1
|
Ameyaw EK, Nutor JJ, Okiring J, Yeboah I, Agbadi P, Getahun M, Agbadi W, Thompson RGA. The role of social support in antiretroviral therapy uptake and retention among pregnant and postpartum women living with HIV in the Greater Accra region of Ghana. BMC Public Health 2024; 24:540. [PMID: 38383341 PMCID: PMC10882784 DOI: 10.1186/s12889-024-18004-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 02/06/2024] [Indexed: 02/23/2024] Open
Abstract
INTRODUCTION The role of social support in antiretroviral therapy (ART) uptake and retention among pregnant and postpartum women in Ghana's capital, Accra, has received limited attention in the literature. This cross-sectional study extends existing knowledge by investigating the role of social support in ART adherence and retention among pregnant and postpartum women in Accra. METHODS We implemented a cross-sectional study in eleven (11) public health facilities. Convenience sampling approach was used to recruit 180 participants, out of which 176 with completed data were included in the study. ART adherence in the three months preceding the survey (termed consistent uptake), and ART retention were the outcomes of interest. Initial analysis included descriptive statistics characterized by frequencies and percentages to describe the study population. In model building, we included all variables that had p-values of 0.2 or lesser in the bivariate analysis to minimize negative confounding. Overall, a two-sided p-value of < 0.05 was considered statistically significant. Data were analyzed using Stata version 14.1 (College Station, TX). RESULTS In the multivariate model, we realized a lower odds trend between social support score and consistent ART adherence, however, this was insignificant. Similarly, both the univariate and multivariate models showed that social support has no relationship with ART retention. Meanwhile, urban residents had a higher prevalence of ART adherence (adjusted Prevalence ratio (aPR) = 2.04, CI = 1.12-3.73) relative to rural/peri-urban residents. As compared to those below age 30, women aged 30-34 (aPR = 0.58, CI = 0.34-0.98) and above 35 (aPR = 0.48, CI = 0.31-0.72) had lower prevalence of ART adherence Women who knew their partner's HIV status had lower prevalence of ART adherence compared to those who did not know (aPR = 0.62, CI = 0.43-0.91). Also, having a rival or co-wife was significantly associated with ART retention such that higher prevalence of ART adherence among women with rivals relative to those without rivals (aOR = 1.98, CI = 1.16-3.36). CONCLUSION Our study showed that social support does not play any essential role in ART adherence among the surveyed pregnant and postpartum women. Meanwhile, factors such as having a rival and being under the age of thirty play an instrumental role. The study has signaled the need for ART retention scale-up interventions to have a multi-pronged approach in order to identify the multitude of underlying factors, beyond social support, that enhance/impede efforts to achieve higher uptake and retention rates.
Collapse
Affiliation(s)
- Edward Kwabena Ameyaw
- Institute of Policy Studies and School of Graduate Studies, Lingnan University, Hong Kong, China
- Africa Interdisciplinary Research Institute, Accra, Ghana
- L & E Research Consult Ltd, Wa, Upper West Region, Ghana
| | - Jerry John Nutor
- Department of Family Health Care Nursing, School of Nursing, University of California San Francisco, San Francisco, CA, USA.
| | - Jaffer Okiring
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Isaac Yeboah
- Africa Interdisciplinary Research Institute, Accra, Ghana
- Institute of Work Employment and Society, University of Professional Studies, Accra, Ghana
| | - Pascal Agbadi
- Africa Interdisciplinary Research Institute, Accra, Ghana
- Department of Sociology and Social Science Policy, Lingnan University, Hong Kong, China
| | - Monica Getahun
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Wisdom Agbadi
- Africa Interdisciplinary Research Institute, Accra, Ghana
- Push Aid Africa, Accra, Ghana
| | - Rachel G A Thompson
- Africa Interdisciplinary Research Institute, Accra, Ghana
- Language Center, College of Humanities, University of Ghana, Accra, Ghana
| |
Collapse
|
2
|
Izquierdo R, Rava M, Moreno-García E, Blanco JR, Asensi V, Cervero M, Curran A, Rubio R, Iribarren JA, Jarrín I. HIV medical care interruption among people living with HIV in Spain, 2004-2020. AIDS 2023; 37:1277-1284. [PMID: 36939068 DOI: 10.1097/qad.0000000000003552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
OBJECTIVE We estimated the incidence rate of HIV medical care interruption (MCI) and its evolution over a 16-year-period, and identified associated risk factors among HIV-positive individuals from the Cohort of the Spanish AIDS Research Network in 2004-2020. DESIGN We included antiretroviral-naive individuals aged at least 18 years at enrolment, recruited between January 1, 2004, and August 30, 2019, and followed-up until November 30, 2020. METHODS Individuals with any time interval of at least 15 months between two visits were defined as having a MCI. We calculated the incidence rate (IR) of having at least one MCI and used multivariable Poisson regression models to identify associated risk factors. RESULTS Of 15 274 individuals, 5481 (35.9%) had at least one MCI. Of those, 2536 (46.3%) returned to HIV care after MCI and 3753 (68.5%) were lost to follow-up at the end of the study period. The incidence rate (IR) of MCI was 7.2/100 person-years (py) [95% confidence interval (CI): 7.0-7.4]. The annual IR gradually decreased from 20.5/100 py (95% CI: 16.4-25.6) in 2004 to 4.9/100 py (95% CI: 4.4-5.5) in 2014, a slight increase was observed between 2015 and 2018, reaching 9.3/100 py (95% CI: 8.6-10.2) in 2019. Risk factors for MCI included younger age, lower educational level, having contracted HIV infection through injecting drug use or heterosexual intercourse, having been born outside of Spain, and CD4 + cell count >200 cell/μl, viral load <100 000 and co-infection with hepatitis C virus at enrolment. CONCLUSIONS Around a third of individuals had at least one MCI during the follow-up. Identified predictors of MCI can help health workers to target and support most vulnerable individuals.
Collapse
Affiliation(s)
- Rebeca Izquierdo
- National Center for Epidemiology, Instituto de Salud Carlos III
- Centre of Biomedical Research for Infectious Diseases (CIBERINFEC), Madrid
| | - Marta Rava
- National Center for Epidemiology, Instituto de Salud Carlos III
- Centre of Biomedical Research for Infectious Diseases (CIBERINFEC), Madrid
| | | | | | - Víctor Asensi
- Infectious Diseases - HIV Unit, Internal Medicine, Hospital Universitario Central de Asturias, Oviedo University School of Medicine, Translational Research in Infective Pathology Lab, ISPA-FINBA
| | - Miguel Cervero
- Internal Medicine Department, Hospital Universitario Severo Ochoa, Leganés
| | - Adrian Curran
- Infectious Diseases Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona
| | - Rafael Rubio
- HIV Unit, Internal Medicine Department, Biomedical Research Institute Imas12, Hospital Universitario 12 de Octubre. Medicine Department. Universidad Complutense de Madrid, Madrid
| | - José Antonio Iribarren
- Department of Infectious Diseases, Donostia University Hospital, IIS Biodonostia, San Sebastián, Spain
| | - Inmaculada Jarrín
- National Center for Epidemiology, Instituto de Salud Carlos III
- Centre of Biomedical Research for Infectious Diseases (CIBERINFEC), Madrid
| |
Collapse
|
3
|
Wada PY, Kim A, Jayathilake K, Duda SN, Abo Y, Althoff KN, Cornell M, Musick B, Brown S, Sohn AH, Chan YJ, Wools-Kaloustian KK, Nash D, Yiannoutsos CT, Cesar C, McGowan CC, Rebeiro PF. Site-Level Comprehensiveness of Care Is Associated with Individual Clinical Retention Among Adults Living with HIV in International Epidemiology Databases to Evaluate AIDS, a Global HIV Cohort Collaboration, 2000-2016. AIDS Patient Care STDS 2022; 36:343-355. [PMID: 36037010 PMCID: PMC9514598 DOI: 10.1089/apc.2022.0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Retention in care (RIC) reduces HIV transmission and associated morbidity and mortality. We examined whether delivery of comprehensive services influenced individual RIC within the International epidemiology Databases to Evaluate AIDS (IeDEA) network. We collected site data through IeDEA assessments 1.0 (2000-2009) and 2.0 (2010-2016). Each site received a comprehensiveness score for service availability (1 = present, 0 = absent), with tallies ranging from 0 to 7. We obtained individual-level cohort data for adults with at least one visit from 2000 to 2016 at sites responding to either assessment. Person-time was recorded annually, with RIC defined as completing two visits at least 90 days apart in each calendar year. Multivariable modified Poisson regression clustered by site yielded risk ratios and predicted probabilities for individual RIC by comprehensiveness. Among 347,060 individuals in care at 122 sites with 1,619,558 person-years of follow-up, 69.8% of person-time was retained in care, varying by region from 53.8% (Asia-Pacific) to 82.7% (East Africa); RIC improved by about 2% per year from 2000 to 2016 (p = 0.012). Every site provided CD4+ count testing, and >90% of individuals received care at sites that provided combination antiretroviral therapy adherence measures, prevention of mother-to-child transmission, tuberculosis screening, HIV-related prevention, and community tracing services. In adjusted models, individuals at sites with more comprehensive services had higher probabilities of RIC (0.71, 0.74, and 0.83 for scores 5, 6, and 7, respectively; p = 0.019). Within IeDEA, greater site-level comprehensiveness of services was associated with improved individual RIC. Much work remains in exploring this relationship, which may inform HIV clinical practice and health systems planning.
Collapse
Affiliation(s)
- Paul Y. Wada
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ahra Kim
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Karu Jayathilake
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Stephany N. Duda
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Yao Abo
- Centre Médical de Suivi des Donneurs de Sang (CMSDS), Centre National de Transfusion Sanguine, Abidjan, Côte d'Ivoire
| | - Keri N. Althoff
- Division of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Morna Cornell
- Center for Infectious Disease Epidemiology & Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Beverly Musick
- Division of Biostatistics and Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Steve Brown
- Division of Biostatistics and Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Annette H. Sohn
- Division of Pediatrics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Yu Jiun Chan
- Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kara K. Wools-Kaloustian
- Division of Biostatistics and Infectious Diseases, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Denis Nash
- Division of Epidemiology and Biostatistics, City University of New York, Institute for Implementation Science in Population Health, New York, New York, USA
| | - Constantin T. Yiannoutsos
- Division of Biostatistics, Indiana University Fairbanks School of Public Health, Indianapolis, Indiana, USA
| | | | - Catherine C. McGowan
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Peter F. Rebeiro
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| |
Collapse
|
4
|
Ingram MV, Amodei N, Perez VV, German V. Factors predicting 12-month retention in care for minority women living with HIV. Ther Adv Infect Dis 2022; 9:20499361221089815. [PMID: 35450384 PMCID: PMC9016542 DOI: 10.1177/20499361221089815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 03/08/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives: Retention in HIV medical care is associated with improved clinical outcomes
and reduced mortality. The present study was conducted to identify
significant predictors of 1-year retention in care for a sample of minority
women whose engagement in HIV care at baseline varied along the care
continuum from newly diagnosed to lost-to-care. Methods: One hundred sixty-five cisgender and transgender women living with HIV in a
southern US state were offered a multicomponent retention intervention that
included outreach, medical case management (MCM), patient navigation
services (PN), and a group intervention for stigma. Multilevel logistic
regression analysis was performed to identify baseline and intervention
predictors of retention in care at 12 months following enrollment. Results: Multilevel logistic regression analysis revealed that baseline
characteristics such as working significantly reduced the odds of being
retained as did increasing CD4 counts. However, greater amounts of patient
navigation and medical case management services received increased the odds
of being retained. Conclusion: MCM services designed to accelerate coordination and linkage or re-linkage to
primary care and PN services to help navigate the complex system of HIV
offered in the present study are particularly effective for minority women
who lack health insurance, have low CD4 counts, and are unemployed.
Collapse
Affiliation(s)
- Mercedes V. Ingram
- Community Initiatives and Population Health, University Health System, 4502 Medical Dr., MS 82-2, San Antonio, TX 78229, USA
| | - Nancy Amodei
- Community Initiatives and Population Health, University Health System, San Antonio, TX, USA
| | - Veronica Villela Perez
- Community Initiatives and Population Health, University Health System, San Antonio, TX, USA
| | - Victor German
- Community Initiatives and Population Health, University Health System, San Antonio, TX, USA
| |
Collapse
|
5
|
Kay ES, Edmonds A, Ludema C, Adimora A, Alcaide ML, Chandran A, Cohen MH, Johnson MO, Kassaye S, Kempf MC, Moran CA, Sosanya O, Wilson TE. Health insurance and AIDS Drug Assistance Program (ADAP) increases retention in care among women living with HIV in the United States. AIDS Care 2021; 33:1044-1051. [PMID: 33233937 PMCID: PMC8144231 DOI: 10.1080/09540121.2020.1849529] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 11/02/2020] [Indexed: 10/22/2022]
Abstract
Our objective was to examine the association between healthcare payer type and missed HIV care visits among 1,366 US women living with HIV (WLWH) enrolled in the prospective Women's Interagency HIV Study (WIHS). We collected secondary patient-level data (October 1, 2017-September 30, 2018) from WLWH at nine WIHS sites. We used bivariate and multivariable binary logistic regression to examine the relationship between healthcare payer type (cross-classification of patients' ADAP and health insurance enrollment) and missed visits-based retention in care, defined as no-show appointments for which patients did not reschedule. Our sample included all WLWH who self-reported having received HIV care at least once during the two consecutive biannual WIHS visits a year prior to October 1, 2017-September 30, 2018. In the bivariate model, compared to uninsured WLWH without ADAP, WLWH with private insurance + ADAP were more likely to be retained in care, as were WLWH with Medicaid only and private insurance only. In the adjusted model, WLWH with private insurance only were more likely to be retained in care compared to uninsured WLWH without ADAP. Private health insurance and ADAP are associated with increased odds of retention in care among WLWH.
Collapse
Affiliation(s)
- Emma Sophia Kay
- Department of Social Work, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew Edmonds
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christina Ludema
- School of Public Health, Indiana University Bloomington, Bloomington, IN, USA
| | - Adaora Adimora
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Aruna Chandran
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mardge H. Cohen
- Department of Medicine Rush University and Stroger Hospital, Chicago, IL, USA
| | - Mallory O. Johnson
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Seble Kassaye
- Department of Medicine, Georgetown University, Washington, D.C., USA
| | - Mirjam-Colette Kempf
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Tracey E. Wilson
- Department of Community Health Sciences, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| |
Collapse
|
6
|
Mody A, Tram KH, Glidden DV, Eshun-Wilson I, Sikombe K, Mehrotra M, Pry JM, Geng EH. Novel Longitudinal Methods for Assessing Retention in Care: a Synthetic Review. Curr HIV/AIDS Rep 2021; 18:299-308. [PMID: 33948789 DOI: 10.1007/s11904-021-00561-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Retention in care is both dynamic and longitudinal in nature, but current approaches to retention often reduce these complex histories into cross-sectional metrics that obscure the nuanced experiences of patients receiving HIV care. In this review, we discuss contemporary approaches to assessing retention in care that captures its dynamic nature and the methodological and data considerations to do so. RECENT FINDINGS Enhancing retention measurements either through patient tracing or "big data" approaches (including probabilistic matching) to link databases from different sources can be used to assess longitudinal retention from the perspective of the patient when they transition in and out of care and access care at different facilities. Novel longitudinal analytic approaches such as multi-state and group-based trajectory analyses are designed specifically for assessing metrics that can change over time such as retention in care. Multi-state analyses capture the transitions individuals make in between different retention states over time and provide a comprehensive depiction of longitudinal population-level outcomes. Group-based trajectory analyses can identify patient subgroups that follow distinctive retention trajectories over time and highlight the heterogeneity of retention patterns across the population. Emerging approaches to longitudinally measure retention in care provide nuanced assessments that reveal unique insights into different care gaps at different time points over an individuals' treatment. These methods help meet the needs of the current scientific agenda for retention and reveal important opportunities for developing more tailored interventions that target the varied care challenges patients may face over the course of lifelong treatment.
Collapse
Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA.
| | - Khai Hoan Tram
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Ingrid Eshun-Wilson
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
| | - Kombatende Sikombe
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
- Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Megha Mehrotra
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Jake M Pry
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
- Centre for Infectious Diseases Research in Zambia, Lusaka, Zambia
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, Missouri, 63110, USA
| |
Collapse
|
7
|
Ferreyra C, Moretó-Planas L, Wagbo Temessadouno F, Alonso B, Tut B, Achut V, Eltom M, Aderie EM, Descalzo-Jorro V. Evaluation of a community-based HIV test and start program in a conflict affected rural area of Yambio County, South Sudan. PLoS One 2021; 16:e0254331. [PMID: 34252129 PMCID: PMC8274874 DOI: 10.1371/journal.pone.0254331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/24/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) coverage in South Sudan is around 10%. Access to HIV care in settings with low ART coverage or conflict affected is still low; innovative strategies are needed to increase access and ensure continuation of ART during instability. A pilot HIV test and start project was implemented in a conflict-affected area of South Sudan. In a retrospective analysis, we determined the feasibility and outcomes of this intervention. METHODS Programme data from July 2015 to June 2018 was analysed. The project involved five mobile teams offering HIV counselling and testing (HCT) and same day ART initiation at community level. Baseline and follow-up information on clinical, immunological and viral load (VL) was routinely recorded, as well as treatment outcomes. A semi-qualitative study was conducted to assess acceptability of the program among beneficiaries and community members. RESULTS By June 2018, 14824 people received counselling and testing for HIV and 498 (3.4%) tested positive. Out of those 395 (79.3%) started ART. A total of 72 ART patients were organized in 26 Community ART Groups (CAGs) and contingency plan was activated 9 times for 101 patients. Kaplan-Meier estimated retention in care (RIC) at 12 and 18 months was 80.6% [95% CI: 75.9-84.5%] and 69.9% [95% CI: 64.4-74.8%] respectively. RIC was significantly higher at 18 months in patients under community ART groups (CAGs) (90.9% versus 63.4% p<0.001) when compared to patients on regular follow up. VL suppression at 12 months was 90.3% and overall virological suppression reached 91.2%. A total of 279 persons were interviewed about the MSF program perception and acceptance: 98% had heard about the programme and 84% found it beneficial for the community, 98% accepted to be tested and only 4% found disadvantages to the programme. CONCLUSIONS Our study shows that HCT and early ART initiation in conflict affected populations can be provided with good program outcomes. RIC and virological suppression are comparable with facility-based HIV programs and to those in stable contexts. This model could be extrapolated to other similar contexts with low access to ART and where security situation is a concern.
Collapse
Affiliation(s)
| | | | | | | | - Buai Tut
- Médecins sans Frontières, Juba, South Sudan
| | - Victoria Achut
- Ministry of Health, Republic of South Sudan, HIV/AIDS/STI, Juba, South Sudan
| | | | | | | |
Collapse
|
8
|
Abstract
Retention is a central component of the Cascade, facilitating monitoring of comorbidity. Country-specific definitions differ and may suit stable and functioning clients, while not appropriately classifying complex clinical presentations characterized by comorbidity. A retrospective file review of 363 people living with HIV attending a Sydney HIV clinic was conducted. Retention was compared with Australian (attendance once/12-months) and World Health Organization (attendance 'appropriate to need') recommendations to identify those attending according to the Australian definition, but not clinician recommendations (AUnotWHO). Multivariable logistic regression analyses determined the impact of age/sex and clinician-assessed comorbidity on retention. Most (97%) participants were considered retained according to the Australian definition, but only 56.7% according to clinician recommendations. Those with psychosocial comorbidity alone were less likely to be in the AUnotWHO group (OR 0.51, 95%CI 0.27-0.96, p = 0.04). The interaction of physical and psychosocial comorbidity was predictive of poor retention (Wald test: χ2 = 6.39, OR 2.39 [95% CI 1.15-4.97], p = 0.01), suggesting a syndemic relationship.
Collapse
|
9
|
Judd RT, Friedman EE, Schmitt J, Ridgway JP. Association between patient-reported barriers and HIV clinic appointment attendance: A prospective cohort study. AIDS Care 2021; 34:545-553. [PMID: 33779423 PMCID: PMC8476655 DOI: 10.1080/09540121.2021.1906401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The association between patients' confidence in their ability to attend appointments and future retention in care has not previously been studied in a general HIV clinic. A survey of potential and known risk factors for poor retention was developed using validated screening tools and administered to 105 patients at an HIV clinic. Retention in care was assessed prospectively using two definitions: (1) two appointments at least three months apart within one year ("HRSA/HAB retention") and (2) no missed appointments within one year ("missed visits retention"). Most patients were African American (86%) and male (59%). Although most patients were confident they could keep their HIV appointments (89%), fewer were retained (HRSA/HAB: 73%; missed visits: 56%). Patients' confidence in their ability to keep future appointments was not associated with retention. Employment was associated with lower odds of HRSA/HAB retention (aOR 0.26 [95% CI 0.09-0.77]), and childcare was a common barrier that was associated with lower odds of missed visits retention (aOR 0.06 [95% CI 0.006-0.62]). Other known risk factors for poor retention were inconsistently associated with retention in care.
Collapse
Affiliation(s)
- Ryan T Judd
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Jessica Schmitt
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | |
Collapse
|
10
|
Whisler A, Dosani N, To MJ, O’Brien K, Young S, Hwang SW. The effect of a Housing First intervention on primary care retention among homeless individuals with mental illness. PLoS One 2021; 16:e0246859. [PMID: 33571302 PMCID: PMC7877594 DOI: 10.1371/journal.pone.0246859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 01/27/2021] [Indexed: 11/22/2022] Open
Abstract
Background Primary care retention, defined as ongoing periodic contact with a consistent primary care provider, is beneficial for people with serious chronic illnesses. This study examined the effect of a Housing First intervention on primary care retention among homeless individuals with mental illness. Methods Two hundred individuals enrolled in the Toronto site of the At Home Project and randomized to Housing First or Treatment As Usual were studied. Medical records were reviewed to determine if participants were retained in primary care, defined as having at least one visit with the same primary care provider in each of two consecutive six-month periods during the 12 month period preceding and following randomization. Results Medical records were obtained for 47 individuals randomized to Housing First and 40 individuals randomized to Treatment As Usual. During the one year period following randomization, the proportion of Housing First and Treatment As Usual participants retained in primary care was not significantly different (38.3% vs. 47.5%, p = 0.39). The change in primary care retention rates from the year preceding randomization to the year following randomization was +10.6% in the Housing First group and -5.0% in the Treatment As Usual group. Conclusion Among homeless individuals with mental illness, Housing First did not significantly affect primary care retention over the follow-up period. These findings suggest Housing First interventions may need to place greater emphasis on connecting clients with primary care providers.
Collapse
Affiliation(s)
- Adam Whisler
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Naheed Dosani
- Inner City Health Associates, Toronto, Ontario, Canada
- Department of Family & Community Medicine, St Michael’s Hospital, Toronto, Ontario, Canada
- Division of Palliative Care, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Division of Palliative Care, William Osler Health System, Brampton, Ontario, Canada
- * E-mail:
| | - Matthew J. To
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Kristen O’Brien
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Samantha Young
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Stephen W. Hwang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
11
|
Monroe AK, Happ LP, Rayeed N, Ma Y, Jaurretche MJ, Terzian AS, Trac K, Horberg MA, Greenberg AE, Castel AD. Clinic-Level Factors Associated With Time to Antiretroviral Initiation and Viral Suppression in a Large, Urban Cohort. Clin Infect Dis 2020; 71:e151-e158. [PMID: 31701144 PMCID: PMC7583410 DOI: 10.1093/cid/ciz1098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/06/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Using the results of a site assessment survey performed at clinics throughout Washington, DC, we studied the impact of clinic-level factors on antiretroviral therapy (ART) initiation and viral suppression (VS) among people living with human immunodeficiency virus (HIV; PLWH). METHODS This was a retrospective analysis from the District of Columbia (DC) Cohort, an observational, clinical cohort of PLWH from 2011-2018. We included data from PLWH not on ART and not virally suppressed at enrollment. Outcomes were ART initiation and VS (HIV RNA < 200 copies/mL). A clinic survey captured information on care delivery (eg, clinical services, adherence services, patient monitoring services) and clinic characteristics (eg, types of providers, availability of evenings/weekends sessions). Multivariate marginal Cox regression models were generated to identify those factors associated with the time to ART initiation and VS. RESULTS Multiple clinic-level factors were associated with ART initiation, including retention in care monitoring and medication dispensing reviews (adjusted hazard ratios [aHRs], 1.34 to 1.40; P values < .05 for both). Furthermore, multiple factors were associated with VS, including retention in HIV care monitoring, medication dispensing reviews, and the presence of a peer interventionist (aHRs, 1.35 to 1.72; P values < .05 for all). In multivariable models evaluating different combinations of clinic-level factors, enhanced adherence services (aHR, 1.37; 95% confidence interval [CI], 1.18-1.58), medication dispensing reviews (aHR, 1.22; 95% CI, 1.10-1.36), and the availability of opioid treatment (aHR, 1.26; 95% CI, 1.01-1.57) were all associated with the time to VS. CONCLUSIONS The observed association between clinic-level factors and ART initiation/VS suggests that the presence of specific clinic services may facilitate the achievement of HIV treatment goals.
Collapse
Affiliation(s)
- Anne K Monroe
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Lindsey P Happ
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | | | - Yan Ma
- Department of Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Maria J Jaurretche
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Arpi S Terzian
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Kevin Trac
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland, USA
| | - Alan E Greenberg
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Amanda D Castel
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| |
Collapse
|
12
|
A Quality Improvement Project to Increase Patient Portal Enrollment and Utilization in Women Living With HIV at Risk for Disengagement in Care. J Assoc Nurses AIDS Care 2020; 31:60-65. [PMID: 31834101 DOI: 10.1097/jnc.0000000000000153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Women living with HIV are less likely to be retained and engaged in consistent care than their male counterparts. The purpose of this quality improvement project was to increase the enrollment and utilization rate of a patient portal, an mHealth technology, by women living with HIV at risk of disengagement in care to improve their overall engagement and retention in care. At-risk women were identified, educated on, and enrolled in a patient portal system during routine clinic appointments. Engagement was measured using portal utilization rates and patient-initiated communication and analyzed using descriptive statistics. Paired 2-tailed Student t-tests were used to evaluate changes in adherence rates, viral loads, and CD4 T-cell counts from 90-day pre-enrollment to 90-day post-enrollment. Overall results indicate improved utilization and engagement through the use of a patient portal system are feasible in this population and promote engagement and retention in care.
Collapse
|
13
|
Alexander CS, Raveis VH, Karus D, Carrero-Tagle M, Lee MC, Pappas G, Lockman K, Brotemarkle R, Memiah P, Mulasi I, Hossain BM, Welsh C, Henley Y, Piet L, N'Diaye S, Murray R, Haltiwanger D, Smith CR, Flynn C, Redfield R, Silva CL, Amoroso A, Selwyn P. Early Use of the Palliative Approach to Improve Patient Outcomes in HIV Disease: Insights and Findings From the Care and Support Access (CASA) Study 2013-2019. Am J Hosp Palliat Care 2020; 38:332-339. [PMID: 32851870 DOI: 10.1177/1049909120951129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Young men of color who have sex with men (yMSM) living with human immunodeficiency virus (HIV) in syndemic environments have been difficult-to-retain in care resulting in their being at-risk for poor health outcomes despite availability of effective once-daily antiretroviral treatment (ART). Multiple methods have been implemented to improve outcomes for this cohort; none with sustainable results. Outpatient HIV staff themselves may be a contributing factor. We introduced multidisciplinary staff to the concept of using a palliative approach early (ePA) in outpatient HIV care management to enable them to consider the patient-level complexity of these young men. Young MSM (18-35 years of age) enrolled in and cared for at the intervention site of the Care and Support Access Study (CASA), completed serial surveys over 18 months. Patients' Global and Summary quality of life (QoL) increased during the study at the intervention site (IS) where staff learned about ePA, compared with patients attending the control site (CS) (p=.021 and p=.018, respectively). Using serial surveys of staff members, we found that in the era of HIV disease control, outpatient staff are stressed more by environmental factors than by patients' disease status seen historically in the HIV epidemic. A Community Advisory Panel of HIV stakeholders contributed to all phases of this study and altered language used in educational activities with staff members to describe the patient cohort.
Collapse
Affiliation(s)
- Carla S Alexander
- Institute of Human Virology, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Victoria H Raveis
- Psychosocial Research Unit on Health, Aging and Community, 70241New York University, New York, NY, USA
| | - Daniel Karus
- Psychosocial Research Unit on Health, Aging and Community, 70241New York University, New York, NY, USA
| | - Monique Carrero-Tagle
- Psychosocial Research Unit on Health, Aging and Community, 70241New York University, New York, NY, USA
| | - Mei Ching Lee
- 12265University of Maryland School of Nursing, Baltimore, MD, USA
| | | | | | | | - Peter Memiah
- Institute of Human Virology, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ila Mulasi
- Institute of Human Virology, 12264University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Christopher Welsh
- Department of Psychiatry, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Leslie Piet
- Johns Hopkins Home Health, Baltimore, MD, USA
| | | | - Renard Murray
- Institute of Human Virology, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - Colin Flynn
- Maryland Department of Health and Human Services Prevention, Baltimore, MD, USA
| | | | - Caroline L Silva
- Institute of Human Virology, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anthony Amoroso
- Institute of Human Virology, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | | |
Collapse
|
14
|
Krentz HB, McPhee P, Arbess G, Jackson L, Stewart AM, Bois D, Rourke SB. Reporting on patients living with HIV "disengaging from care". Who is actually "lost to follow-up"? AIDS Care 2020; 33:114-120. [PMID: 32408758 DOI: 10.1080/09540121.2020.1761516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Retention in care remains an important concern for health care providers. However, accurately identifying who is or is not retained in care can be problematic. Not all patients believed to be engaged in care are actually in care, and not all patients believed to be disengaged are truly disengaged. Identifying the status of individuals within populations is important for clinical, administrative and surveillance concerns. As part of the Linkage and Retention in Care Project at St Michael's Hospital in Toronto, Canada, we investigated the status of patients diagnosed with HIV. Detailed investigation determined who was actually Lost-to-Follow-Up (i.e., disengaged from care >12 months) and who had disengaged for known reasons. This approach determined more precisely who was currently followed in care and who was not, and to target efforts to contact and reengage patients more effectively. This study illustrates the importance of accurately monitoring populations enhancing disease management.
Collapse
Affiliation(s)
- Hartmut B Krentz
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Canada
| | - Paul McPhee
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Canada
| | - Gordon Arbess
- Department of Family & Community Medicine, St Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Linda Jackson
- Primary and Community Care, Unity Health Toronto, Toronto, Canada
| | - Ann M Stewart
- Department of Medicine, University of Toronto, Toronto, Canada.,St Michael's Hospital, Toronto, Canada
| | | | - Sean B Rourke
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, Canada
| |
Collapse
|
15
|
Sayegh CS, Wood SM, Belzer M, Dowshen NL. Comparing Different Measures of Retention in Care Among a Cohort of Adolescents and Young Adults Living with Behaviorally-Acquired HIV. AIDS Behav 2020; 24:304-310. [PMID: 31429029 PMCID: PMC6954955 DOI: 10.1007/s10461-019-02568-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Young people living with HIV (YLWH) have some of the lowest rates of retention in HIV care, putting them at risk for negative health outcomes. To better understand retention in care in this age group, we conducted a retrospective cohort analysis of YLWH initiating care at a multidisciplinary, adolescent-focused HIV clinic (N = 344). Retention was calculated using a variety of definitions, and relationships between different definitions were assessed. During the 1-year study period, on average YLWH missed two scheduled appointments, and attended 80% of appointments, usually at least once every 3 months. About one-quarter experienced a 6-month gap in care and about two-thirds met the Health Resources and Services Administration's retention criteria. Although most retention definitions were significantly correlated, not all were. Researchers, clinicians, and policymakers should consider the impact of varying definitions of retention, in order to optimally measure this outcome in YLWH, a key vulnerable population.
Collapse
Affiliation(s)
- Caitlin S Sayegh
- Division of Adolescent and Young Adult Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
| | - Sarah M Wood
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Craig-Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marvin Belzer
- Division of Adolescent and Young Adult Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Nadia L Dowshen
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Craig-Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
16
|
Impact of a Youth-Focused Care Model on Retention and Virologic Suppression Among Young Adults With HIV Cared for in an Adult HIV Clinic. J Acquir Immune Defic Syndr 2019; 80:e41-e47. [PMID: 30422910 DOI: 10.1097/qai.0000000000001902] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Young adults with HIV (YAHIV) are less likely to be retained in care or achieve viral suppression (VS) when seen in adult clinics. We assessed the outcomes of a youth-focused care model versus standard of care (SOC) within a large adult HIV clinic. SETTING The Accessing Care Early (ACE) program for YAHIV is embedded within an adult clinic. Eligibility for ACE includes age 18-30 years with ≥1 criteria: transfer from pediatric care, mental health diagnosis, substance use, or identified adherence barriers. Ineligible patients receive SOC. METHODS Retrospective analysis of patients entering ACE versus SOC from 2012 to 2014. Multivariable logistic regression assessed variables associated with retention and VS <200 copies per milliliter, and in separate analysis, clinical services utilization. RESULTS One hundred thirty-seven YAHIV entered care (2012-2014), 61 ACE and 76 SOC. Despite higher risk factors, ACE YAHIV were less likely to be lost to follow-up compared with SOC (16% versus 37%, P < 0.01). At 24 months, 49% in ACE versus 26% in SOC met the retention measure (P < 0.01). In adjusted analysis, ACE was associated with retention in care [AOR 3.26 (1.23-8.63)]. Of those meeting the retention measure, 60% of ACE versus 89% of SOC had VS [AOR 0.63 (0.35-1.14)]. Retention was associated with more frequent social work visits, nurse phone calls, and peer navigator interactions. CONCLUSIONS Higher risk ACE YAHIV had better retention than SOC YAHIV in an adult clinic. Improved retention did not lead to improved VS, underscoring the need for additional interventions to optimize VS for YAHIV.
Collapse
|
17
|
Heglar R, Mood R, Priest JL, Schulman KL, Fusco GP. Benchmarking HIV Quality Measures in the US OPERA HIV Cohort. Open Forum Infect Dis 2019; 6:ofz418. [PMID: 31660374 PMCID: PMC6800831 DOI: 10.1093/ofid/ofz418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Quality measures are effective tools to improve patient outreach, retention in care, adherence, and outcomes. This study benchmarks National Quality Forum-endorsed HIV quality measures in a US clinical cohort. Methods This observational study utilized prospectively captured data from the Observational Pharmaco-Epidemiology Research and Analysis (OPERA) database over 2014-2016 to assess quality measure achievement among patients with HIV in terms of medical visit frequency (#2079), medical visit gaps (#2080), viral suppression (#2082), and antiretroviral therapy (ART) prescriptions (#2083). The proportion of patients meeting each measure was calculated. Generalized estimating equations assessed trends in measure achievement. Results The OPERA sample included 23 059-42 285 patients with similar demographics and characteristics across measurement periods. Overall, 62%-66% of patients met the visit frequency measure (#2079), 81%-85% had no gaps between visits (#2080), 71%-73% achieved viral suppression (#2082), and 92%-94% were prescribed ART (#2083). The adjusted odds of achieving viral suppression and being prescribed ART increased over time by 3% and 19%, respectively, despite a significant decline in patient engagement (16% for #2079, 25% for #2080). Patients <30 years of age were significantly less likely to meet all measures than older patients (P < .0001), with particularly low levels of engagement. Measure achievement also varied by gender, ethnicity, region, and select clinical characteristics. Conclusions Despite gains in the rate of ART prescription and viral suppression, there remains room for improvement in the care of patients with HIV. Strategies for quality improvement may be more effective if tailored by age group.
Collapse
Affiliation(s)
- Robert Heglar
- Familiy Medicine, AIDS Healthcare Foundation, Fort Lauderdale, Florida, USA
| | - Rodney Mood
- Health Economics and Outcomes Research, Epividian Inc., Durham, North Carolina, USA
| | - Julie L Priest
- US Health Outcomes, ViiV Healthcare, Durham, North Carolina, USA
| | - Kathy L Schulman
- Health Economics and Outcomes Research, Epividian Inc., Durham, North Carolina, USA
| | - Gregory P Fusco
- Health Economics and Outcomes Research, Epividian Inc., Durham, North Carolina, USA
| |
Collapse
|
18
|
Enns EA, Reilly CS, Horvath KJ, Baker-James K, Henry K. HIV Care Trajectories as a Novel Longitudinal Assessment of Retention in Care. AIDS Behav 2019; 23:2532-2541. [PMID: 30852729 DOI: 10.1007/s10461-019-02450-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Consistent engagement in care is associated with positive health outcomes among people living with HIV (PLWH). However, traditional retention measures ignore the evolving dynamics of engagement in care. To understand the longitudinal patterns of HIV care, we analyzed medical records from 2008 to 2015 of PLWH ≥ 18 years-old receiving care at a public, hospital-based HIV clinic (N = 2110). Using latent class analysis, we identified five distinct care trajectory classes: (1) consistent care (N = 1281); (2) less frequent care (N = 270); (3) return to care after initial attrition (N = 192); (4) moderate attrition (N = 163); and (5) rapid attrition (N = 204). The majority of PLWH in Class 1 (73.9%) had achieved sustained viral suppression (viral load ≤ 200 copies/mL at last test and > 12 months prior) by study end. Among the other care classes, there was substantial variation in sustained viral suppression (61.1% in Class 2 to 3.4% in Class 5). Care trajectories could be used to prioritize re-engagement efforts.
Collapse
Affiliation(s)
- Eva A Enns
- Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St. SE, MMC 729, Minneapolis, MN, 55455, USA.
| | - Cavan S Reilly
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Keith J Horvath
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Karen Baker-James
- Best Practices Integrated Informatics Core, Clinical and Translational Sciences Institute, University of Minnesota, Minneapolis, MN, USA
| | - Keith Henry
- Division of Infectious Diseases, Hennepin County Medical Center, Minneapolis, MN, USA
| |
Collapse
|
19
|
Batey DS, Kay ES, Westfall AO, Zinski A, Drainoni ML, Gardner LI, Giordano T, Keruly J, Rodriguez A, Wilson TE, Mugavero MJ. Are missed- and kept-visit measures capturing different aspects of retention in HIV primary care? AIDS Care 2019; 32:98-103. [PMID: 31462060 DOI: 10.1080/09540121.2019.1659918] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The literature recognizes six measures of retention in care, an integral component of the HIV Continuum of Care. Given prior research showing that different retention measures are differentially associated with HIV health outcomes (e.g., CD4 count and viral suppression), we hypothesized that different groups of people living with HIV (PLWH) would also have differential retention outcomes based on the retention measure applied. We conducted a cross-sectional analysis of multisite patient-level medical record data (n = 10,053) from six academically-affiliated HIV clinics using six different measures of retention. Principal component analysis indicated two distinct retention constructs: kept-visit-measures and missed-visit measures. Although black (compared to white) PLWH had significantly poorer retention on the three missed-visit measures, race was not significantly associated with any of the three kept-visit measures. Males performed significantly worse than females on all kept-visit measures, but sex differences were not observed for any missed-visit retention measures. IDU risk transmission group and younger age were associated with poorer retention on both missed- and kept-visit retention measures. Missed- and kept-visit measures may capture different aspects of retention, as indicated in the observed differential associations among race, sex, age, and risk transmission group. Multiple measures are needed to effectively assess retention across patient subgroups.
Collapse
Affiliation(s)
- D Scott Batey
- Department of Social Work, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Emma Sophia Kay
- School of Social Work, University of Michigan, Ann Arbor, MI, USA
| | - Andrew O Westfall
- School of Public Health, Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Anne Zinski
- School of Medicine, Department of Medical Education, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mari-Lynn Drainoni
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA.,Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Lytt I Gardner
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Jeanne Keruly
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Tracey E Wilson
- Downstate Medical Center, State University of New York, Brooklyn, NY, USA
| | - Michael J Mugavero
- School of Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | -
- Department of Social Work, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
20
|
Umeokonkwo CD, Onoka CA, Agu PA, Ossai EN, Balogun MS, Ogbonnaya LU. Retention in care and adherence to HIV and AIDS treatment in Anambra State Nigeria. BMC Infect Dis 2019; 19:654. [PMID: 31331280 PMCID: PMC6647106 DOI: 10.1186/s12879-019-4293-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 07/16/2019] [Indexed: 12/04/2022] Open
Abstract
Background Retaining patients on antiretroviral treatment in care is critical to sustaining the 90:90:90 vision. Nigeria has made some progress in placing HIV-positive patients on treatment. In an effort to increase access to treatment, ART decentralization has been implemented in the country. This is aimed at strengthening lower level health facilities to provide comprehensive antiretroviral treatment. We determined the level of retention and adherence to treatment as well as the associated factors among private and public secondary level hospitals in Anambra State. Method We conducted a cross-sectional study among patients who had taken antiretroviral treatment for at least one complete year. A structured questionnaire and patient record review were used to extract information on patient adherence to treatment, and retention in care. Adherence to treatment was ascertained by patient self-report of missed pills in the 30 days prior to date of interview. Retention in care was ascertained using the 3-month visit constancy method reviewing the period spanning 12 months prior to the study. Result We found a comparable level of retention in care (private 81.1%; public 80.3%; p = 0.722). However, treatment adherence was significantly higher amongst participants in the private hospitals compared to those in the public hospitals (private: 95.3%; public: 90.7%; p = 0.001). Determinants of good retention in the private hospitals included disclosure of one’s HIV status (AOR: 1.94, 95% CI: 1.09–3.46), being on first-line regimen (AOR: 3.07, 95% CI: 1.27–7.41), whereas being on once-daily regimen (AOR: 0.58, 95% CI: 0.36–0.92), and being currently married (AOR: 0.54 95% CI: 0.32–0.91) determined poor retention. In the public hospitals, only disclosure (AOR: 3.12 95% CI: 1.81–5.56) determined good retention, whereas, spending less than N1000 on transport (AOR: 0.230 95% CI: 0.07–0.78) and residing in a rural area (AOR: 0.64 95% CI: 0.41–0.99) determined poor retention. None of the factors determined adherence. Conclusion Retention in care was high and comparable among the different hospital types and HIV disclosure status was an important factor relating to retention in care. The other factors that determined retention were however different at public and private hospitals. The HIV program manager should consider these variations in designing programs to improve patient retention in care and adherence to treatment.
Collapse
Affiliation(s)
- Chukwuma David Umeokonkwo
- Department of Community Medicine, Federal Teaching Hospital Abakaliki, Ebonyi State, Nigeria. .,Nigeria Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria.
| | - Chima Ariel Onoka
- Department of Community Medicine, University of Nigeria Teaching Hospital Ituku Ozalla, Enugu State, Nigeria
| | - Pearl Adaoha Agu
- Department of Community Medicine, Federal Teaching Hospital Abakaliki, Ebonyi State, Nigeria.,Department of Community Medicine, College of Health Sciences, Ebonyi State University Abakaliki, Ebonyi State, Nigeria.,African Institute for Health Policy and Health Systems, Ebonyi State University Abakaliki Ebonyi State, Ebonyi State, Nigeria
| | - Edmund Ndudi Ossai
- Department of Community Medicine, Federal Teaching Hospital Abakaliki, Ebonyi State, Nigeria.,Department of Community Medicine, College of Health Sciences, Ebonyi State University Abakaliki, Ebonyi State, Nigeria
| | | | - Lawrence Ulu Ogbonnaya
- Department of Community Medicine, Federal Teaching Hospital Abakaliki, Ebonyi State, Nigeria.,Department of Community Medicine, College of Health Sciences, Ebonyi State University Abakaliki, Ebonyi State, Nigeria.,African Institute for Health Policy and Health Systems, Ebonyi State University Abakaliki Ebonyi State, Ebonyi State, Nigeria
| |
Collapse
|
21
|
Stafford KA, Odafe SF, Lo J, Ibrahim R, Ehoche A, Niyang M, Aliyu GG, Gobir B, Onotu D, Oladipo A, Dalhatu I, Boyd AT, Ogorry O, Ismail L, Charurat M, Swaminathan M. Evaluation of the clinical outcomes of the Test and Treat strategy to implement Treat All in Nigeria: Results from the Nigeria Multi-Center ART Study. PLoS One 2019; 14:e0218555. [PMID: 31291273 PMCID: PMC6619660 DOI: 10.1371/journal.pone.0218555] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/04/2019] [Indexed: 12/30/2022] Open
Abstract
In December 2016, the Nigerian Federal Ministry of Health updated its HIV guidelines to a Treat All approach, expanding antiretroviral therapy (ART) eligibility to all individuals with HIV infection, regardless of CD4+ cell count, and recommending ART be initiated within two weeks of HIV diagnosis (i.e., the Test and Treat strategy). The Test and Treat policy was first piloted in 32 local government areas (LGAs). The primary objective of this study was to evaluate the clinical outcomes of adult patients initiated on ART within two weeks of HIV diagnosis during this pilot. We conducted a retrospective cohort analysis of patients who initiated ART within two weeks of new HIV diagnosis between October 2015 and September 2016 in eight randomly selected LGAs participating in the Test and Treat pilot study. 2,652 adults were newly diagnosed and initiated on ART within two weeks of HIV diagnosis. Of these patients, 8% had documentation of a 12-month viral load measurement, and 13% had documentation of a six-month viral load measurement. Among Test and Treat patients with a documented viral load, 79% were suppressed (≤400 copies/ml) at six months and 78% were suppressed at 12 months. By 12 months post-ART initiation, 34% of the patients who initiated ART under the Test and Treat strategy were lost to follow-up. The median CD4 cell count among patients initiating ART within two weeks of HIV diagnosis was 323 cells/mm3 (interquartile range, 161–518). While randomized controlled trials have demonstrated that Test and Treat strategies can improve patient retention and increase viral suppression compared to standard of care, these findings indicate that the effectiveness of Test and Treat in some settings may be far lower than the efficacy demonstrated in randomized controlled trials. Significant attention to the way Test and Treat strategies are implemented, monitored, and improved particularly related to early retention, can help expand access to ART for all patients.
Collapse
Affiliation(s)
- Kristen A. Stafford
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland, United States of America
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
| | - Solomon F. Odafe
- Centers for Disease Control and Prevention, CGH/DGHT, Abuja, Nigeria
| | - Julia Lo
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Ramat Ibrahim
- Maryland Global Initiatives Corporation, Abuja, Nigeria
| | - Akipu Ehoche
- Maryland Global Initiatives Corporation, Abuja, Nigeria
| | - Mercy Niyang
- Maryland Global Initiatives Corporation, Abuja, Nigeria
| | - Gambo G. Aliyu
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland, United States of America
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Bola Gobir
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Maryland Global Initiatives Corporation, Abuja, Nigeria
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Dennis Onotu
- Centers for Disease Control and Prevention, CGH/DGHT, Abuja, Nigeria
| | - Ademola Oladipo
- Centers for Disease Control and Prevention, CGH/DGHT, Abuja, Nigeria
| | - Ibrahim Dalhatu
- Centers for Disease Control and Prevention, CGH/DGHT, Abuja, Nigeria
| | - Andrew T. Boyd
- Centers for Disease Control and Prevention, CGH/DGHT, Atlanta, Georgia, United States of America
| | | | - Lawal Ismail
- Walter Reed Army Institute of Research, Military HIV Research Program, Abuja, Nigeria
| | - Manhattan Charurat
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | | |
Collapse
|
22
|
Outcomes of a Comprehensive Retention Strategy for Youth With HIV After Transfer to Adult Care in the United States. Pediatr Infect Dis J 2019; 38:722-726. [PMID: 30985513 PMCID: PMC6752883 DOI: 10.1097/inf.0000000000002309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The retention of youth living with HIV (YLHIV) in adult care after transfer from pediatric care in the United States is a challenge. A targeted comprehensive retention strategy (CRS) may improve retention among YLHIV. METHODS A retrospective cohort study of YLHIV after transfer from pediatric to adult care for patients with at least 1 adult visit at 2 urban HIV care programs in the United States employing CRSs with internal medicine/pediatrics-trained providers, peer navigators, social workers and mental health resources. Primary outcomes were successful retention in care after transfer (≥2 provider visits in the adult clinic ≥90 days apart within 1 year of transfer) and successful transition (successful retention plus a stable HIV viral load (VL) defined as VL 1 year after transfer that was less than or equal to the VL obtained at or immediately before transfer). Logistic regression assessed factors associated with successful transition. A subgroup analysis was performed to examine rates of successful transfer and linkage from pediatric to adult clinics (attending at least 1 adult visit after transition). RESULTS Of the 89 patients included in the study, 79 (89%) patients had successful retention and 53 (60%) had successful transition to the adult program. Factors associated with successful transition included non-African American race [adjusted odds ratio (aOR) = 11.26, 95% confidence interval (CI): 1.32-95.51], perinatal HIV (aOR = 8.00, 95% CI: 1.39-46.02) and CD4 count > 500 cells/mm (aOR = 5.22, 95% CI: 1.54-17.70). Of those who were retained, 53/79 (67%) had stable or improved virologic control at 1 year after transition. In a subgroup analysis, 54/56 (96%) patients who were targeted to transition successfully linked to adult care. CONCLUSIONS Overall, YLHIV in the United States engaged in a CRS program appear to have high retention rates but suboptimal virologic control after transfer from pediatric HIV care.
Collapse
|
23
|
Primary care engagement is associated with increased pharmacotherapy prescribing for alcohol use disorder (AUD). Addict Sci Clin Pract 2019; 14:19. [PMID: 31039820 PMCID: PMC6492411 DOI: 10.1186/s13722-019-0147-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 03/26/2019] [Indexed: 02/06/2023] Open
Abstract
Background Primary care provider skills such as screening, longitudinal monitoring, and medication management are generalizable to prescribing alcohol use disorder (AUD) pharmacotherapy. The association between primary care engagement (i.e., longitudinal utilization of primary care services) and prescribing of AUD pharmacotherapy is unknown. Methods We examined a 5-year (2010–2014) retrospective cohort of patients with AUD, 18 years and older, at an urban academic medical center in the Bronx, NY, USA. Our main exposure was level of primary care engagement (no primary care, limited primary care, and engaged with primary care) and our outcome was any AUD pharmacotherapy prescription within 2 years of AUD diagnosis. Using multivariable logistic regression, we examined the association between primary care engagement and pharmacotherapy prescribing, accounting for demographic and clinical factors. Results Of 21,159 adults (28.9% female) with AUD, 2.1% (n = 449) were prescribed pharmacotherapy. After adjusting for confounders, the probability of receiving an AUD pharmacotherapy prescription for patients with no primary care was 1.61% (95% CI 1.39, 1.84). The probability of AUD pharmacotherapy prescribing was 2.56% (95% CI 2.06, 3.06) for patients with limited primary care and 2.89% (95% CI 2.44, 3.34%) for patients engaged with primary care. Conclusions The percentage of AUD patients prescribed AUD pharmacotherapy was low; however, primary care engagement was associated with a higher, but modest, probability of receiving a prescription. Efforts to increase primary care engagement among patients with AUD may translate into increased AUD pharmacotherapy prescribing; however, strategies to increase prescribing across health care settings are needed. Electronic supplementary material The online version of this article (10.1186/s13722-019-0147-3) contains supplementary material, which is available to authorized users.
Collapse
|
24
|
Ulloa AC, Puskas C, Yip B, Zhang W, Stanley C, Stone S, Pedromingo M, Lima VD, Montaner JSG, Guillemi S, Barrios R. Retention in care and mortality trends among patients receiving comprehensive care for HIV infection: a retrospective cohort study. CMAJ Open 2019; 7:E236-E245. [PMID: 30979728 PMCID: PMC6461542 DOI: 10.9778/cmajo.20180136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Studies examining the relation between comprehensive care and health outcomes associated with comorbidities unrelated to HIV infection have focused mainly on the health outcomes of HIV-infected people and comorbid substance use disorders. We aimed to assess the impact of retention in comprehensive HIV infection care on overall, AIDS-related and non-AIDS-related mortality. METHODS Using a retrospective cohort design, we collected data for HIV-infected patients aged 19 years or more who first visited a comprehensive HIV infection clinic in Vancouver between Jan. 1, 2004, and Dec. 31, 2014. We defined retention in care as visit constancy (whether the patient attended the clinic at least once per given period) of 75% or greater. We used Poisson regression modelling to examine mortality trends. We performed Cox proportional hazards modelling to assess survival by retention during the first year of follow-up and identify factors associated with death. RESULTS A total of 2101 patients were included in the study. Of the 2101, 1340 (63.8%) were retained in the first year of care, and 271 (12.9%) died during the study period. Among the 264 cases in which the cause of death was known, although the primary underlying cause of death (74 [28.0%]) was AIDS-related, half of all AIDS-related deaths (37/74 [50%]) occurred early in the study (2004-2007). In later years, most deaths (147/184 [79.9%]) were non-AIDS-related. Overall mortality was significantly reduced among patients with higher retention in care during the first year of follow-up (per 20% increase in visit constancy; adjusted hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.79-0.96). Higher retention was also associated with reduced risk of AIDS-related death (adjusted HR 0.79, 95% CI 0.64-0.97). INTERPRETATION Although there was an overall trend toward decreased AIDS-related mortality over time, retention in care markedly decreased the likelihood of death. Maintaining patient engagement in comprehensive ancillary care is a patient-centred way of decreasing mortality rates among HIV-infected people.
Collapse
Affiliation(s)
- Ana C Ulloa
- BC Centre for Excellence in HIV/AIDS (Ulloa, Puskas, Yip, Zhang, Lima, Montaner, Guillemi, Barrios); John Ruedy Immunodeficiency Clinic (Stanley, Stone, Pedromingo), St. Paul's Hospital; Division of AIDS (Lima, Montaner), Department of Family Practice (Guillemi) and School of Population and Public Health (Barrios), University of British Columbia, Vancouver, BC
| | - Cathy Puskas
- BC Centre for Excellence in HIV/AIDS (Ulloa, Puskas, Yip, Zhang, Lima, Montaner, Guillemi, Barrios); John Ruedy Immunodeficiency Clinic (Stanley, Stone, Pedromingo), St. Paul's Hospital; Division of AIDS (Lima, Montaner), Department of Family Practice (Guillemi) and School of Population and Public Health (Barrios), University of British Columbia, Vancouver, BC
| | - Benita Yip
- BC Centre for Excellence in HIV/AIDS (Ulloa, Puskas, Yip, Zhang, Lima, Montaner, Guillemi, Barrios); John Ruedy Immunodeficiency Clinic (Stanley, Stone, Pedromingo), St. Paul's Hospital; Division of AIDS (Lima, Montaner), Department of Family Practice (Guillemi) and School of Population and Public Health (Barrios), University of British Columbia, Vancouver, BC
| | - Wendy Zhang
- BC Centre for Excellence in HIV/AIDS (Ulloa, Puskas, Yip, Zhang, Lima, Montaner, Guillemi, Barrios); John Ruedy Immunodeficiency Clinic (Stanley, Stone, Pedromingo), St. Paul's Hospital; Division of AIDS (Lima, Montaner), Department of Family Practice (Guillemi) and School of Population and Public Health (Barrios), University of British Columbia, Vancouver, BC
| | - Cole Stanley
- BC Centre for Excellence in HIV/AIDS (Ulloa, Puskas, Yip, Zhang, Lima, Montaner, Guillemi, Barrios); John Ruedy Immunodeficiency Clinic (Stanley, Stone, Pedromingo), St. Paul's Hospital; Division of AIDS (Lima, Montaner), Department of Family Practice (Guillemi) and School of Population and Public Health (Barrios), University of British Columbia, Vancouver, BC
| | - Sarah Stone
- BC Centre for Excellence in HIV/AIDS (Ulloa, Puskas, Yip, Zhang, Lima, Montaner, Guillemi, Barrios); John Ruedy Immunodeficiency Clinic (Stanley, Stone, Pedromingo), St. Paul's Hospital; Division of AIDS (Lima, Montaner), Department of Family Practice (Guillemi) and School of Population and Public Health (Barrios), University of British Columbia, Vancouver, BC
| | - Miguel Pedromingo
- BC Centre for Excellence in HIV/AIDS (Ulloa, Puskas, Yip, Zhang, Lima, Montaner, Guillemi, Barrios); John Ruedy Immunodeficiency Clinic (Stanley, Stone, Pedromingo), St. Paul's Hospital; Division of AIDS (Lima, Montaner), Department of Family Practice (Guillemi) and School of Population and Public Health (Barrios), University of British Columbia, Vancouver, BC
| | - Viviane Dias Lima
- BC Centre for Excellence in HIV/AIDS (Ulloa, Puskas, Yip, Zhang, Lima, Montaner, Guillemi, Barrios); John Ruedy Immunodeficiency Clinic (Stanley, Stone, Pedromingo), St. Paul's Hospital; Division of AIDS (Lima, Montaner), Department of Family Practice (Guillemi) and School of Population and Public Health (Barrios), University of British Columbia, Vancouver, BC
| | - Julio S G Montaner
- BC Centre for Excellence in HIV/AIDS (Ulloa, Puskas, Yip, Zhang, Lima, Montaner, Guillemi, Barrios); John Ruedy Immunodeficiency Clinic (Stanley, Stone, Pedromingo), St. Paul's Hospital; Division of AIDS (Lima, Montaner), Department of Family Practice (Guillemi) and School of Population and Public Health (Barrios), University of British Columbia, Vancouver, BC
| | - Silvia Guillemi
- BC Centre for Excellence in HIV/AIDS (Ulloa, Puskas, Yip, Zhang, Lima, Montaner, Guillemi, Barrios); John Ruedy Immunodeficiency Clinic (Stanley, Stone, Pedromingo), St. Paul's Hospital; Division of AIDS (Lima, Montaner), Department of Family Practice (Guillemi) and School of Population and Public Health (Barrios), University of British Columbia, Vancouver, BC
| | - Rolando Barrios
- BC Centre for Excellence in HIV/AIDS (Ulloa, Puskas, Yip, Zhang, Lima, Montaner, Guillemi, Barrios); John Ruedy Immunodeficiency Clinic (Stanley, Stone, Pedromingo), St. Paul's Hospital; Division of AIDS (Lima, Montaner), Department of Family Practice (Guillemi) and School of Population and Public Health (Barrios), University of British Columbia, Vancouver, BC
| |
Collapse
|
25
|
Watt MH, Cichowitz C, Kisigo G, Minja L, Knettel BA, Knippler ET, Ngocho J, Manavalan P, Mmbaga BT. Predictors of postpartum HIV care engagement for women enrolled in prevention of mother-to-child transmission (PMTCT) programs in Tanzania. AIDS Care 2018; 31:687-698. [PMID: 30466304 DOI: 10.1080/09540121.2018.1550248] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Prevention of mother-to-child transmission of HIV (PMTCT) is a foundational component of a comprehensive HIV treatment program. In addition to preventing vertical transmission to children, PMTCT is an important catch-point for universal test-and-treat strategies that can reduce community viral load and slow the epidemic. However, systematic reviews suggest that care engagement in PMTCT programs is sub-optimal. This study enrolled a cohort of 200 women initiating PMTCT in Kilimanjaro, Tanzania, and followed them to assess HIV care engagement and associated factors. Six months after delivery, 42/200 (21%) of participants were identified as having poor care engagement, defined as HIV RNA >200 copies/mL or, if viral load was unavailable, being lost-to-follow-up in the clinical records or self-reporting being out of care. In a multivariable risk factor analysis, younger women were more likely to have poor postpartum care engagement; with each year of age, women were 7% less likely to have poor care engagement (aRR: 0.93; 95% CI: 0.89, 0.98). Additionally, women who had told at least one person about their HIV status were 47% less likely to have poor care engagement (aRR: .53; 95% CI: 0.29, 0.97). Among women who entered antenatal care with an established HIV diagnosis, those who were pregnant for the first time had increased risk of poor care engagement (aRR 4.16; 95% CI 1.53, 11.28). The findings suggest that care engagement remains a concern in PMTCT programs, and must be addressed to realize the goals of PMTCT. Comprehensive counseling on HIV disclosure, along with community-based stigma reduction programs to provide a supportive environment for people living with HIV, are crucial to address barriers to care engagement and support long-term treatment. Women presenting to antenatal care with an established HIV status require support for care engagement during the crucial period surrounding childbirth, particularly those pregnant for the first time.
Collapse
Affiliation(s)
- Melissa H Watt
- a Duke Global Health Institute , Duke University , Durham , NC , USA
| | - Cody Cichowitz
- a Duke Global Health Institute , Duke University , Durham , NC , USA.,b School of Medicine, Johns Hopkins University , Baltimore , MD , USA
| | - Godfrey Kisigo
- a Duke Global Health Institute , Duke University , Durham , NC , USA.,c Kilimanjaro Clinical Research Institute , Moshi , Tanzania
| | - Linda Minja
- c Kilimanjaro Clinical Research Institute , Moshi , Tanzania
| | - Brandon A Knettel
- a Duke Global Health Institute , Duke University , Durham , NC , USA
| | | | - James Ngocho
- d Kilimanjaro Christian Medical Centre , Moshi , Tanzania.,e Kilimanjaro Christian Medical University College , Moshi , Tanzania
| | - Preeti Manavalan
- a Duke Global Health Institute , Duke University , Durham , NC , USA
| | - Blandina T Mmbaga
- a Duke Global Health Institute , Duke University , Durham , NC , USA.,c Kilimanjaro Clinical Research Institute , Moshi , Tanzania.,d Kilimanjaro Christian Medical Centre , Moshi , Tanzania.,e Kilimanjaro Christian Medical University College , Moshi , Tanzania
| |
Collapse
|
26
|
Brooks RB, Feldman KA, Blythe D, Flynn C. Completeness of HIV nucleotide sequence ascertainment and its potential impact on understanding HIV transmission - Maryland, 2011-2013 .. AIDS Care 2018; 31:621-628. [PMID: 30430842 DOI: 10.1080/09540121.2018.1545983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
HIV nucleotide sequences generated through routine drug resistance testing (DRT) and reported to Maryland's Molecular HIV Surveillance system are most effective for elucidating transmission patterns and identifying outbreaks if DRT is ordered promptly and sequences are reported completely. Among reported cases of HIV infection newly diagnosed during 2011-2013 in Maryland residents aged ≥13 years, we assessed sequence ascertainment completeness. To better understand which populations were most likely to have a sequence, we examined associations between sequence ascertainment and clinical and demographic characteristics. During 2011-2013, 4423 new HIV infection diagnoses were reported; sequences were ascertained for 1282 (29.0%). Among 3267 cases with complete data, odds for having a sequence ascertained were highest for cases in persons living inside Maryland's Central Region with initial CD4 counts ≤500 cells/mm3 (adjusted odds ratio [aOR] 2.4, 95% confidence interval [CI] 1.9-3.1). Sequence ascertainment did not vary significantly by patient age, sex, race/ethnicity or HIV transmission category. Educational interventions, policy changes and improved processes to increase timely DRT and subsequent sequence reporting with a focus on testing at entry to care, particularly for those with higher CD4 counts and those living outside the Central Region, might improve ascertainment completeness.
Collapse
Affiliation(s)
- Richard B Brooks
- a Epidemic Intelligence Service, Division of Scientific Education and Professional Development , Centers for Disease Control and Prevention , Atlanta , GA , USA.,b Infectious Disease Epidemiology and Outbreak Response Bureau , Maryland Department of Health , Baltimore , MD , USA
| | - Katherine A Feldman
- b Infectious Disease Epidemiology and Outbreak Response Bureau , Maryland Department of Health , Baltimore , MD , USA
| | - David Blythe
- b Infectious Disease Epidemiology and Outbreak Response Bureau , Maryland Department of Health , Baltimore , MD , USA
| | - Colin Flynn
- b Infectious Disease Epidemiology and Outbreak Response Bureau , Maryland Department of Health , Baltimore , MD , USA
| |
Collapse
|
27
|
Horberg MA, Blank JG, Rubenstein KB, Certa JM, Hurley LB, Kadlecik PM, Klein DB, Silverberg MJ. Impact of Alternative Encounter Types on HIV Viral Suppression Rates in an Integrated Health System. AIDS Patient Care STDS 2018; 32:425-431. [PMID: 30398954 DOI: 10.1089/apc.2018.0079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Kaiser Permanente Mid-Atlantic States (KPMAS) members are increasingly utilizing electronic encounter types, such as telephone appointments and secure messaging for healthcare purposes, although their impact on health outcomes is unknown. We evaluated whether use of alternative encounters by adult human immunodeficiency virus (HIV)-infected patients affected the likelihood of achieving viral suppression (VS). Our study population of 3114 patients contributed 6520 patient-years between 2014 and 2016. We compared VS (HIV RNA <200 copies/mL) by number of in-person visits (1 or ≥2), with further stratification for additional phone and/or e-mail encounters (none, phone only, e-mail only, and both phone and e-mail). Rate ratios (RRs) for VS by number of in-person visits and encounter types were obtained from Poisson modeling, adjusting for age, sex, race/ethnicity, and HIV risk. Compared to those with ≥2 visits, patients with one in-person visit alone were significantly less likely to achieve VS (RR = 0.93; 95% confidence interval, CI: [0.87-1.00]), as were those with one in-person visit plus a telephone encounter (0.93; [0.90-0.97]). We did not find significant differences in VS comparing patients with one in-person visit plus e-mail only (RR = 1.00; 95% CI: [0.97-1.02]) or plus e-mail and telephone (0.99; [0.97-1.01]) to those with ≥2 in-person visits. If supplemented by e-mail communications (with or without telephone contact), patients with one in-person visit per year had similar estimated rates of VS compared with ≥2 in-person visits. More research is needed to know if these findings apply to other care systems.
Collapse
Affiliation(s)
- Michael A. Horberg
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
- Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland
| | - Jackie G. Blank
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Kevin B. Rubenstein
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Julia M. Certa
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Leo B. Hurley
- Kaiser Permanente Northern California, Division of Research, Oakland, California
| | - Peter M. Kadlecik
- Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland
| | - Daniel B. Klein
- Kaiser Permanente Northern California, San Leandro, California
| | | |
Collapse
|
28
|
Umeokonkwo CD, Aniebue PN, Onoka CA, Agu AP, Sufiyan MB, Ogbonnaya L. Patients' satisfaction with HIV and AIDS care in Anambra State, Nigeria. PLoS One 2018; 13:e0206499. [PMID: 30365560 PMCID: PMC6203402 DOI: 10.1371/journal.pone.0206499] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 10/15/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction HIV and AIDS care requires frequent visits to the hospital. Patient satisfaction with care services during hospital visits is important in considering quality and outcome of care. Increasing number of patients needing treatment led to the decentralization of care to lower level hospitals without documented patient perception on the quality of services. The study determined and compared patient satisfaction with HIV and AIDS care services in public and private hospitals and identified the factors that influence it. Method This was a cross-sectional comparative study of patients receiving antiretroviral treatment in public and private hospitals in Anambra State. The sampling frame for the hospitals consisted of all registered public and private hospitals that have rendered antiretroviral services for at least one year. There were three public urban, nine public rural, eleven private urban and ten private rural hospitals that met the criteria. One hospital was selected by simple random sampling (balloting) from each group. Out of a total of 6334 eligible patients (had received ART for at least 12 months), 1270 were recruited by simple random sampling from the hospitals proportionate to size of patient in each hospital. Adapted, validated and pretested Patient Satisfaction Questionnaire (PSQ18) was interviewer-administered on consenting patients as an exit interview. A Chi-square test and logistic regression analysis were conducted at 5% level of significance. Result There were 635 participants each in public and private hospitals. Of the 408 patients who had primary education or less, 265(65.0%) accessed care in public hospitals compared to 143(35.0%) who accessed care in private hospital (p<0.001). Similarly, of the 851 patients who were currently married, 371 (43.6%) accessed their care in public compared to 480 (56.4%) who accessed care in private (p<0.001). The proportion of participants who were satisfied were more in public hospitals (71.5%) compared to private hospitals (41.4%). The difference in proportion was statistically significant (χ2 = 116.85, p <0.001). Good retention in care [AOR: 2.3, 95%CI: 1.5–3.5] was the only predictor of satisfaction in public hospitals while primary education [adjusted odds ratio (AOR); 2.3, 95%CI: 1.5–3.4], residing in rural area [AOR: 2.0, 95%CI: 1.4–2.9], and once-daily dosing [AOR: 3.2, 95%CI: 2.1–4.8] were independent predictors of patient' satisfaction among private hospital respondents. Conclusion Satisfaction was higher among patients attending public hospitals. Patient’s satisfaction was strongly associated with retention in care among patients in public hospitals. However, in private hospitals, it was influenced by the patient’s level of education, place of residence, and antiretroviral medication dosing frequency.
Collapse
Affiliation(s)
- Chukwuma David Umeokonkwo
- Department of Community Medicine, Federal Teaching Hospital Abakaliki, Ebonyi State, Nigeria
- Nigeria Field Epidemiology Training Program, Abuja, Nigeria
- * E-mail:
| | - Patricia Nonye Aniebue
- Department of Community Medicine, University of Nigeria Enugu Campus, Enugu, Enugu State, Nigeria
| | - Chima Ariel Onoka
- Department of Community Medicine, University of Nigeria Enugu Campus, Enugu, Enugu State, Nigeria
| | - Adaoha Pearl Agu
- Department of Community Medicine, Ebonyi State University, Abakaliki Ebonyi State, Nigeria
| | | | - Lawrence Ogbonnaya
- Department of Community Medicine, Ebonyi State University, Abakaliki Ebonyi State, Nigeria
| |
Collapse
|
29
|
Miranda WDA, Medeiros LBD, Nascimento JAD, Ribeiro KSQS, Nogueira JDA, Leadebal ODCP. A predictive model for retention in specialized HIV/AIDS care. CAD SAUDE PUBLICA 2018; 34:e00209416. [PMID: 30365750 DOI: 10.1590/0102-311x00209416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 03/06/2018] [Indexed: 11/21/2022] Open
Abstract
The establishment of universal targets for HIV/AIDS control and the implementation of treatment as prevention reinforce the need for on-going clinical follow-up of persons living with HIV/AIDS as an essential element of their care, where retention in care is both a need and a challenge. This study aimed to create a predictive model for retention of persons living with HIV/AIDS in health care. A decision tree statistical model was created, based on sociodemographic, clinical, and health behavior variables, identified in a database with information from 260 persons with HIV/AIDS, enrolled in a specialized treatment service. The model enabled the identification of nine variables with significant information gains in relation to the outcome variable, probable retention in health care, and the development of 24 decision rules, giving rise to a decision tree with 80.4% correct answers, which can help identify possible strategies to optimize retention and contribute to achieving the proposed targets for confronting the epidemic in the coming years.
Collapse
|
30
|
Transition from paediatric to adult care among persons with perinatal HIV infection in New York City, 2006-2015. AIDS 2018; 32:1821-1828. [PMID: 29894382 DOI: 10.1097/qad.0000000000001923] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the transition process from paediatric to adult care among persons with perinatal HIV infection in New York City (NYC). DESIGN A retrospective prepost study and a matched exposed/unexposed nested cohort study. METHODS Using data from the NYC HIV registry, a retrospective prepost study was performed among persons who transitioned from paediatric to adult care to assess pre and posttransition retention in care (≥1 CD4 cell count/viral load in a 12-month period), CD4 cell count and viral suppression (≤200 copies/ml). A 1 : 3 matched exposed/unexposed nested cohort study was conducted to assess pre and posttransition 1-year mortality by matching persons who transitioned to adult care and persons who remained in paediatric care on calendar year (±1 year) and age at transition (±1 year). RESULTS A total of 735 persons with perinatal HIV infection transitioned to adult care in NYC during 2006-2015, of whom 53.9% were women, 57.7% black and 37.1% Hispanic. Pretransition (Year 0), and posttransition Year 1, Year 2 and Year 3 proportions of persons with CD4 cell count at least 500 cells/μl were 35.2, 38.3, 38.9 and 39.0%, respectively, and viral suppression were 45.9, 48.6, 51.1 and 51.8%, respectively. One-year mortality rates before and after transition were 2.3/1000 and 55.8/1000, respectively. CONCLUSION Persons with perinatal HIV infection in NYC who transitioned from paediatric to adult care saw improvements in CD4 cell count and viral suppression after transition. The increase in mortality after transition was likely caused by the conditions before or leading to the transition.
Collapse
|
31
|
Measuring Retention in Antiretroviral Therapy Programs—a Synthetic Review of Different Approaches for Field Use in Low- and Middle-Income Settings. CURRENT TROPICAL MEDICINE REPORTS 2018. [DOI: 10.1007/s40475-018-0153-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
32
|
Rebeiro PF, Howe CJ, Rogers WB, Bebawy SS, Turner M, Kheshti A, McGowan CC, Raffanti SP, Sterling TR. The relationship between adverse neighborhood socioeconomic context and HIV continuum of care outcomes in a diverse HIV clinic cohort in the Southern United States. AIDS Care 2018; 30:1426-1434. [PMID: 29678121 DOI: 10.1080/09540121.2018.1465526] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Retention in care and viral suppression are critical to delaying HIV progression and reducing transmission. Neighborhood socioeconomic context (NSEC) may affect HIV care receipt. We therefore assessed NSEC's impact on retention and viral suppression in a diverse HIV clinical cohort. HIV-positive adults with ≥1 visit at the Vanderbilt Comprehensive Care Clinic and 5-digit ZIP code tabulation area (ZCTA) information between 2008 and 2012 contributed. NSEC z-score indices used neighborhood-level socioeconomic indicators for poverty, education, labor-force participation, proportion of males, median age, and proportion of residents of black race by ZCTA. Retention was defined as ≥2 HIV care visits per calendar year, >90 days apart. Viral suppression was defined as an HIV-1 RNA <200 copies/mL at last measurement per calendar year. Modified Poisson regression was used to estimate risk ratios (RR) and 95% confidence intervals (CI). Among 2272 and 2541 adults included for retention and viral suppression analyses, respectively, median age and CD4 count at enrollment were approximately 38 (1st and 3rd quartile: 30, 44) years and 351 (176, 540) cells/μL, respectively, while 24% were female, and 39% were black. Across 243 ZCTAs, median NSEC z-score was 0.09 (-0.66, 0.48). Overall, 79% of person-time contributed was retained and 74% was virally suppressed. In adjusted models, NSEC was not associated with retention, though being in the 4th vs. 1st NSEC quartile was associated with lack of viral suppression (RR = 0.88; 95% CI: 0.80-0.97). Residing in the most adverse NSEC was associated with lack of viral suppression. Future studies are needed to confirm this finding.
Collapse
Affiliation(s)
- Peter F Rebeiro
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Chanelle J Howe
- b Epidemiology , Brown University School of Public Health , Providence , RI , USA
| | - William B Rogers
- c Medicine , Indiana University School of Medicine , Indianapolis , IN , USA
| | - Sally S Bebawy
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Megan Turner
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Asghar Kheshti
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Catherine C McGowan
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Stephen P Raffanti
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Timothy R Sterling
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
| |
Collapse
|
33
|
Larbi AA, Spielberg F, Kamanu Elias N, Athey E, Ogbuawa N, Murphy N. Using a retention in care protocol to promote positive health and systems related outcomes. AIDS Care 2018; 30:1-7. [PMID: 29669423 DOI: 10.1080/09540121.2018.1465173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
People living with HIV can experience the full benefits of retention when they are continuously engaged in care. Continuous engagement in care promotes improved adherence to ART and positive health outcomes. An infectious disease clinic has implemented a protocol to primarily improve patient retention. The retrospective, facility-based, costing study took place in an infectious disease clinic in Washington DC. Retention was defined in two ways and over a 12-month period. Micro-costing direct measurement methods were used to collect unit costs in time series. Return on investment accounted for the cost of treatment based on CD4 strata. ROI was expressed in 2016USD. The difference in CD4 and viral load levels between the two periods of analysis were determined for active patients, infected with HIV. The year before the intervention was compared to the year of the intervention. Total treatment expenditure decreased from $2,435,653.00 to $2,283,296.23, resulting in a $152,356.77 gain from investment for the healthcare system over a 12-month investment period. The viral load suppression rate increased from 81 to 95 (p = 0.04) over the investment period. The number of patients in need of HIV related opportunistic infection prophylaxis decreased from 21 to 13 (p = 0.06). Improved immunologic, virologic and healthcare expenditure outcomes can be linked to the quality of retention practice.
Collapse
Affiliation(s)
- Alfred A Larbi
- a United Medical Center, Care Center for Infectious Diseases , Washington DC , USA
| | - Freya Spielberg
- b Department of Population Health , The University of Texas at Austin, Dell Medical School , Austin , Texas , USA
| | - Nnemdi Kamanu Elias
- a United Medical Center, Care Center for Infectious Diseases , Washington DC , USA
| | - Erin Athey
- a United Medical Center, Care Center for Infectious Diseases , Washington DC , USA
| | - Ngozi Ogbuawa
- a United Medical Center, Care Center for Infectious Diseases , Washington DC , USA
| | - Nancy Murphy
- a United Medical Center, Care Center for Infectious Diseases , Washington DC , USA.,c Division of Nursing , Howard University, College of Nursing & Allied Health Sciences , Washington DC , USA
| |
Collapse
|
34
|
Gardner LI, Marks G, Patel U, Cachay E, Wilson TE, Stirratt M, Rodriguez A, Sullivan M, Keruly JC, Giordano TP. Gaps Up To 9 Months Between HIV Primary Care Visits Do Not Worsen Viral Load. AIDS Patient Care STDS 2018; 32:157-164. [PMID: 29630849 PMCID: PMC5972770 DOI: 10.1089/apc.2018.0001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Current guidelines specify that visit intervals with viral monitoring should not exceed 6 months for HIV patients. Yet, gaps in care exceeding 6 months are common. In an observational cohort using US patients, we examined the association between gap length and changes in viral load status and sought to determine the length of the gap at which significant increases in viral load occur. We identified patients with gaps in care greater than 6 months from 6399 patients from six US HIV clinics. Gap strata were >6 to <7, 7 to <8, 8 to <9, 9 to <12, and ≥12 months, with viral load measurements matched to the opening and closing dates for the gaps. We examined visit gap lengths in association with two viral load measurements: continuous (log10 viral load at gap opening and closing) and dichotomous (whether patients initially suppressed but lost viral suppression by close of the care gap). Viral load increases were nonsignificant or modest when gap length was <9 months, corresponding to 10% or fewer patients who lost viral suppression. For gaps ≥12 months, there was a significant increase in viral load as well as a much larger loss of viral suppression (in 23% of patients). Detrimental effects on viral load after a care gap were greater in young patients, black patients, and those without private health insurance. On average, shorter gaps in care were not detrimental to patient viral load status. HIV primary care visit intervals of 6 to 9 months for select patients may be appropriate.
Collapse
Affiliation(s)
- Lytt I. Gardner
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gary Marks
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Unnati Patel
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention and ICF, Atlanta, Georgia
| | - Edward Cachay
- Department of Medicine, University of California School of Medicine, San Diego, California
| | - Tracey E. Wilson
- Department of Community Health Sciences, School of Public Health, State University of New York, Downstate Medical Center, Brooklyn, New York
| | - Michael Stirratt
- Division of AIDS Research, National Institute of Mental Health, Bethesda, Maryland
| | - Allan Rodriguez
- Division of Infectious Diseases, Miller School of Medicine, University of Miami, Miami, Florida
| | - Meg Sullivan
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Jeanne C. Keruly
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thomas P. Giordano
- Department of Medicine, Baylor College of Medicine, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Thomas Street Health Center and Harris Health System, Houston, Texas
| |
Collapse
|
35
|
Agaba PA, Genberg BL, Sagay AS, Agbaji OO, Meloni ST, Dadem NY, Kolawole GO, Okonkwo P, Kanki PJ, Ware NC. Retention in Differentiated Care: Multiple Measures Analysis for a Decentralized HIV Care and Treatment Program in North Central Nigeria. ACTA ACUST UNITED AC 2018; 9. [PMID: 29682399 PMCID: PMC5909978 DOI: 10.4172/2155-6113.1000756] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective Differentiated care refers collectively to flexible service models designed to meet the differing needs of HIV-infected persons in resource-scarce settings. Decentralization is one such service model. Retention is a key indicator for monitoring the success of HIV treatment and care programs. We used multiple measures to compare retention in a cohort of patients receiving HIV care at “hub” (central) and “spoke” (decentralized) sites in a large public HIV treatment program in north central Nigeria. Methods This retrospective cohort study utilized longitudinal program data representing central and decentralized levels of care in the Plateau State Decentralization Initiative, north central Nigeria. We examined retention with patient- level (retention at fixed times, loss-to-follow-up [LTFU]) and visit-level (gaps-in-care, visit constancy) measures. Regression models with generalized estimating equations (GEE) were used to estimate the effect of decentralization on visit-level measures. Patient-level measures were examined using survival methods with Cox regression models, controlling for baseline variables. Results Of 15,650 patients, 43% were enrolled at the hub. Median time in care was 3.1 years. Hub patients were less likely to be LTFU (adjusted hazard ratio (AHR)=0.91, 95% CI: 0.85-0.97), compared to spoke patients. Visit constancy was lower at the hub (−4.5%, 95% CI: −3.5, −5.5), where gaps in care were also more likely to occur (adjusted odds ratio=1.95, 95% CI: 1.83-2.08). Conclusion Decentralized sites demonstrated better retention outcomes using visit-level measures, while the hub achieved better retention outcomes using patient-level measures. Retention estimates produced by incorporating multiple measures showed substantial variation, confirming the influence of measurement strategies on the results of retention research. Future studies of retention in HIV care in sub-Saharan Africa will be well-served by including multiple measures.
Collapse
Affiliation(s)
| | - Becky L Genberg
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Oche O Agbaji
- Faculty of Medical Sciences, University of Jos, Nigeria
| | | | - Nancin Y Dadem
- APIN Centre, Jos University Teaching Hospital, Jos, Nigeria
| | | | | | | | - Norma C Ware
- Harvard Medical School, Boston MA, USA.,Brigham & Women's Hospital, Boston, MA, USA
| |
Collapse
|
36
|
Perry A, Kasaie P, Dowdy DW, Shah M. What Will It Take to Reduce HIV Incidence in the United States: A Mathematical Modeling Analysis. Open Forum Infect Dis 2018; 5:ofy008. [PMID: 29423424 PMCID: PMC5798078 DOI: 10.1093/ofid/ofy008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 01/05/2018] [Indexed: 12/01/2022] Open
Abstract
Background The National HIV/AIDS Strategy has set ambitious goals to improve the epidemic in the United States. However, there is a paucity of usable program-level benchmarks tied to population-level epidemiologic goals. Our objective was to define tangible benchmarks for annual rates along the care continuum that are likely to translate to meaningful reductions in incidence. Methods We used a validated mathematical model of HIV transmission and care engagement to characterize care continuum parameters that would translate into 50% reductions in incidence by 2025, compared with a base case scenario of the current US care continuum. We generated a large pool of simulations in which rates of screening, linkage, and retention in care were varied across wide ranges to evaluate permutations that halved incidence by 2025. Results Among all simulations, 7% achieved a halving of incidence. It was impossible for our simulations to achieve this target if the annual rate of disengagement from care exceeded 20% per year, even at high rates of care reengagement. When retention in care was 95% per year and people living with HIV (PLWH) out of care reengaged within 1.5 years (on average), the probability of halving incidence by 2025 was approximately 90%. Conclusions HIV programs should aim to retain at least 95% of PLWH in care annually and reengage people living with HIV into care within an average of 1.5 years to achieve the goal of halving HIV incidence by 2025.
Collapse
Affiliation(s)
- Allison Perry
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryl
| | - Parastu Kasaie
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryl
| | - David W Dowdy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryl
| | - Maunank Shah
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| |
Collapse
|
37
|
Monroe AK, Fleishman JA, Voss CC, Keruly JC, Nijhawan AE, Agwu AL, Aberg JA, Rutstein RM, Moore RD, Gebo KA. Assessing Antiretroviral Use During Gaps in HIV Primary Care Using Multisite Medicaid Claims and Clinical Data. J Acquir Immune Defic Syndr 2017; 76:82-89. [PMID: 28797023 DOI: 10.1097/qai.0000000000001469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Some individuals who appear poorly retained by clinic visit-based retention measures are using antiretroviral therapy (ART) and maintaining viral suppression. We examined whether individuals with a gap in HIV primary care (≥180 days between HIV outpatient clinic visits) obtained ART during that gap after 180 days. SETTING HIV Research Network data from 5 sites and Medicaid Analytic Extract eligibility and pharmacy data were combined. METHODS Factors associated with having both an HIV primary care gap and a new (ie, nonrefill) ART prescription during a gap were evaluated with multinomial logistic regression. RESULTS Of 6892 HIV Research Network patients, 6196 (90%) were linked to Medicaid data, and 4275 had any Medicaid ART prescription. Over half (54%) had occasional gaps in HIV primary care. Women, older people, and those with suppressed viral load were less likely to have a gap. Among those with occasional gaps (n = 2282), 51% received a new ART prescription in a gap. Viral load suppression before gap was associated with receiving a new ART prescription in a gap (odds ratio = 1.91, 95% confidence interval: 1.57 to 2.32), as was number of days in a gap (odds ratio = 1.04, 95% confidence interval: 1.02 to 1.05), and the proportion of months in the gap enrolled in Medicaid. CONCLUSIONS Medicaid-insured individuals commonly receive ART during gaps in HIV primary care, but almost half do not. Retention measures based on visit frequency data that do not incorporate receipt of ART and/or viral suppression may misclassify individuals who remain suppressed on ART as not retained.
Collapse
Affiliation(s)
- Anne K Monroe
- *Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD;†Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD;‡Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD;§Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX;‖Divisions of Adult and Pediatric Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD;¶Department of Medicine, Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY; and#Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
De Wit S, Battegay M, D'Arminio Monforte A, Lundgren JD, Oprea C, Antinori A, Bhagani S, Fätkenheuer G, Friis-Moller N, Furrer H, Mussini C. European AIDS Clinical Society Second Standard of Care Meeting, Brussels 16-17 November 2016: a summary. HIV Med 2017; 19:77-80. [PMID: 29076235 DOI: 10.1111/hiv.12559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2017] [Indexed: 12/01/2022]
Abstract
The European AIDS Clinical Society (EACS) organized a second meeting on Standard of Care in Europe on November 16-17 th, 2016. The aims of the meeting were to discuss and propose actions on three topics, namely: Adherence to guidelines for treatment initiation, treatment monitoring and outcomes, Retention in care and HIV and tuberculosis co-infection. Several actions need to be implemented in order to further improve quality of care and treatment of HIV in Europe. A common ground for standard of care, based on the EACS Guidelines should be established throughout Europe. EACS plans to interact with policy makers and other stakeholders to insure this common minimal level of standard of care, in particular for initiating of ART, accessibility of drugs and monitoring of ART with viral load. Progress should be made to monitor retention in care, prevent lost to follow and insure return to care. Improving integration of services and accessibility to care play a major role. Integration is also key for optimizing care of HIV-tuberculosis co-infection, as well as diagnosis and prevention of tuberculosis in population at risk. The Standard of Care meeting organized every other year by EACS provides a unique opportunity to monitor progresses and pitfalls in HIV patient care throughout Europe. It is also a forum for advocacy towards policy makers and other stakeholders to constantly improve HIV patient global management, aiming to provide the same level of quality on the whole continent.
Collapse
Affiliation(s)
- S De Wit
- Department of Infectious Diseases, Saint-Pierre University Hospital, Free University of Brussels (ULB), Brussels, Belgium
| | - M Battegay
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | | | - J D Lundgren
- Centre of Excellence for Health, Immunity and Infections, Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - C Oprea
- Victor Babes Clinical Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | - A Antinori
- Lazzaro Spallanzani, National Institute for Infectious Diseases, Rome, Italy
| | | | - G Fätkenheuer
- Internal Medicine, University of Cologne, Köln, Germany
| | - N Friis-Moller
- Zealand University Hospital, Unit of Infectious Diseases, Roskilde, Denmark
| | - H Furrer
- Klinik und Poliklinik für Infektiologie, University Hospital Bern, Bern, Switzerland
| | - C Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | | |
Collapse
|
39
|
Levison JH, Bogart LM, Khan IF, Mejia D, Amaro H, Alegría M, Safren S. "Where It Falls Apart": Barriers to Retention in HIV Care in Latino Immigrants and Migrants. AIDS Patient Care STDS 2017; 31:394-405. [PMID: 28891715 DOI: 10.1089/apc.2017.0084] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Latino immigrants in the United States are disproportionately affected by HIV. Barriers to consistent attendance (retention) in HIV primary care constrain opportunities for HIV treatment success, but have not been specifically assessed in this population. We conducted semistructured interviews with 37 HIV-infected Latinos (aged ≥18 years and born in Puerto Rico or a Latin American Spanish-speaking country) and 14 HIV providers in metropolitan Boston (total n = 51). The Andersen Model of Healthcare Utilization informed a semistructured interview guide, which bilingual research staff used to explore barriers to HIV care. We used thematic analysis to explore the processes of retention in care. Six ubiquitous themes were perceived to influence HIV clinic attendance: (1) stigma as a barrier to HIV serostatus disclosure; (2) social support as a safety net during negative life circumstances; (3) unaddressed trauma and substance use leading to interruption in care; (4) a trusting relationship between patient and provider motivating HIV clinic attendance; (5) basic unmet needs competing with the perceived value of HIV care; and (6) religion providing a source of hope and optimism. Cultural subthemes were the centrality of family (familismo), masculinity (machismo), and trusting relationships (confianza). The timing of barriers was acute (e.g., eviction) and chronic (e.g., family conflict). These co-occurring and dynamic constellation of factors affected HIV primary care attendance over time. HIV-infected Latino immigrants and migrants experienced significant challenges that led to interruptions in HIV care. Anticipatory guidance to prepare for these setbacks may improve retention in HIV care in this population.
Collapse
Affiliation(s)
- Julie H. Levison
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | | | - Iman F. Khan
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Dianna Mejia
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Hortensia Amaro
- Suzanne Dworak-Peck School of Social Work and Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Margarita Alegría
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Steven Safren
- Department of Psychology, University of Miami, Miami, Florida
| |
Collapse
|
40
|
Perlman DC, Jordan AE. Considerations for the Development of a Substance-Related Care and Prevention Continuum Model. Front Public Health 2017; 5:180. [PMID: 28770195 PMCID: PMC5513894 DOI: 10.3389/fpubh.2017.00180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/04/2017] [Indexed: 12/19/2022] Open
Abstract
There are significant gaps in the identification and engagement in care and prevention services of people who use illicit substances. Care continuum models have proven to be useful tools in the evaluation of care for HIV and other conditions; numerous issues in substance-related care and prevention resemble those identified in other continua models. Systems of care for substance misuse and substance use disorders (SUDs) can be viewed as consisting of a prevention and care continuum, reflecting incidence and prevalence of substance misuse and SUDs, screening and identification, medical and psychosocial evaluation for treatment, engagement in evidence-based treatment, treatment retention, relapse prevention, timeliness of step completion, and measures of overall and substance use-related specific morbidity and mortality. Care and prevention continuum models could potentially be applied at program, local, regional, state, and national levels. We discuss important lessons that can be drawn from applications of continuum models in other fields. The development and use of a substance-related care and prevention continuum may yield significant patient care, program evaluation and improvement, and population-level benefits.
Collapse
Affiliation(s)
- David C. Perlman
- Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, United States
- Center for Drug Use and HIV Research, New York, NY, United States
| | - Ashly E. Jordan
- Center for Drug Use and HIV Research, New York, NY, United States
- Department of Epidemiology, School of Public Health, City University of New York, New York, NY, United States
| |
Collapse
|
41
|
Zulliger R, Kennedy C, Barrington C, Perez M, Donastorg Y, Kerrigan D. A multi-level examination of the experiences of female sex workers living with HIV along the continuum of care in the Dominican Republic. Glob Public Health 2017. [PMID: 28648109 DOI: 10.1080/17441692.2017.1342850] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Female sex workers (FSWs) are disproportionately affected by HIV, but there is limited research on their HIV care experiences. This study explored the experiences of 44 FSWs living with HIV in Santo Domingo, Dominican Republic along the HIV care continuum using in-depth interviews and focus groups. Data were analysed through narrative and thematic analysis. Individual-level factors that facilitated engagement in HIV care were physical and mental health. At the interpersonal level, disclosure of HIV or sex work status and receipt of emotional and economic support were important influences on engagement. Yet, negative reactions to or lack of disclosure of these statuses compromised engagement, further highlighting the role of stigma and discrimination. At the environmental level, FSWs described considerable challenges with the health system including long waits and treatment stock-outs at their clinics, but were generally satisfied with HIV clinic staff. At the structural level, lack of economic resources complicated care and treatment adherence. Findings underscore the need for psychosocial and economic support tailored to the unique needs of FSWs to maximise the individual and public health benefits of HIV care.
Collapse
Affiliation(s)
- Rose Zulliger
- a Department of Health, Behavior & Society, The Johns Hopkins Bloomberg School of Public Health , Johns Hopkins University , Baltimore , MD , USA
| | - Caitlin Kennedy
- a Department of Health, Behavior & Society, The Johns Hopkins Bloomberg School of Public Health , Johns Hopkins University , Baltimore , MD , USA
| | - Clare Barrington
- b Department of Health Behavior , The University of North Carolina Gillings School of Global Public Health , Chapel Hill , NC , USA
| | - Martha Perez
- c Instituto Dermatologico y Cirugia de la Piel , Santo Domingo , Dominican Republic
| | - Yeycy Donastorg
- c Instituto Dermatologico y Cirugia de la Piel , Santo Domingo , Dominican Republic
| | - Deanna Kerrigan
- a Department of Health, Behavior & Society, The Johns Hopkins Bloomberg School of Public Health , Johns Hopkins University , Baltimore , MD , USA
| |
Collapse
|
42
|
Howarth AR, Burns FM, Apea V, Jose S, Hill T, Delpech VC, Evans A, Mercer CH, Michie S, Morris S, Sachikonye M, Sabin C. Development and application of a new measure of engagement in out-patient HIV care. HIV Med 2017; 18:267-274. [PMID: 27535219 PMCID: PMC5347876 DOI: 10.1111/hiv.12427] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Commonly used measures of engagement in HIV care do not take into account that the frequency of attendance is related to changes in treatment and health status. This study developed a new measure of engagement in care (EIC) incorporating clinical factors. METHODS We conducted semi-structured interviews with eight HIV physicians to identify factors associated with the timing of patients' next scheduled appointments. These factors informed the development of an algorithm to classify each month of follow-up as "in care" (on or before the time of the next expected attendance) or "out of care" (after the time of the next expected attendance). The EIC algorithm was applied to data from the UK Collaborative HIV Cohort (UK CHIC) study, a large clinical cohort study. RESULTS The interviews indicated that time to next appointment varied depending on psychosocial and physical comorbidities, and clinical factors (time since diagnosis, AIDS diagnosis, treatment status, CD4 count and viral load). The resulting EIC algorithm was applied to 44 432 patients; 83.9% of the 3 021 224 person-months were "in care". Greater EIC was independently associated with older age, white ethnicity, HIV acquisition through sex between men, current use of antiretroviral therapy (ART), a higher nadir CD4 count, later calendar year and being seen at the clinic for the first time within the last year. CONCLUSIONS This algorithm describing engagement in HIV care incorporates a time-updated measure of patients' treatment and health status. It adds to the options available for measuring this key performance indicator.
Collapse
Affiliation(s)
- AR Howarth
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | - FM Burns
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
- Royal Free London NHS Foundation TrustLondonUK
| | - V Apea
- Barts Health NHS TrustLondonUK
| | - S Jose
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | - T Hill
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | | | - A Evans
- Royal Free London NHS Foundation TrustLondonUK
| | - CH Mercer
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | - S Michie
- Centre for Behaviour ChangeUniversity College LondonLondonUK
| | - S Morris
- Department of Applied Health ResearchUniversity College LondonLondonUK
| | | | - C Sabin
- Research Department of Infection and Population HealthUniversity College LondonLondonUK
| | | | | |
Collapse
|
43
|
Rebeiro PF, Abraham AG, Horberg MA, Althoff KN, Yehia BR, Buchacz K, Lau BM, Sterling TR, Gange SJ. Sex, Race, and HIV Risk Disparities in Discontinuity of HIV Care After Antiretroviral Therapy Initiation in the United States and Canada. AIDS Patient Care STDS 2017; 31:129-144. [PMID: 28282246 PMCID: PMC5359655 DOI: 10.1089/apc.2016.0178] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Peter F. Rebeiro
- Vanderbilt University School of Medicine, Department of Medicine, Division of Infectious Diseases, Nashville, Tennessee
| | - Alison G. Abraham
- Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland
| | - Michael A. Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland
| | - Keri N. Althoff
- Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland
| | - Baligh R. Yehia
- University of Pennsylvania, Perelman School of Medicine, Department of Medicine, Philadelphia, Pennsylvania
| | - Kate Buchacz
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Bryan M. Lau
- Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland
| | - Timothy R. Sterling
- Vanderbilt University School of Medicine, Department of Medicine, Division of Infectious Diseases, Nashville, Tennessee
| | - Stephen J. Gange
- Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland
| |
Collapse
|
44
|
Hellinger FJ. In Four ACA Expansion States, The Percentage Of Uninsured Hospitalizations For People With HIV Declined, 2012-14. Health Aff (Millwood) 2017; 34:2061-8. [PMID: 26643626 DOI: 10.1377/hlthaff.2015.0718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This study examines the influence of the Affordable Care Act's optional state Medicaid expansion on insurance coverage and health outcomes for hospitalized patients with HIV. I used data from the State Inpatient Databases of the Healthcare Cost and Utilization Project for all hospitalizations of patients with HIV from 2012 through the first six months of 2014 in four states that expanded their Medicaid programs and two states that did not. I found that the percentage of hospitalizations of uninsured people with HIV in the four expansion states fell from 13.7 percent to 5.5 percent in the study period, while the percentage in the two nonexpanding states increased from 14.5 percent to 15.7 percent. I also found that hospitalized patients with HIV who did not have insurance were 40 percent more likely to die during their hospital stays than comparable patients with insurance.
Collapse
Affiliation(s)
- Fred J Hellinger
- Fred J. Hellinger is a senior economist in the Center for Delivery, Organization, and Markets at the Agency for Healthcare Research and Quality, in Rockville, Maryland
| |
Collapse
|
45
|
Perlman DC, Jordan AE, Nash D. Conceptualizing Care Continua: Lessons from HIV, Hepatitis C Virus, Tuberculosis and Implications for the Development of Improved Care and Prevention Continua. Front Public Health 2017; 4:296. [PMID: 28119910 PMCID: PMC5222805 DOI: 10.3389/fpubh.2016.00296] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 12/23/2016] [Indexed: 01/04/2023] Open
Abstract
Background To examine the application of continuum models to tuberculosis, HIV, and other conditions; to theorize the concept of continua; and to learn lessons that could inform the development of improved care and prevention continua as public health metrics. Methods An analytic review of literature drawn from several fields of health care. Results The continuum construct is now part of public health evaluation systems for HIV, and is increasingly used in public health and the medical literature. Issues with the comparability and optimal design of care continuum models have been raised, and their methodologic and theoretic underpinnings and scope of focus have been under-addressed. Review of relevant publications suggests that a key limitation of current models is their lack of measures reflecting incidence and mortality. Issues relating to continua data being longitudinal or cross-sectional, definition of numerators and denominators for each step, data sources, measures of timeliness of step completion, theoretic models to facilitate inferences of causes of care continuum gaps, how measures of prevention efforts, reinfection/relapses, and interactions of continua for co-occurring comorbidities should be reflected, and how analyses of differences in retention over time, across geographic regions, and in response to interventions should be conducted are critical to the development of sound care and prevention continuum models. Conclusion Lessons learned from the application of continuum models to HIV and other conditions suggest that the application of well-formulated constructs of care and prevention continua, that depict, in well defined, standardized steps, incidence and mortality, along with degrees of and time to screening, engagement in care and prevention, treatment and treatment outcomes, including relapse or reinfection, may be vital tools in evaluating intervention and program outcomes, and in improving population health and population health metrics for a wide range conditions.
Collapse
Affiliation(s)
- David C Perlman
- Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA; Center for Drug Use and HIV Research, New York, NY, USA
| | - Ashly E Jordan
- Department of Epidemiology, School of Public Health, City University of New York, New York, NY, USA; Center for Drug Use and HIV Research, New York, NY, USA
| | - Denis Nash
- Department of Epidemiology, School of Public Health, City University of New York , New York, NY , USA
| |
Collapse
|
46
|
Gillis J, Loutfy M, Bayoumi AM, Antoniou T, Burchell AN, Walmsley S, Cooper C, Klein MB, Machouf N, Montaner JSG, Rourke SB, Tsoukas C, Hogg R, Raboud J. A Multi-State Model Examining Patterns of Transitioning Among States of Engagement in Care in HIV-Positive Individuals Initiating Combination Antiretroviral Therapy. J Acquir Immune Defic Syndr 2016; 73:531-539. [PMID: 27851713 PMCID: PMC5119642 DOI: 10.1097/qai.0000000000001109] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 05/09/2016] [Indexed: 12/03/2022]
Abstract
BACKGROUND Common measures of engagement in care fail to acknowledge that infrequent follow-up may occur either intentionally among patients with sustained virologic suppression or unintentionally among patients with poor clinical outcomes. METHODS Five states of HIV care were defined within the Canadian Observational Cohort Collaboration following combination antiretroviral therapy (cART) initiation: (1) guidelines HIV care [suppressed viral load (VL) and CD4 >200 cells per cubic millimeter, no gaps in cART >3 months, no gaps in CD4 or VL measurement >6 months], (2) successful care with decreased frequency of follow-up (as above except no gaps in CD4 or VL measurement >12 months), (3) suboptimal care (unsuppressed VL, CD4 <200 cells per cubic millimeter on 2 consecutive visits, ≥1 gap in cART >3 months, or ≥1 gap in CD4 or VL measurement >12 months), (4) loss to follow-up (no contact for 18 months), and (5) death. Multi-state models were used to determine factors associated with transitioning among states. RESULTS In total, 7810 participants were included. Younger age, female gender, Indigenous ethnicity, and people who have injected drugs were associated with increased likelihoods of transitioning from guidelines to suboptimal care and decreased likelihoods of transitioning from suboptimal to guidelines care. One-fifth of individuals in successful, decreased follow-up after cART initiation (mean sojourn time 0.72 years) were in suboptimal care in subsequent years. CONCLUSIONS Using routinely collected data, we have developed a flexible framework that characterizes patient transitions among states of HIV clinical care. We have demonstrated that multi-state models provide a useful approach to supplement "cascade of care" work.
Collapse
Affiliation(s)
- Jennifer Gillis
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Mona Loutfy
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Maple Leaf Medical Clinic, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed M. Bayoumi
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Centre for Urban Health Solutions, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Tony Antoniou
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ann N. Burchell
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Centre for Urban Health Solutions, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sharon Walmsley
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Immunodeficiency Clinic, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Marina B. Klein
- McGill University Health Centre, McGill University, Montreal, Québec, Canada
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Nima Machouf
- Clinique Médicale l'Actuel, Montreal, Québec, Canada
| | - Julio S. G. Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean B. Rourke
- Centre for Urban Health Solutions, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Ontario HIV Treatment Network, Toronto, Ontario, Canada; and
| | - Christos Tsoukas
- McGill University Health Centre, McGill University, Montreal, Québec, Canada
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Robert Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Janet Raboud
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - the CANOC Collaboration
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Maple Leaf Medical Clinic, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Centre for Urban Health Solutions, Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Immunodeficiency Clinic, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- McGill University Health Centre, McGill University, Montreal, Québec, Canada
- Department of Medicine, McGill University, Montreal, Québec, Canada
- Clinique Médicale l'Actuel, Montreal, Québec, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Ontario HIV Treatment Network, Toronto, Ontario, Canada; and
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| |
Collapse
|
47
|
The Challenge of and Opportunities for Transitioning and Maintaining a Continuum of Care Among Adolescents and Young Adults Living with HIV in Resource Limited Settings. CURRENT TROPICAL MEDICINE REPORTS 2016; 3:149-157. [PMID: 30854282 DOI: 10.1007/s40475-016-0091-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
An unprecedented number of youth living with HIV (YLHIV) are aging into adolescence and young adulthood, increasing concerns about the possibility of these youth being lost in the transition from supported care (sometimes in pediatric settings) to more independent healthcare settings and perhaps furthering the emerging disparities in outcomes (e.g., higher nonadherence to treatment, increased morbidity and mortality). In resource-rich settings where there is likely greater recognition of adolescent cognitive and developmental challenges, transitioning YLHIV to adult healthcare has emerged as a major challenge. In resource limited settings (RLS), where the burden of HIV is significant and healthcare resources often stretched, the challenge to move toward healthcare independence and maintain a fluid continuum of care for YLHIV may be the greatest. We review key issues in transitioning YLHIV in RLS, highlighting steps in the transition process, examining evidence where available, and discussing challenges and opportunities to understanding and optimizing outcomes.
Collapse
|
48
|
Enns EA, Reilly CS, Virnig BA, Baker K, Vogenthaler N, Henry K. Potential Impact of Integrating HIV Surveillance and Clinic Data on Retention-in-Care Estimates and Re-Engagement Efforts. AIDS Patient Care STDS 2016; 30:409-15. [PMID: 27610462 DOI: 10.1089/apc.2016.0169] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Retention in care is essential to the health of people living with HIV and also for their communities. We sought to quantify the value of integrating HIV surveillance data with clinical records for improving the accuracy of retention-in-care estimates and the efficiency of efforts to re-engage out-of-care patients. Electronic medical records (EMRs) of HIV+ patients ≥18 years old from a public, hospital-based clinic in Minneapolis, MN between 2008 and 2014 were merged with state surveillance data on HIV-related laboratory tests, out-of-state relocation, and mortality. We calculated levels of retention and estimated the number of required case investigations to re-engage patients who appeared to be out of care over the study period with and without surveillance data integration. Retention was measured as the proportion of years in compliance with Health Resources and Services Administration (HRSA) guidelines (two clinical encounters >90 days apart annually) and the proportion of patients experiencing a gap in care >12 months. With data integration, retention estimates improved from an average HRSA compliance of 70.3% using EMR data alone to 77.5% with surveillance data, whereas the proportion of patients experiencing a >12-month gap in care decreased from 45.0% to 34.4%. If case investigations to re-engage patients were initiated after a 12-month gap in care, surveillance data would avoid 330 (29.3%) investigations over the study period. Surveillance data integration improves the accuracy of retention-in-care estimates and would avert a substantial number of unnecessary case investigations for patients who appear to be out of care but, in fact, receive care elsewhere or have died.
Collapse
Affiliation(s)
- Eva A. Enns
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Cavan S. Reilly
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Beth A. Virnig
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota
| | - Karen Baker
- Analytic Center of Excellence, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Nicholas Vogenthaler
- Division of Infectious Diseases, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Keith Henry
- Division of Infectious Diseases, Hennepin County Medical Center, Minneapolis, Minnesota
| |
Collapse
|
49
|
Abstract
OBJECTIVE Hospital readmissions impose considerable physical and psychological hardships on patients and represent a high, but possibly preventable, cost for insurers and hospitals alike. The objective of this study was to identify patient characteristics associated with 30-day readmission among persons living with HIV/AIDS (PLWH) using a statewide administrative database and to characterize the movement of patients between facilities. DESIGN Retrospective cohort analysis of HIV-infected individuals in New York State using a comprehensive, all-payer database. SETTING All hospitals in New York State. PARTICIPANTS HIV-infected adults admitted to a medical service in 2012. PLWH identified using International Classification of Disease (ICD)-9 diagnosis codes 042 and V08. RESULTS Of 23,544 index hospitalizations, 21.8% (5121) resulted in readmission. Multivariable predictors of readmission included insurance status, housing instability, psychoses, multiple comorbid chronic conditions, substance use, and past inpatient and emergency department visits. Over 30% of readmissions occurred at a different facility than that of the initial hospitalization. CONCLUSION A number of patient characteristics were independently associated with hospital readmission within 30 days. Behavioral health disorders and comorbid conditions may be the strongest predictors of readmission in PLWH. Readmissions, especially those in urban areas, often result in fragmented care which may compromise the quality of care and result in harmful discontinuity of medical treatment.
Collapse
|
50
|
Comparison of Single-Visit and Multiple-Visit Measures of Retention in Care for HIV Monitoring and Evaluation. J Acquir Immune Defic Syndr 2016; 71:e59-62. [PMID: 26505331 DOI: 10.1097/qai.0000000000000878] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|