Clinic-Level Factors Associated With Time to Antiretroviral Initiation and Viral Suppression in a Large, Urban Cohort

Examining the Association Between a Modified Quan-Charlson Comorbidity Index and HIV Viral Suppression: A Cross-Sectional Analysis of DC Cohort Participants

With the advancement of effective antiretroviral therapy, people with HIV live longer, and many are developing non-AIDS comorbidities. It is important to assess how comorbidities are associated with HIV-related health outcomes, such as viral suppression (VS). The aim of this study was to analyze the association between comorbidity burden, measured using a modified Quan-Charlson Comorbidity Index (QCCI), and VS (viral load result of <200 copies/mL). We hypothesized that an increase in QCCI score, indicating a higher risk for mortality, would correlate with lower likelihood of VS because of the burden of comorbidity treatment, possibly leading to worse antiretroviral adherence. Our analysis included participants from the DC Cohort Longitudinal HIV Study in Washington, DC. Eligible participants were aged ≥18 years and enrolled in the cohort as of January 1, 2018 (n = 2,471). A modified QCCI score, which weighs selected comorbidities (not including HIV/AIDS) and predicts mortality, was calculated using International Classification of Disease-9/10 codes from electronic health records. Multivariable logistic regressions were used to characterize the association between QCCI composite scores and VS. Participants were predominantly virally suppressed (89.6%), male (73.9%), non-Hispanic Black (74.7%), and between 18 and 55 years (59.3%). The median QCCI score was 1 (range = 1-12, interquartile range = 0-2), demonstrating predominately low mortality risk. We did not establish a statistically significant association between QCCI score and VS (adjusted odds ratio = 1.06, 95% confidence interval 0.96-1.17). Our findings suggest that a higher QCCI score was not associated with lower VS in this population, which may be partly due to the high retention in care among cohort participants.

Profile of the cohort of people being treated for HIV infection in the SUS, Brazil, 2015-2018

OBJECTIVE

To build an integrated database of individual and service data from the cohort of people who started antiretroviral therapy (ART), from 2015 to 2018, in Brazil.

METHODS

Open cohort study that includes people aged 15 years or older who started ART from 2015 to 2018, with follow-up in services of the Brazilian Unified Health System (SUS), and who responded to the 2016/2017 Qualiaids national survey. The source of individual data was the related HIV database, derived from the probabilistic linkage between data from the SUS systems of diagnostic information, medication, tests, and deaths. The data source for the services was the services' response database to the Qualiaids survey. After analysis of consistency and exclusions, the database of individuals was deterministically related to the database of services.

RESULTS

The cohort comprised 132,540 people monitored in 941 SUS services. Of these services, 59% are located in the Southeast region and 49% followed 51 to 500 cohort participants. The average performance of organization and management of patient care ranged from 29% to 75%. Most of the cohort participants are male, black and mixed, aged between 20 and 39 years old, and have between 4 and 11 years of schooling. Median baseline T-CD4 was 419 cells/mm3, 6% had an episode of tuberculosis, and 2% died of HIV disease.

CONCLUSION

For the first time in Brazil, this cohort provides the opportunity for a joint analysis of individual factors and services in the production of positive and negative clinical outcomes of HIV treatment.

Evaluation of the implementation and effectiveness of a mobile health intervention to improve outcomes for people with HIV in the DC Cohort: a study protocol for a cluster randomized controlled trial

Background

Gaps remain in achieving retention in care and durable HIV viral load suppression for people with HIV in Washington, DC (hereafter DC). Although people with HIV seeking care in DC have access to a range of supportive services, innovative strategies are needed to enhance patient engagement in this setting. Mobile health (mHealth) interventions have shown promise in reaching previously underengaged groups and improving HIV-related outcomes in various settings.

Objective

This study will evaluate the implementation and effectiveness of a clinic-deployed, multifeature mHealth intervention called PositiveLinks (PL) among people with HIV enrolled in the DC Cohort, a longitudinal cohort of people with HIV receiving care in DC. A cluster randomized controlled trial will be conducted using a hybrid effectiveness-implementation design and will compare HIV-related outcomes between clinics randomized to PL versus usual care.

Methods

The study aims are threefold: (1) We will perform a formative evaluation of PL in the context of DC Cohort clinics to test the feasibility, acceptability, and usability of PL and tailor the platform for use in this context. (2) We will conduct a cluster randomized controlled trial with 12 DC Cohort clinics randomized to PL or usual care (n=6 [50%] per arm) and measure the effectiveness of PL by the primary outcomes of patient visit constancy, retention in care, and HIV viral load suppression. We aim to enroll a total of 482 participants from DC Cohort clinic sites, specifically including people with HIV who show evidence of inconsistent retention in care or lack of viral suppression. (3) We will use the Consolidated Framework for Implementation Research (CFIR) and the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to measure implementation success and identify site, patient, provider, and system factors associated with successful implementation. Evaluation activities will occur pre-, mid-, and postimplementation.

Results

Formative data collection was completed between April 2021 and January 2022. Preliminary mHealth platform modifications have been performed, and the first round of user testing has been completed. A preimplementation evaluation was performed to identify relevant implementation outcomes and design a suite of instruments to guide data collection for evaluation of PL implementation throughout the trial period. Instruments include those already developed to support DC Cohort Study activities and PL implementation in other cohorts, which required modification for use in the study, as well as novel instruments designed to complete data collection, as guided by the CFIR and RE-AIM frameworks.

Conclusions

Formative and preimplementation evaluations will be completed in spring 2022 when the trial is planned to launch. Specifically, comprehensive formative data analysis will be completed following data collection, coding, preliminary review, and synthesis. Corresponding platform modifications are ready for beta testing within the DC Cohort. Finalization of the platform for use in the trial will follow beta testing.

Trial Registration

ClinicalTrials.gov NCT04998019; https://clinicaltrials.gov/ct2/show/NCT04998019

International Registered Report Identifier (IRRID)

PRR1-10.2196/37748

Factors Influencing Successful Recruitment of Racial and Ethnic Minority Patients for an Observational HIV Cohort Study in Washington, DC

The process of recruiting racial and ethnic minority persons living with HIV (PLWH) is important for research studies to ensure inclusivity of underrepresented groups. To understand factors associated with recruitment of minority PLWH, this study examined the recruitment process of PLWH for an observational study of their routine medical care at 14 clinics in Washington, DC. Research assistant (RA) recruiters were interviewed to assess their consenting processes and strategies. Data were collected on clinic services, patient demographics, and recruitment logs of patient approaches for obtaining informed consent resulting in agreement or refusal. A median of 96% of eligible patients was approached to obtain consent, yielding a median consent rate of 78% across all sites. A total of 8438 patients consented and 1326 refused study participation. Clinical sites with more comprehensive services had higher consent rates. black/African American and Hispanic/Latinx PLWH consented or refused study participation in similar proportions, while significantly more white patients enrolled than refused. More men, compared with women, enrolled than refused study participation. The most frequent reasons for refusing study participation were the lack of interest in research (33.2%) and no specific reason provided (28%). RAs identified that effective recruitment strategies used culturally sensitive approaches, built rapport with patients, and obtained provider support for the study. Recruitment strategies that are gender sensitive to address the disparity of underrepresentation of women, address perceived barriers, and examine clinic-specific services are needed to maximize research participation for minority PLWH to improve prevention and health outcomes.

Comparison of Clinical Outcomes of Persons Living With HIV by Enrollment Status in Washington, DC: Evaluation of a Large Longitudinal HIV Cohort Study

Background

HIV cohort studies have been used to assess health outcomes and inform the care and treatment of people living with HIV disease. However, there may be similarities and differences between cohort participants and the general population from which they are drawn.

Objective

The objective of this analysis was to compare people living with HIV who have and have not been enrolled in the DC Cohort study and assess whether participants are a representative citywide sample of people living with HIV in the District of Columbia (DC).

Methods

Data from the DC Health (DCDOH) HIV surveillance system and the DC Cohort study were matched to identify people living with HIV who were DC residents and had consented for the study by the end of 2016. Analysis was performed to identify differences between DC Cohort and noncohort participants by demographics and comorbid conditions. HIV disease stage, receipt of care, and viral suppression were evaluated. Adjusted logistic regression assessed correlates of health outcomes between the two groups.

Results

There were 12,964 known people living with HIV in DC at the end of 2016, of which 40.1% were DC Cohort participants. Compared with nonparticipants, participants were less likely to be male (68.0% vs 74.9%, P<.001) but more likely to be black (82.3% vs 69.5%, P<.001) and have a heterosexual contact HIV transmission risk (30.3% vs 25.9%, P<.001). DC Cohort participants were also more likely to have ever been diagnosed with stage 3 HIV disease (59.6% vs 47.0%, P<.001), have a CD4 <200 cells/µL in 2017 (6.2% vs 4.6%, P<.001), be retained in any HIV care in 2017 (72.9% vs 59.4%, P<.001), and be virally suppressed in 2017. After adjusting for demographics, DC Cohort participants were significantly more likely to have received care in 2017 (adjusted odds ratio 1.8, 95% CI 1.70-2.00) and to have ever been virally suppressed (adjusted odds ratio 1.3, 95% CI 1.20-1.40).

Conclusions

These data have important implications when assessing the representativeness of patients enrolled in clinic-based cohorts compared with the DC-area general HIV population. As participants continue to enroll in the DC Cohort study, ongoing assessment of representativeness will be required.