coordination of comprehensive care for people with HIV. We examined the effect of six health information technology (HIT) interventions in a Ryan White-funded Special Projects of National Significance (SPNS) on care completion services, engagement in HIV care, and viral suppression.

METHODS

Interventions included use of surveillance data to identify out-of-care individuals, extending access to electronic health records to support service providers, use of electronic laboratory ordering and prescribing, and development of a patient portal. Data from a sample of electronic patient records from each site were analyzed to assess changes in utilization of comprehensive care (prevention screening, support service utilization), engagement in primary HIV medical care (receipt of services and use of antiretroviral therapy), and viral suppression. We used weighted generalized estimating equations to estimate outcomes while accounting for the unequal contribution of data and differences in the distribution of patient characteristics across sites and over time.

RESULTS

We observed statistically significant changes in the desired direction in comprehensive care utilization and engagement in primary care outcomes targeted by each site. Five of six sites experienced statistically significant increases in viral suppression.

DISCUSSION

These results provide additional support for the use of HIT as a valuable tool for achieving the NHAS goal of providing comprehensive care for all people living with HIV. HIT has the potential to increase utilization of services, improve health outcomes for people with HIV, and reduce community viral load and subsequent transmission of HIV.

Disparities in CD4+ T-Lymphocyte Monitoring Among Human Immunodeficiency Virus-Positive Medicaid Beneficiaries: Evidence of Differential Treatment at the Point of Care

BACKGROUND

Monitoring of immune function, measured by CD4 cell count, is an essential service for people with Human Immunodeficiency Virus (HIV). Prescription of antiretroviral (ARV) medications is contingent on CD4 cell count; patients without regular CD4 monitoring are unlikely to receive ARVs when indicated. This study assesses disparities in CD4 monitoring among HIV-positive Medicaid beneficiaries.

METHODS

In this retrospective observational study, we examined 24 months of administrative data on 2,250 HIV-positive, continuously-enrolled fee-for-service Medicaid beneficiaries with at least two outpatient healthcare encounters. We used logistic regression to evaluate the association of patient demographics (age, gender, race/ethnicity, and language) with receipt of at least one CD4 test per year, controlling for other potentially confounding variables.

RESULTS

Having a history of ARV therapy was positively associated with receipt of CD4 tests. We found racial/ethnic, gender, and age disparities in CD4 testing. Among individuals with a history of ARV use, all racial/ethnic groups were significantly less likely to have CD4 tests than White non-Latinos (African Americans, OR = 0.35, p<0.0001; Asian/Pacific Islanders, OR = 0.31, p=0.0047; and, Latinos, OR = 0.42, p<0.0001).

CONCLUSIONS

Disparities in receipt of CD4 tests elucidate one potential pathway for previously reported disparities in ARV treatment. Further qualitative and quantitative research is needed to identify the specific factors that account for these disparities, so that appropriate interventions can be implemented.

Development and validation of an algorithm to identify patients newly diagnosed with HIV infection from electronic health records

An algorithm was developed that identifies patients with new diagnoses of HIV infection by the use of electronic health records. It was based on the sequence of HIV diagnostic tests, entry of ICD-9-CM diagnostic codes, and measurement of HIV-1 plasma RNA levels in persons undergoing HIV testing from 2006 to 2012 at four large urban Veterans Health Administration (VHA) facilities. Source data were obtained from the VHA National Corporate Data Warehouse. Chart review was done by a single trained abstractor to validate site-level data regarding new diagnoses. We identified 1,153 patients as having a positive HIV diagnostic test within the VHA. Of these, 57% were determined to have prior knowledge of their HIV status from testing at non-VHA facilities. An algorithm based on the sequence and results of available laboratory tests and ICD-9-CM entries identified new HIV diagnoses with a sensitivity of 83%, specificity of 86%, positive predictive value of 85%, and negative predictive value of 90%. There were no meaningful demographic or clinical differences between newly diagnosed patients who were correctly or incorrectly classified by the algorithm. We have validated a method to identify cases of new diagnosis of HIV infection in large administrative datasets. This method, which has a sensitivity of 83%, specificity of 86%, positive predictive value of 85%, and negative predictive value of 90% can be used in analyses of the epidemiology of newly diagnosed HIV infection.

African American race and HIV virological suppression: beyond disparities in clinic attendance

Racial disparities in clinic attendance may contribute to racial disparities in plasma human immunodeficiency virus type 1 : HIV-1) RNA levels among HIV-positive patients in care. Data from 946 African American and 535 Caucasian patients receiving HIV care at the University of North Carolina Center for AIDS Research HIV clinic between January 1, 1999, and August 1, 2012, were used to estimate the association between African American race and HIV virological suppression (i.e., undetectable HIV-1 RNA) when racial disparities in clinic attendance were lessened. Clinic attendance was measured as the proportion of scheduled clinic appointments attended (i.e., visit adherence) or the proportion of six 4-month intervals with at least 1 attended scheduled clinic appointment (i.e., visit constancy). In analyses accounting for patient characteristics, the risk ratio for achieving suppression when comparing African Americans with Caucasians was 0.91 (95% confidence interval: 0.85, 0.98). Lessening disparities in adherence or constancy lowered disparities in virological suppression by up to 44.4% and 11.1%, respectively. Interventions that lessen disparities in adherence may be more effective in eliminating disparities in suppression than interventions that lessen disparities in constancy. Given that gaps in care were limited to be no more than 2 years for both attendance measures, the impact of lessening disparities in adherence may be overstated.

Impact of non-HIV related comorbidities on retention in HIV medical care: does retention improve over time?

The purpose of this study was to understand how the presence of comorbid conditions affects retention in HIV medical care over time. A retrospective cohort design employing a medical chart review was conducted. A generalized linear mixed model was used to determine the predictors that affect retention over time. The mean follow-up for the study population was 5.75 years, and only 48.6 % achieved optimal retention. During the study period, 882 non-HIV related comorbidities were diagnosed in 610 (44.9 %) patients of whom, approximately 31 % had ≥2 comorbidities diagnosed. In the mixed model, the number of comorbidities diagnosed during the study period was associated with improved retention over time (odds ratio = 2.28; 95 % confidence interval = 1.83-2.71). Having a non-HIV related comorbid condition was associated with improved retention, while those patients who were 'healthier' had worse retention. More research is needed to identify factors that improve retention and to quantify the impact of these factors.

The role of at-risk alcohol/drug use and treatment in appointment attendance and virologic suppression among HIV(+) African Americans

The causes of poor clinic attendance and incomplete virologic suppression among HIV(+) African Americans (AAs) are not well understood. We estimated the effect of at-risk alcohol/drug use and associated treatment on attending scheduled appointments and virologic suppression among 576 HIV(+) AA patients in the University of Alabama at Birmingham (UAB) 1917 Clinic Cohort who contributed 591 interviews to the analysis. At interview, 78% of patients were new to HIV care at UAB, 38% engaged in at-risk alcohol/drug use or received associated treatment in the prior year, while the median (quartiles) age and CD4 count were 36 (28; 46) years and 321 (142; 530) cells/μl, respectively. In the 2 years after an interview, half of the patients had attended at least 82% of appointments while half had achieved virologic suppression for at least 71% of RNA assessments. Compared to patients who did not use or receive treatment, the adjusted risk ratio (aRR) for attending appointments for patients who did use but did not receive treatment was 0.97 (95% confidence limits: 0.92, 1.03). The corresponding aRR for virologic suppression was 0.94 (0.86, 1.03). Compared to patients who did not receive treatment but did use, the aRR for attending appointments for patients who did receive treatment and did use was 0.86 (0.78, 0.95). The corresponding aRR for virologic suppression was 1.07 (0.92, 1.24). Use was negatively associated with attendance and virologic suppression among patients not in treatment. Among users, treatment was negatively associated with attendance yet positively associated with virologic suppression. However, aRR estimates were imprecise.

Hospitalization rates of people living with HIV in the United States, 2009

OBJECTIVES

We determined hospitalization rates and disparities among people with HIV, which may have been underestimated in previous studies, as only those in medical care were included.

METHODS

We estimated the hospitalization rate of people with diagnosed HIV infection in the U.S. in 2009 using two nationally representative datasets. We took the number of hospitalizations from the Nationwide Inpatient Sample and searched each discharge for International Classification of Diseases, Ninth Revision codes for HIV infection and opportunistic infections (OIs). We divided the number of hospitalizations by the number of prevalent diagnosed HIV cases estimated by CDC to produce hospitalization rates, and then compared those rates using Z-tests.

RESULTS

The estimated nationwide hospitalization rate was 26.6 per 100 population. Women had a 51% higher rate than men (35.5 vs. 23.5 per 100 population, p=0.002). Black people (31.2 per 100 population, p=0.01) had a 42% higher rate, and Hispanic people (18.2 per 100 population, p=0.23) had an 18% lower rate than white people (22.1 per 100 population) of hospitalization for any illness. Of hospitalizations with an OI, females with HIV had a 50% higher rate than males with HIV (5.0 vs. 3.4 per 100 population, p=0.003). Black people with HIV (4.7 per 100 population, p<0.001) had a 72% higher rate and Hispanic people with HIV (2.9 per 100 population, p=0.78) had a similar rate of hospitalization with an OI compared with white people with HIV (2.7 per 100 population).

CONCLUSIONS

Hospitalization rates among people living with HIV in the U.S. are higher than have been previously estimated. Substantial gender and racial/ethnic disparities in hospitalization rates exist, suggesting that the benefits of antiretroviral therapy have not been realized across all groups equally.

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.

Factors associated with virological failure in a cohort of combination antiretroviral therapy-treated patients managed at a tertiary referral centre

BACKGROUND

Recent antiretroviral regimens are potent and better tolerated, resulting in a low prevalence of treatment failure. It is important to identify the drivers of virological failure, so that patients at risk can be identified early and prevention strategies implemented.

METHODS

We performed a retrospective case-control study of HIV-positive patients on antiretroviral therapy and managed at The Alfred Hospital during 2010 to evaluate the predictors of virological failure. Controls were matched 3:1 to cases by gender, and by clinical review in the same week as the diagnosis of virological failure in the case. Predictors of virological failure were identified by multivariate conditional logistic regression.

RESULTS

Thirty-nine patients were identified with treatment failure. In the multivariate model, characteristics associated with virological failure were missed clinic appointments in 1 year before virological failure (odds ratio (OR)=13.1, 95% confidence interval (CI): 2.8-61.1), multiple previous combined antiretroviral therapy regimens (OR =4.2, 95% CI:1.2-15.3), current hepatitis C infection (OR=8.6, 95% CI: 1.9-38.7), older age at HIV diagnosis (OR=1.1, 95% CI: 1.0-1.2), younger age at time of virological failure (OR=0.9, 95% CI: 0.8 to 1.0), and CD4 cell count at virological failure (OR=0.7, 95% CI: 0.5 to 0.9).

CONCLUSIONS

Targeted and appropriate adherence support should be provided to treatment-experienced patients, particularly those who have missed clinical appointments and those with hepatitis C coinfection. Further elucidation of the barriers to clinic attendance may optimise linkage and retention in care.

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.

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.

Longitudinal changes in engagement in care and viral suppression for HIV-infected injection drug users

OBJECTIVE

To examine temporal trends and predictors of linkage to HIV care, longitudinal retention in care and viral suppression among injection drug users (IDUs) infected with HIV.

DESIGN

Community-based, prospective cohort study.

METHODS

We prospectively studied 790 HIV-infected IDUs participating in the AIDS Linked to the Intravenous Experience (ALIVE) study from 1998 through 2011. IDUs were considered linked to care if they attended any HIV care visit during follow-up and retained in care if they reported HIV clinic attendance at every semi-annual study visit. We used logistic regression to identify predictors of poor retention in care and failure to achieve sustained viral suppression in response to ART.

RESULTS

Of 790 HIV-infected IDUs studied, 740 (93.6%) were ever linked to care. The majority of IDUs (76.7%) received ART at some point during observation and of these, most (85.4%) achieved viral suppression. However, over a median of 8.7 years of follow-up, only 241 (30.5%) IDUs were continuously retained with no 6-month lapses in HIV care and only 63 (10.2%) had sustained viral suppression at every study visit after first receiving ART. Suboptimal engagement in care was associated with poor access to medical care, active drug use, and incarceration.

CONCLUSION

Compared with national estimates of retention in care and virologic suppression in the United States, IDUs are substantially less likely to remain fully engaged in HIV care. Strategies to optimize HIV care should acknowledge the elevated risk of poor engagement in care among IDUs.

Effects of an intervention addressing information, motivation, and behavioral skills on HIV care adherence in a southern clinic cohort

Multiple studies have shown that subtherapeutic appointment adherence and medication adherence are associated with worse clinical outcomes for people living with HIV disease. Thus, poor appointment and medication adherence diminish individual and community HIV control and transmission. Yet not enough is known about interventions that can improve retention in HIV care. The purpose of this study was to test an intervention to improve retention and/or medication adherence in a public clinic in the Deep South. One hundred participants with retention or medication adherence difficulties were randomized to either a six-month intervention or usual care, and followed longitudinally for one year. The intervention was multidimensional, based on the Information-Motivation-Behavioral Skills (IMB) model. The intervention addressed information about HIV and the importance of retention/adherence, motivation to be retained and/or adhere to medications, and the behavioral skills needed to manage and maintain these healthy behaviors in a combination of face-to-face and telephone sessions. The proportion of those with at least one visit in each four-month block (third) of the year increased in those with minimal exposure to the intervention (three out of eight intervention contacts) as compared to those with less intervention exposure (p = 0.098). Those with at least this minimal exposure averaged a significantly higher number of thirds that included a clinic visit as compared to those with less intervention exposure (p = 0.013). The intervention did not demonstrate a significant effect on medication adherence, though this is contradictory to a previous study testing a version of this intervention designed to address only medication adherence. Further study to increase uptake of the intervention is needed to increase its efficacy.

Routine depression screening in an HIV clinic cohort identifies patients with complex psychiatric co-morbidities who show significant response to treatment

This study described characteristics, psychiatric diagnoses and response to treatment among patients in an outpatient HIV clinic who screened positive for depression. Depressed (25 %) were less likely to have private insurance, less likely to have suppressed HIV viral loads, had more anxiety symptoms, and were more likely to report current substance abuse than not depressed. Among depressed, 81.2 % met diagnostic criteria for a depressive disorder; 78 % for an anxiety disorder; 61 % for a substance use disorder; and 30 % for co-morbid anxiety, depression, and substance use disorders. Depressed received significantly more treatment for depression and less HIV primary care than not depressed patients. PHQ-9 total depression scores decreased by 0.63 from baseline to 6-month follow-up for every additional attended depression treatment visit. HIV clinics can routinely screen and treat depressive symptoms, but should consider accurate psychiatric diagnosis as well as co-occurring mental disorders.

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.

Development of a personalized bidirectional text messaging tool for HIV adherence assessment and intervention among substance abusers

We describe the development of a two-way text messaging intervention tool for substance users who are non-adherent with HIV medications, and examine message flow data for feasibility and acceptability. The assessment and intervention tool, TxText, is fully automated, sending participants mood, substance use, and medication adherence queries by text message. Participants respond, the tool recognizes the category of response, and sends the personalized intervention message that participants designed in return. In 10months, the tool sent 16,547 messages (half initial, half follow-up) to 31 participants assigned to the TxText condition, who sent 6711 messages in response to the initial messages. Response rates to substance use (n=2370), medication (n=2918) and mood (n=4639) queries were 67, 69, and 64%, respectively. Responses indicating medication adherence, abstinence from substances, and good moods were more common than negative responses. The TxText tool can send messages daily over a 3month period, receive responses, and decode them to deliver personalized affirming or intervention messages. While we await the outcomes of a pilot randomized trial, the process analysis shows that TxText is acceptable and feasible for substance abusers with HIV, and may serve as a complement to HIV medical care.