HIV-infected patients and treatment outcomes: an equivalence study of community-located, primary care-based HIV treatment vs. hospital-based specialty care in the Bronx, New York

Factors Associated with Time to Initial Antiretroviral Therapy Discontinuation in the DC Cohort

When an initial antiretroviral therapy (ART) regimen is effective and well-tolerated, it can be maintained for years as long as the patient adheres. Prior research has revealed that shorter initial ART duration is associated with regimen type, female sex, injection drug use as the HIV transmission category, and lower baseline CD4 count. We examined potential factors associated with initial regimen discontinuation among a subset of newly diagnosed virally unsuppressed PWH in the DC Cohort, an ongoing prospective observation study that uses electronic health record data from clinic sites to collect relevant information, including demographic and clinical information. Participants were excluded from the analysis if they had less than 6 months of follow-up and were virally suppressed at enrollment. There were 479 individuals included in the study. The median age of participants was 33.9 years [interquartile range (IQR) 26-43.9]. The sample was predominantly male (79.1%) and of Black race (70.8%). Over half of the study participants (56.4%) attended community-based clinic sites. The median time to the discontinuation of initial ART was 2.7 years [95% confidence interval (CI): 2.3, 3.4]. Females had a shorter time to ART discontinuation [adjusted hazard ratio (aHR) 1.55, 95% CI: 1.14, 2.11] as did individuals who started on a protease inhibitor-based regimen versus integrase strand transfer inhibitors (aHR 1.87, 95% CI: 1.34, 2.61) and those receiving HIV care at a community-based site (aHR 1.46, 95% CI: 1.11,1.93). Although limited by lack of reason for discontinuation, we demonstrated that ART-naïve women, community clinic attendees, and patients starting on PIs had a shorter duration of initial ART. More anticipatory guidance may be needed to help patients stay on their initial therapy and manage the side effects or to be flexible in trying different regimens.

A community-based model of HIV care for men who have sex with men and transgender women in Chicago

Socioeconomically disadvantaged men who have sex with men (MSM) and transgender women (TGW) share a disproportionate burden of the HIV epidemic. Providing care in the community may help improve retention and treatment outcomes of these clients. Our objective was to compare HIV outcomes between a community-based model (CBM) and a hospital-based model (HBM) of HIV care. This was a retrospective cohort study of MSM and TGW with HIV treated at community clinics or at a hospital-based clinic. The primary outcome was the cumulative probability of virologic failure (HIV viral load ≥200 copies/ml). We conducted multivariable Cox proportional hazard regression to identify differences in outcome by care setting. Of 258 MSM and TGW, approximately half received care in the CBM. They were more likely to be African American (71% versus 59%), uninsured (48% versus 39%), and used illicit drugs (40% versus 25%). There was no difference in virologic failure by setting (58% CBM, 53% HBM; cumulative incidence of virologic failure: 35% CBM, 25% HBM; adjusted HR = 1.11; 95% CI: 0.88–1.39). Despite serving clients at greater risk for failure, virologic failure in our CBM was similar to a traditional HBM for MSM and TGW living with HIV.

HIV prescriptions on the frontlines: Primary care providers' use of antiretrovirals for prevention in the Southeast United States, 2017

HIV disproportionately affects persons in Southeast United States. Primary care providers (PCPs) are vital for HIV prevention. Data are limited about their prescribing of antiretrovirals (ARVs) for prevention, including non-occupational post-exposure prophylaxis (nPEP), pre-exposure prophylaxis (PrEP), and antiretroviral therapy (ART). We examined these practices to assess gaps. During April-August 2017, we conducted an online survey of PCPs in Atlanta, Baltimore, Baton Rouge, Miami, New Orleans, and Washington, DC to assess HIV-related knowledge, attitudes and practices. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) were used to estimate correlates of nPEP, PrEP and ART prescribing practices. Adjusting for MSA and specialty, the weighted sample (n = 820, 29.6% adjusted response rate) comprised 60.2% white and 59.4% females. PCPs reported ever prescribing nPEP (31.0%), PrEP (18.1%), and ART (27.2%). Prescribing nPEP was associated with nPEP familiarity (aPR = 2.63, 95% CI 1.59, 4.35) and prescribing PrEP (aPR = 3.57, 95% CI 2.78, 4.55). Prescribing PrEP was associated with PrEP familiarity (aPR = 4.35, 95% CI 2.63, 7.14), prescribing nPEP (aPR = 5.00, 95% CI 2.00, 12.50), and providing care for persons with HIV (aPR = 1.56, 95% CI 1.06, 2.27). Prescribing ART was associated with nPEP familiarity (aPR = 1.89, 95% CI 1.27, 2.78) and practicing in outpatient public practice versus hospital-based facilities (aPR = 2.14 95% CI 1.51, 3.04), and inversely associated with collaborations involving specialists (aPR = 0.60, 95% CI 0.42, 0.86). A minority of PCPs surveyed from the Southeast report ever prescribing ARVs for prevention. Future efforts should include enhancing HIV care coordination and developing strategies to increase use of biomedical tools.

DEBATE-statistical analysis plans for observational studies

Background

All clinical research benefits from transparency and validity. Transparency and validity of studies may increase by prospective registration of protocols and by publication of statistical analysis plans (SAPs) before data have been accessed to discern data-driven analyses from pre-planned analyses.

Main message

Like clinical trials, recommendations for SAPs for observational studies increase the transparency and validity of findings. We appraised the applicability of recently developed guidelines for the content of SAPs for clinical trials to SAPs for observational studies. Of the 32 items recommended for a SAP for a clinical trial, 30 items (94%) were identically applicable to a SAP for our observational study. Power estimations and adjustments for multiplicity are equally important in observational studies and clinical trials as both types of studies usually address multiple hypotheses. Only two clinical trial items (6%) regarding issues of randomisation and definition of adherence to the intervention did not seem applicable to observational studies. We suggest to include one new item specifically applicable to observational studies to be addressed in a SAP, describing how adjustment for possible confounders will be handled in the analyses.

Conclusion

With only few amendments, the guidelines for SAP of a clinical trial can be applied to a SAP for an observational study. We suggest SAPs should be equally required for observational studies and clinical trials to increase their transparency and validity.

How the delivery of HIV care in Canada aligns with the Chronic Care Model: A qualitative study

With the advent of continuous antiretroviral therapy, HIV has become a complex chronic, rather than acute, condition. The Chronic Care Model (CCM) provides an integrated approach to the delivery of care for people with chronic conditions that could therefore be applied to the delivery of care for people living with HIV. Our objective was to assess the alignment of HIV care settings with the CCM. We conducted a mixed methods study to explore structures, organization and care processes of Canadian HIV care settings. The quantitative results of phase one are published elsewhere. For phase two, we conducted semi-structured interviews with key informants from 12 HIV care settings across Canada. Irrespective of composition of the care setting or its location, HIV care in Canada is well aligned with several components of the CCM, most prominently in the areas of linkage to community resources and delivery system design with inter-professional team-based care. We propose the need for improvements in the availability of electronic clinical information systems and self-management support services to support better care delivery and health outcomes among people living with HIV in Canada.

Immunological and virologic outcomes of people living with HIV in Guangxi, China: 2012-2017

BACKGROUND

Limited data are available on clinical outcomes of people living with HIV (PLWH) in China, especially after the implementation of the 2016 national treatment guideline. The objective of the current study is to examine the treatment patterns, clinical outcomes and their associated factors among PLWH in Guangxi, China before and after this new guideline.

METHODS

Data from three community-based projects conducted at different time points over a period of six years (2012-2017) in Guangxi were analyzed in our study. The interviewer-administered questionnaire was used for data collection. Measures of clinical outcomes were retrieved from the patients' medical records. Descriptive analysis was employed to display treatment patterns and the time trends of clinical outcomes. Chi-square test or ANOVA was used to compare the differences in background characteristics and treatment history between different levels of clinical outcomes.

RESULTS

Among the pooled sample of 4224 participants, 77.3% were receiving antiretroviral therapy (ART), the median CD4 count was 328 cells/mm3, and 82.5% were virally suppressed. An increasing trend in both ART coverage (from 72.1% to 91.2%) and CD4 count (from 318 cells/mm3 to 357 cells/mm3) was observed over time in the three samples, while rates of viral suppression did not show a similar trend. A number of socio-demographic characteristics (e.g., female gender, younger age, Han ethnicity, and employment) and treatment-related variables (e.g., longer durations of HIV diagnosis and ART uptake, lower prevalence of comorbidity, fewer treatment interruptions, and more knowledge on ART) were associated with improved clinical outcomes.

CONCLUSIONS

We observed a high rate of viral suppression and increasing trends in ART coverage and CD4 count over six years in Guangxi, China. However, suboptimal clinical outcomes continue to be a problem, particularly among some subgroups of PLWH. Future clinical management strategies should be tailored for PLWH with different sociodemographic characteristics and treatment trajectories.

Training Internal Medicine Residents to Provide Care and Treatment for Human Immunodeficiency Virus-1-Infected Patients

Background

Human immunodeficiency virus (HIV) infection is now considered a chronic infection manageable on antiretroviral therapy. If trained in HIV care, primary care physicians would be well suited to work in consultation with infectious disease specialists to provide care for HIV patients.

Methods

Human immunodeficiency virus training was incorporated into our internal medicine residency program. All residents were given an internally developed preprogram survey about HIV infection to establish a baseline level of HIV knowledge; at the end of 1 year, a postprogram survey was distributed. These results were compared. Human immunodeficiency virus didactic lectures were mandatory for attendance. Human immunodeficiency virus training included methods of testing, treatment including all classes of antiretroviral therapy, and prevention methods. Additional, mandatory online training modules were used. All program year-2 residents were assigned to an outpatient HIV clinical rotation.

Results

Eighty-three residents participated. Residents received either 1 or 2 years of training. Results of preprogram scores and postprogram scores were calculated for each resident. Year 1-test scores preprogram were 52.2% vs postprogram 87.1%; year 2-test scores preprogram were 56.3% vs postprogram 89.8% (both P < .0001). There was no difference in posttest scores among residents who attended a clinical rotation.

Conclusions

Residents showed significant improvement in HIV knowledge between preprogram and postprogram test scores. Postgraduate surveys showed among those who completed the survey, and most found the program helpful to in their current practice.

Loneliness and perceived social support in pregnancy and early postpartum of mothers living with HIV in Ontario, Canada

The HIV Mothering Study (n = 72) was a prospective, observational, cohort study exploring psychosocial experiences and needs of WLWHIV in pregnancy and postpartum. We performed quantitative analysis of determinants of loneliness (UCLA Loneliness Scale) and lower perceived social support (SS) (Medical Outcomes Study-Social Support Survey). The hypothesized determinants included: age, years with HIV, racism (Everyday Discrimination Scale), depression (Edinburgh Postnatal Depression Scale [EPDS]), nadir CD4 (<200 cells/μL), tertiary vs. community HIV care, and marital status. The median age was 33 (IQR = 30-37); 65.3% were African/Caribbean/Black. Multivariable analyses revealed associations between marital status and perceived social support (β = -16.48, p < 0.0001), and this association was also seen with change over time (p = 0.02). Variables associated with SS that did not change over time were: income, EDS racism, EPDS score. Significant associations with loneliness were seen with the same variables associated with SS. Variables associated with loneliness that also changed over time were: EDS Racism (β = 0.22, p = 0.0005, and over time p = 0.003), and EPDS score (β = 0.74, p < 0.0001), and over time (p = 0.0211). Variables associated with loneliness but that did not change over time were: marital status and income. This analysis provides clinicians with prenatal risk factors which may be associated with increase loneliness and lower SS during pregnancy and postpartum: marital status, income, racism and depression.

Use of national standards to monitor HIV care and treatment in a high prevalence city-Washington, DC

We sought to benchmark the quality of HIV care being received by persons living with HIV in care in Washington, DC and identify individual-level and structural-level differences. Data from the DC Cohort, an observational HIV cohort of persons receiving outpatient care in DC, were used to estimate the Institute of Medicine (IOM) and Department of Health and Human Services (HHS) quality of care measures. Differences in care by demographics and clinic type were assessed using χ2 tests and multivariable regression models. Among 8,047 participants, by HHS standards, 69% of participants were retained in care (RIC), 95% were prescribed antiretroviral therapy (ART), and 84% were virally suppressed (VS). By IOM standards, 84% were in continuous care; and 78% and 80% underwent regular CD4 and VL monitoring, respectively. Screening for syphilis, chlamydia, and gonorrhea was 51%, 31%, and 26%, respectively. Older participants were 1.5 times more likely to be RIC compared to younger participants (OR: 1.5; 95% CI: 1.3, 1.8). Participants enrolled in community-based clinics were more likely to be RIC (OR: 1.7; 95% CI: 1.4, 2.0) versus those enrolled at hospital-based clinics. Older participants were more likely to achieve VS than younger participants (OR: 1.8; 95% CI: 1.5, 2.2) while Black participants were less likely compared to white participants (OR: 0.4; 95% CI: 0.3, 0.5). Despite high measures of quality of care, disparities remain. Continued monitoring of the quality of HIV care and treatment can inform the development of public health programs and interventions to optimize care delivery.

Reaching Key Populations: PrEP Uptake in an Urban Health Care System in the Bronx, New York

Pre-exposure prophylaxis (PrEP) has been established as an effective HIV prevention tool, but real world studies are limited. To inform dissemination efforts, we sought to describe individuals prescribed PrEP in the largest health care system in the Bronx, New York, an urban region with a high burden of HIV. We used a clinical database and chart review to identify individuals prescribed PrEP between 2011 and 2015 (n = 108). A majority were Black and Hispanic, half were men who have sex with men, and nearly a third were cisgender women who have sex with men. Primary care settings were the most common site of PrEP prescription and PrEP prescription rates increased over time. Despite reaching a diverse patient population, PrEP prescribing rates were low, underscoring the urgent need for PrEP scale-up.

Health outcomes and retention in care following release from prison for patients of an urban post-incarceration transitions clinic

Chronic health conditions are overrepresented among prisoners who often face barriers to medical care following release. Transitions clinics seek to provide timely access to medical care following release. This retrospective cohort study investigated care delivery and health outcomes for recently released prisoners receiving care at the Bronx Transitions Clinic. Among 135 recently released prisoners, median time from release to initial medical visit was 10 days (IQ Range: 5-31). Six-month retention in care was high for HIV-infection (86%), but lower for opioid dependence (33%), hypertension (45%) and diabetes (43%). At six months, 54% of HIV-patients had a suppressed viral load, but fewer buprenorphine-treated patients reduced opioid use (19%), and fewer hypertensive and diabetic patients reached respective blood pressure (35%) and hemoglobin A1c (14%) goals. Access to medical care is necessary but not sufficient to control chronic health conditions. Additional interventions are necessary for formerly incarcerated people to achieve optimal health outcomes.

Clinical outcomes of HIV care delivery models in the US: a systematic review

With over 1 million people living with HIV, the US faces national challenges in HIV care delivery due to an inadequate HIV specialist workforce and the increasing role of non-communicable chronic diseases in driving morbidity and mortality in HIV-infected patients. Alternative HIV care delivery models, which include substantial roles for advanced practitioners and/or coordination between specialty and primary care settings in managing HIV-infected patients, may address these needs. We aimed to systematically review the evidence on patient-level HIV-specific and primary care health outcomes for HIV-infected adults receiving outpatient care across HIV care delivery models. We identified randomized trials and observational studies from bibliographic and other databases through March 2016. Eligible studies met pre-specified eligibility criteria including on care delivery models and patient-level health outcomes. We considered all available evidence, including non-experimental studies, and evaluated studies for risk of bias. We identified 3605 studies, of which 13 met eligibility criteria. Of the 13 eligible studies, the majority evaluated specialty-based care (9 studies). Across all studies and care delivery models, eligible studies primarily reported mortality and antiretroviral use, with specialty-based care associated with mortality reductions at the clinician and practice levels and with increased antiretroviral initiation or use at the clinician level but not the practice level. Limited and heterogeneous outcomes were reported for other patient-level HIV-specific outcomes (e.g., viral suppression) as well as for primary care health outcomes across all care delivery models. No studies addressed chronic care outcomes related to aging. Limited evidence was available across geographic settings and key populations. As re-design of care delivery in the US continues to evolve, better understanding of patient-level HIV-related and primary care health outcomes, especially across different staffing models and among different patient populations and geographic locations, is urgently needed to improve HIV disease management.

Structure and quality of outpatient care for people living with an HIV infection

Policy-makers and clinicians are faced with a gap of evidence to guide policy on standards for HIV outpatient care. Ongoing debates include which settings of care improve health outcomes, and how many HIV-infected patients a health-care provider should treat to gain and maintain expertise. In this article, we evaluate the studies that link health-care facility and care provider characteristics (i.e., structural factors) to health outcomes in HIV-infected patients. We searched the electronic databases MEDLINE, PUBMED, and EMBASE from inception until 1 January 2015. We included a total of 28 observational studies that were conducted after the introduction of combination antiretroviral therapy in 1996. Three aspects of the available research linking the structure to quality of HIV outpatient care were evaluated: (1) assessed structural characteristics (i.e., health-care facility and care provider characteristics); (2) measures of quality of HIV outpatient care; and (3) reported associations between structural characteristics and quality of care. Rather than scarcity of data, it is the diversity in methodology in the identified studies and the inconsistency of their results that led us to the conclusion that the scientific evidence is too weak to guide policy in HIV outpatient care. We provide recommendations on how to address this heterogeneity in future studies and offer specific suggestions for further reading that could be of interest for clinicians and researchers.

Developing a performance framework for measuring comprehensive, community-based primary healthcare for people with HIV

OBJECTIVES

People with human immunodeficiency virus (HIV) are living longer lives and like many other patients, need a health system better adapted for the management of complex chronic conditions. A key element of system transformation is measuring and reporting on system performance indicators relevant to the different stakeholders. Our objective was to produce a performance measurement framework for assessing the quality of comprehensive community-based primary healthcare for people with HIV.

METHODS

Semi-structured interviews were performed with HIV providers, advocates, and policy-makers to obtain input on a draft performance framework, constructed using existing HIV-specific indicators, as well as the use of performance data in improving care for people with HIV.

RESULTS

Stakeholders were overwhelmingly supportive of the framework's comprehensiveness. Many noted the absence of indicators addressing social determinants of health and had mixed opinions on the importance of indicators addressing access to after-hours care and the frequency of routine screening for behavioural risk factors. The draft framework was modified to reflect stakeholder input, triangulated against expert opinion and recently released HIV care guidelines, and finalized at 79 indicators. The resources and infrastructure to collect and use performance data will have to be improved for performance measurement to contribute to improving care for people with HIV.

CONCLUSIONS

This framework presents a comprehensive though not exhaustive tool to support performance measurement and improvement in the care for people with HIV. However, advances in data collection and use across the system will be needed to support performance measurement driving quality improvement.

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.

A population-based study evaluating family physicians' HIV experience and care of people living with HIV in Ontario

PURPOSE

Greater physician experience managing human immunodeficiency virus (HIV) infection has been associated with better HIV-specific outcomes. The objective of this study was to evaluate whether the HIV experience of a family physician modifies the association between the model of care delivery and the quality of care for people living with HIV.

METHODS

We retrospectively analyzed data from a population-based observational study conducted between April 1, 2009, and March 31, 2012. A total of 13,417 patients with HIV in Ontario were stratified into 5 possible patterns or models of care. We used multivariable hierarchical logistic regression analyses, adjusted for patient characteristics and pairwise comparisons, to evaluate the modification of the association between care model and indicators of quality of care (receipt of antiretroviral therapy, cancer screening, and health care use) by level of physician HIV experience (≤5, 6-49, ≥50 patients during study period).

RESULTS

The majority of HIV-positive patients (52.8%) saw family physicians exclusively for their care. Among these patients, receipt of antiretroviral therapy was significantly lower for those receiving care from family physicians with 5 or fewer patients and 6-49 patients compared with those with 50 or more patients (mean levels of adherence [95% CIs] were 0.34 [0.30-0.39] and 0.40 [0.34-0.45], respectively, vs 0.77 [0.74-0.80]). Patients' receipt of cancer screenings and health care use were unrelated to family physician HIV experience.

CONCLUSIONS

Family physician HIV experience was strongly associated with receipt of antiretroviral therapy by HIV-positive patients, especially among those seeing only family physicians for their care. Future work must determine the best models for integrating and delivering comprehensive HIV care among diverse populations and settings.

A population-based study comparing patterns of care delivery on the quality of care for persons living with HIV in Ontario

OBJECTIVES

Physician specialty is often positively associated with disease-specific outcomes and negatively associated with primary care outcomes for people with chronic conditions. People with HIV have increasing comorbidity arising from antiretroviral therapy (ART) related longevity, making HIV a useful condition to examine shared care models. We used a previously described, theoretically developed shared care framework to assess the impact of care delivery on the quality of care provided.

DESIGN

Retrospective population-based observational study from 1 April 2009 to 31 March 2012.

PARTICIPANTS

13 480 patients with HIV and receiving publicly funded healthcare in Ontario were assigned to one of five patterns of care.

OUTCOME MEASURES

Cancer screening, ART prescribing and healthcare utilisation across models using adjusted multivariable hierarchical logistic regression analyses.

RESULTS

Models in which patients had an assigned family physician had higher odds of cancer screening than those in exclusively specialist care (colorectal cancer screening, exclusively primary care adjusted OR (AOR)=3.12, 95% CI (1.90 to 5.13), family physician-dominant co-management AOR=3.39, 95% CI (1.94 to 5.93), specialist-dominant co-management AOR=2.01, 95% CI (1.23 to 3.26)). The odds of having one emergency department visit did not differ among models, although the odds of hospitalisation and HIV-specific hospitalisation were lower among patients who saw exclusively family physicians (AOR=0.23, 95% CI (0.14 to 0.35) and AOR=0.15, 95% CI (0.12 to 0.21)). The odds of antiretroviral prescriptions were lower among models in which patients' HIV care was provided predominantly by family physicians (exclusively primary care AOR=0.15, 95% CI (0.12 to 0.21), family physician-dominant co-management AOR=0.45, 95% CI (0.32 to 0.64)).

CONCLUSIONS

How care is provided had a potentially important influence on the quality of care delivered. Our key limitation is potential confounding due to the absence of HIV stage measures.

Comparison of HIV outcomes for patients linked at hospital versus community-based clinics

Outpatient care for people living with HIV is delivered in diverse settings. Differences in setting may impact HIV outcomes. We evaluated HIV-infected adults in care at Ryan White-funded clinics in Philadelphia, PA, between 2008 and 2011 to determine how setting of care (hospital versus community-based) influenced HIV outcomes. Clinics were categorized as hospital-based if they were located onsite at a hospital. The composite outcome was completion of the final three steps of the HIV care continuum: (1) retention in care; (2) use of antiretroviral therapy (ART); and (3) viral suppression. Mixed-effects logistic regression, accounting for patient and clinic factors, examined the relationship between care setting and the outcome. In total, 12,637 patients, contributing 32,515 patient-years, received care at 25 clinics (12 hospital-based). Women, non-Hispanic blacks, those with private insurance, and individuals with higher household incomes more commonly attended hospital-based clinics (p<0.05). Of the 12,962 patient-years (40%) during which patients attended community-based clinics, 59% met the outcome. Similarly, 59% of the 19,553 patient-years (60%) in which patients attended hospital-based clinics met the outcome. Adjusting for patient and clinic factors, setting was not associated with the outcome (adjusted odds ratio=1.24, 95% CI=0.84-1.84). In summary, demographics differ among patients visiting hospital and community-based clinics. Completion of the final three steps of the HIV care continuum did not vary between hospital and community-based clinics, which may reflect advances in HIV therapy and the wide availability of HIV care resources.

Comparable sustained virologic suppression between community- and academic-based HIV care settings

PURPOSE

The human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome epidemic in the United States is evolving because of factors such as aging and geographic diffusion. Provider shortages are also driving the restructuring of HIV care delivery away from specialized settings, and family medicine providers may play a larger role in the future. We attempted to compare the effectiveness of HIV treatment delivered at community versus hospital care settings.

METHODS

The outcome of interest was sustained virologic suppression defined as 2 consecutive HIV-1 RNA measurements ≤400 copies/mL within 1 year after antiretroviral initiation. We used data from the multistate HIV Research Network cohort to compare sustained virologic suppression outcomes among 15,047 HIV-infected adults followed from 2000 to 2008 at 5 community- and 8 academic hospital-based ambulatory care sites. Community-based sites were mostly staffed by family medicine and general internal medicine physicians with HIV expertise, whereas hospital sites were primarily staffed by infectious disease subspecialists. Multivariate mixed effects logistic regression controlling for potential confounding variables was applied to account for clustering effects of study sites.

RESULTS

In an unadjusted analysis the rate of sustained virologic suppression was significantly higher among subjects treated in community-based care settings: 1,646 of 2,314 (71.1%) versus 8,416 of 12,733 (66.1%) (P < .01). In the adjusted multivariate model with potential confounding variables, the rate was higher, although not statistically significant, in the community-based settings (adjusted odds ratio, 1.26; 95% confidence interval, 0.73-2.16).

CONCLUSION

Antiretroviral therapy can be delivered effectively through community-based treatment settings. This finding is potentially important for new program development, shifting HIV care into community-based settings as the landscape of accountable care, health reform, and HIV funding and resources evolves.

HIV-Infected Individuals Who Delay, Decline, or Discontinue Antiretroviral Therapy: Comparing Clinic- and Peer-Recruited Cohorts

A substantial proportion of persons living with HIV/AIDS (PLHA) delay, decline, or discontinue antiretroviral therapy (ART) when it is medically indicated (40–45%), largely African-Americans and Latinos/Hispanics. This study explores the feasibility of locating PLHA, who are not on ART (PLHA-NOA) through clinics and peer-referral; compares the two cohorts on multi-level barriers to ART; and examines readiness to initiate/reinitiate ART, a predictor of treatment outcomes. We recruited adult HIV-infected African-American and Latino/Hispanic PLHA-NOA through HIV hospital clinics and peer-referral in 2012–2013. Participants were engaged in structured 1-h assessments with reliable/valid measures on barriers to ART. We found that recruitment through peers (63.2%, 60/95) was more feasible than in clinics (36.8%, 35/90). Participants were 48.0 years old and had lived with HIV for 14.7 years on average, and 56.8% had taken ART previously. Most (61.1%) were male and African-American (76.8%), and 23.2% were Latino/Hispanic. Peer-recruited participants were older, had lived with HIV longer, were less engaged in HIV care, and were more likely to have taken ART previously. The cohorts differed in reasons for discontinuing ART. Levels of ART knowledge were comparable between cohorts (68.5% correct), and there were no differences in attitudes toward ART (e.g., mistrust), which were in the neutral range. In bivariate linear regression, readiness for ART was negatively associated with physician mistrust (B = −10.4) and positively associated with self-efficacy (B = 5.5), positive outcome expectancies (B = 6.3), beliefs about personal necessity of ART (B = 17.5), and positive internal norms (B = 7.9). This study demonstrates the feasibility of engaging this vulnerable population through peer-referral. Peer-recruited PLHA evidence particularly high rates of risk factors compared to those in hospital clinics. Interventions to support ART initiation and continuation are sorely needed for both subgroups.

Outcomes of antiretroviral treatment programmes in rural Lesotho: health centres and hospitals compared

Introduction

Lesotho was among the first countries to adopt decentralization of care from hospitals to nurse-led health centres (HCs) to scale up the provision of antiretroviral therapy (ART). We compared outcomes between patients who started ART at HCs and hospitals in two rural catchment areas in Lesotho.

Methods

The two catchment areas comprise two hospitals and 12 HCs. Patients ≥16 years starting ART at a hospital or HC between 2008 and 2011 were included. Loss to follow-up (LTFU) was defined as not returning to the facility for ≥180 days after the last visit, no follow-up (no FUP) as not returning after starting ART, and retention in care as alive and on ART at the facility. The data were analysed using logistic regression, competing risk regression and Kaplan-Meier methods. Multivariable analyses were adjusted for sex, age, CD4 cell count, World Health Organization stage, catchment area and type of ART. All analyses were stratified by gender.

Results

Of 3747 patients, 2042 (54.5%) started ART at HCs. Both women and men at hospitals had more advanced clinical and immunological stages of disease than those at HCs. Over 5445 patient-years, 420 died and 475 were LTFU. Kaplan-Meier estimates for three-year retention were 68.7 and 69.7% at HCs and hospitals, respectively, among women (p=0.81) and 68.8% at HCs versus 54.7% at hospitals among men (p<0.001). These findings persisted in adjusted analyses, with similar retention at HCs and hospitals among women (odds ratio (OR): 0.89, 95% confidence interval (CI): 0.73–1.09) and higher retention at HCs among men (OR: 1.53, 95% CI: 1.20–1.96). The latter result was mainly driven by a lower proportion of patients LTFU at HCs (OR: 0.68, 95% CI: 0.51–0.93).

Conclusions

In rural Lesotho, overall retention in care did not differ significantly between nurse-led HCs and hospitals. However, men seemed to benefit most from starting ART at HCs, as they were more likely to remain in care in these facilities compared to hospitals.

Decentralising HIV treatment in lower- and middle-income countries

BACKGROUND

Policy makers, health staff and communities recognise that health services in lower- and middle-income countries need to improve people's access to HIV treatment and retention to treatment programmes. One strategy is to move antiretroviral delivery from hospitals to more peripheral health facilities or even beyond health facilities. This could increase the number of people with access to care, improve health outcomes, and enhance retention in treatment programmes. On the other hand, providing care at less sophisticated levels in the health service or at community-level may decrease quality of care and result in worse health outcomes. To address these uncertainties, we summarised the research studies examining the risks and benefits of decentralising antiretroviral therapy service delivery.

OBJECTIVES

To assess the effects of various models that decentralised HIV treatment and care to more basic levels in the health system for initiating and maintaining antiretroviral therapy.

SEARCH METHODS

We conducted a comprehensive search to identify all relevant studies regardless of language or publication status (published, unpublished, in press, and in progress) from 1 January 1996 to 31 March 2013, and contacted relevant organisations and researchers. The search terms included 'decentralisation', 'down referral', 'delivery of health care', and 'health services accessibility'.

SELECTION CRITERIA

Our inclusion criteria were controlled trials (randomised and non-randomised), controlled-before and after studies, and cohorts (prospective and retrospective) in which HIV-infected people were either initiated on antiretroviral therapy or maintained on therapy in a decentralised setting in lower- and middle-income countries. We define decentralisation as providing treatment at a more basic level in the health system to the comparator.

DATA COLLECTION AND ANALYSIS

Two authors applied the inclusion criteria and extracted data independently. We designed a framework to describe different decentralisation strategies, and then grouped studies against these strategies. Data were pooled using random-effects meta-analysis. Because loss to follow up in HIV programmes is known to include some deaths, we used attrition as our primary outcome, defined as death plus loss to follow-up. We assessed evidence quality with GRADE methodology.

MAIN RESULTS

Sixteen studies met the inclusion criteria, all but one were from Africa, comprising two cluster randomised trials and 14 cohort studies. Antiretroviral therapy started at a hospital and maintained at a health centre (partial decentralisation) probably reduces attrition (RR 0.46, 95% CI 0.29 to 0.71, 4 studies, 39 090 patients, moderate quality evidence). There may be fewer patients lost to care with this model (RR 0.55, 95% CI 0.45 to 0.69, low quality evidence).We are uncertain whether there is a difference in attrition for antiretroviral therapy started and maintained at a health centre (full decentralisation) compared to a hospital at 12 months (RR 0.70, 95% CI 0.47 to 1.02; four studies, 56 360 patients, very low quality evidence), but there are probably fewer patients lost to care with this model (RR 0.3, 95% CI 0.17 to 0.54, moderate quality evidence).When antiretroviral maintenance therapy is delivered at home by trained volunteers, there is probably no difference in attrition at 12 months (RR 0.95, 95% CI 0.62 to 1.46, two trials, 1453 patients, moderate quality evidence).

AUTHORS' CONCLUSIONS

Decentralisation of HIV care aims to improve patient access and retention in care. Most data were from good quality cohort studies but confounding between site of treatment and outcomes cannot be excluded. Nevertheless, this review found that attrition appears to be lower in partial decentralisation models of treatment, where antiretrovirals were started at hospital and continued in the health centre; with antiretroviral drugs started and continued at health centres, no difference in attrition was detected, but there were fewer patients lost to care. For antiretroviral therapy provided at home by trained volunteers, no difference in outcomes were detected when compared to facility-based care.