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

Prevention, treatment and cure of HIV infection

The development of antiretroviral therapy for the prevention and treatment of HIV infection has been marked by a series of remarkable successes. However, the efforts to develop a vaccine have largely failed, and efforts to discover a cure are only now beginning to gain traction. In this Review, we describe recent progress on all fronts - pre-exposure prophylaxis, vaccines, treatment and cure - and we discuss the unmet needs, both current and in the coming years. We describe the emerging arsenal of drugs, biologics and strategies that will hopefully address these needs. Although HIV research has largely been siloed in the past, this is changing, as the emerging research agenda is marked by multiple cross-discipline synergies and collaborations. As the limitations of antiretroviral drugs as a means to truly end the epidemic are becoming more apparent, there is a great need for continued efforts to develop an effective preventative vaccine and a scalable cure, both of which remain formidable challenges.

Describing Engagement in the HIV Care Cascade: A Methodological Study

Introduction

Engagement in the HIV care cascade is required for people living with HIV (PLWH) to achieve an undetectable viral load. However, varying definitions of engagement exist, contributing to heterogeneity in research regarding how many individuals are actively participating and benefitting from care. A standardized definition is needed to enhance comparability and pooling of data from engagement studies.

Objectives

The objective of this paper was to describe the various definitions for engagement used in HIV clinical trials.

Methods

Articles were retrieved from CASCADE, a database of 298 clinical trials conducted to improve the HIV care cascade (https://hivcarecascade.com/), curated by income level, vulnerable population, who delivered the intervention, the setting in which it was delivered, the intervention type, and the level of pragmatism of the intervention. Studies with engagement listed as an outcome were selected from this database.

Results

13 studies were eligible, of which five did not provide an explicit definition for engagement. The remaining studies used one or more of the following: appointment adherence (n=6), laboratory testing (n=2), adherence to antiretroviral therapy (n=2), time specification (n=5), intervention adherence (n=5), and quality of interaction (n=1).

Conclusion

This paper highlights the existing diversity in definitions for engagement in the HIV care cascade and categorize these definitions into appointment adherence, laboratory testing, adherence to antiretroviral therapy, time specification, intervention adherence, and quality of interaction. We recommend consensus on how to describe and measure engagement.

Health outcomes and healthcare utilization of Native Hawaiians and other Pacific Islanders living with HIV in Hawai'i: A mixed-methods study

OBJECTIVES

Past research shows mixed outcomes in terms of HIV-related disparities among Native Hawaiians and Pacific Islanders (NHOPI). This study investigates HIV-related disparities among NHOPI living with HIV in Hawai'i.

DESIGN

An explanatory sequential design was utilized. The quantitative portion analyzed survey data from a statewide Ryan White Needs Assessment (N = 398) to examine the differences in viral suppression and satisfaction with care between NHOPI and other ethnic groups. Utilizing the behavioral model for vulnerable populations (BMVP), semi-structured interviews (N = 16) were conducted next to explain what factors play a role in satisfaction with care and viral suppression when it comes to NHOPI living with HIV in Hawai'i.

RESULTS

Among the 398 participants 13% were NHOPI. NHOPI were more likely to have a viral load of ≥10,000 copies/mL compared to those who didn't identify as NHOPI. However, there were no significant differences for other viral load levels (20-199 or 200-9999), and only 20 participants (5.2%) had a viral load of 10,000 copies/mL or more. No significant ethnic differences were found in satisfaction with medical care. In the qualitative phase, factors from all domains of the BMVP were represented within the four themes identified: (1) Care coordination is essential- with AIDs service organizations taking the lead; (2) HIV care, as well as overall health, is defined by the effectiveness of medication; (3) Initial diagnosis is a critical moment for intervention; and (4) Aspects of culture are intangible.

CONCLUSION

Among NHOPI in Hawai'i who are engaged in case management, there appears to be no substantial disparities in either viral load or satisfaction with care compared to other ethnic groups. Despite this, qualitative findings provide insights on how ethnicity and culture may still be playing a role. Addressing all domains of the BMVP is crucial to addressing this.

Virological suppression among gay, bisexual, and other men who have sex with men living with HIV in Vancouver, Canada: A longitudinal cohort study from 2012-2017

INTRODUCTION

In 2010, British Columbia (BC) implemented HIV Treatment as Prevention (TasP) as policy. We examined trends in virologic suppression and determinants of significant viremia among a prospective biobehavioural cohort of men who have sex with men (gbMSM) in Vancouver from 2012-2017.

METHODS

Respondent-driven sampling was used to recruit sexually active gbMSM (≥16 years) who completed biannual study visits with a computer-assisted self-interview and clinical CD4 and viral load (VL) testing. We linked participant data with the BC HIV Drug Treatment Program to obtain antiretroviral dispensing and VL data. We conducted a trend analysis of VL suppression using univariable generalized estimating equation (GEE) multi-level modelling and multivariable GEE to identify factors associated with episodes of VL ≥200 copies/mL.

RESULTS

Of 774 participants, 223 were living with HIV at baseline and 16 were diagnosed during follow-up (n = 239). We observed a significant trend towards reduced levels of unsuppressed VL (>200 copies/mL) from 22% (07/2012-12/2012) to 12% (07/2016-12/2016) (OR:0.87; 95%CI:0.83-0.91 for each 6-month period). Among those with at least one follow-up visit, (n = 178, median follow-up = 3.2 years, median age = 46.9 years), younger age (aOR:0.97; 95%CI:0.94-0.99, per year), ecstasy use (aOR:1.69; 95%CI:1.13-2.53), crystal methamphetamine use (aOR:1.71; 95%CI:1.18-2.48), seeking sex via websites (aOR:1.46; 95%CI:1.01-2.12), and lower HIV treatment optimism (aOR:0.94; 95%CI:0.90-0.97) were associated with episodes of elevated viremia.

CONCLUSIONS

During a period when TasP policy was actively promoted, we observed a significant trend towards reduced levels of unsuppressed VL. Continued efforts should promote HIV treatment optimism and engagement, especially among younger gbMSM and those who use ecstasy and crystal methamphetamine.

Effectiveness of an HIV care model integrated into addiction care based on medication-assisted treatment for HIV-positive people who use drugs

Our objective was to evaluate the effectiveness of initiated or reinitiated antiretroviral therapy (ART) in HIV-positive active drug users receiving integrated HIV and addiction care in a harm reduction setting. We performed a study of HIV-positive persons who use drugs (PWUD) in a harm reduction unit in Madrid, Spain. Participants received HIV care integrated into addiction care and received at least one dose of observed ART based on medication-assisted treatment between January 2013 and December 2019. Individuals newly diagnosed with HIV (n = 13) had a greater median CD4 cell count at baseline were less likely to be late presenters, had a greater CD4 cell count increase, and were less likely to have AIDS in comparison to those who were aware of their HIV status (n = 87) at initiation or reinitiation of ART. The overall VS was 73% in the intention-to-treat (ITT) analysis and 92.4% in the modified intention-to-treat (mITT) analysis. People who were engaged in OST, people with >90% adherence to ART, and older people were positively associated with VS in the multivariate analysis. An HIV care model integrated into a harm reduction facility demonstrated a high uptake of HIV treatment, retention in care, improvement in adherence, and achievement of VS.

Barriers to HIV Care by Viral Suppression Status Among US Adults With HIV: Findings From the Centers for Disease Control and Prevention Medical Monitoring Project

ABSTRACT

Failure to maintain viral suppression may be attributed to suboptimal care engagement. Using data collected during 2015-2018, we describe nationally representative estimates of engagement in care among US adults with diagnosed HIV, overall and by viral suppression. Of those who felt they did not receive enough care, we described detailed information on barriers to care by viral suppression. We reported weighted percentages and evaluated differences between groups using Rao-Scott chi-square tests (p < .05). Persons who were not virally suppressed were less likely to be retained in care (57.3 vs. 90.8%). Common barriers to care included life circumstances that impeded receipt of care (50.0%), financial barriers (34.5%), and not feeling sick enough to take medicine (32.0%). Barriers to care varied by viral suppression status, and people who were not virally suppressed were more likely to report more than one barrier to care. These findings demonstrate that barriers can be multifaceted; addressing barriers to care by expanding comprehensive care models in HIV care settings could improve clinical outcomes among people with HIV.

Characterizing the Human Immunodeficiency Virus Care Continuum Among Transgender Women and Cisgender Women and Men in Clinical Care: A Retrospective Time-series Analysis

BACKGROUND

Prior studies suggest that transgender women (TW) with human immunodeficiency virus (HIV) are less likely to be virally suppressed than cisgender women (CW) and cisgender men (CM). However, prior data are limited by small sample sizes and cross-sectional designs. We sought to characterize the HIV care continuum comparing TW to CW and CM in the United States and Canada.

METHODS

We analyzed annual HIV care continuum outcomes by gender status from January 2001 through December 2015 among adults (aged ≥18 years) in 15 clinical cohorts. Outcomes were retention in care and viral suppression.

RESULTS

The study population included TW (n = 396), CW (n = 14 094), and CM (n = 101 667). TW had lower proportions retained in care than CW and CM (P < .01). Estimates of retention in care were consistently lower in TW, with little change over time within each group. TW and CW had similar proportions virally suppressed over time (TW, 36% in 2001 and 80% in 2015; CW, 35% in 2001 and 83% in 2015) and were lower than CM (41% in 2001 and 87% in 2015). These differences did not reach statistical significance after adjusting for age, race, HIV risk group, and cohort.

CONCLUSIONS

TW experience challenges with retention in HIV care. However, TW who are engaged in care achieve viral suppression that is comparable to that of CW and CM of similar age, race, and HIV risk group. Further research is needed to understand care engagement disparities.

Health Care-Specific Enacted HIV-Related Stigma's Association with Antiretroviral Therapy Adherence and Viral Suppression Among People Living with HIV in Florida

Among people living with HIV (PLWH) in Florida, <2/3 are virally suppressed (viral load <200 copies/mL). Previous theoretical frameworks have pointed to HIV-related stigma as an important factor for viral suppression; an important outcome related to the HIV continuum of care. This study aims to analyze the association between enacted HIV-related stigma and antiretroviral therapy (ART) adherence and viral suppression among a sample of PLWH in Florida. The overall sample (n = 932) was male (66.0%), majority greater than 45 years of age (63.5%), black (58.1%), and non-Hispanic (79.7%). Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were estimated using logistic regression models. The odds of nonadherence to ART was not significantly greater for those reporting low/moderate or high levels of general enacted HIV-related stigma (vs. no stigma) [AOR = 1.30, CI: (0.87-1.95), p = 0.198; AOR = 1.17, CI: (0.65-2.11), p = 0.600, respectively]. Moreover, the odds of nonviral suppression were not significantly greater for those reporting low/moderate or high levels of general enacted HIV-related stigma (vs. no stigma) [AOR = 0.92, CI: (0.60-1.42), p = 0.702; AOR = 1.16, CI: (0.64-2.13), p = 0.622, respectively]. However, ever experiencing health care-specific enacted HIV-related stigma was associated with both nonadherence [AOR = 2.29, CI: (1.25-4.20), p = 0.008] and nonsuppression [AOR = 2.16, CI: (1.19-3.92), p = 0.011]. Despite limitations, the results suggest that the perpetuation of stigma by health care workers may have a larger impact on continuum of care outcomes of PLWH than other sources of enacted stigma. Based on the results, there is a need to develop and evaluate interventions for health care workers intended to reduce experienced stigma among PLWH and improve health outcomes.

Using HIV Surveillance and Clinic Data to Optimize Data to Care Efforts in Community Health Centers in Massachusetts: The Massachusetts Partnerships for Care Project

BACKGROUND

We describe Data to Care processes of the Massachusetts Partnerships for Care (MA P4C) project and identify factors associated with engagement, retention, and viral suppression outcomes.

METHODS

The Massachusetts Department of Public Health and participating community health centers generated lists of patients not in care based on a temporal gap in laboratory results, missed clinic visits, and provider concern regarding engagement. The Massachusetts Department of Public Health and community health centers reviewed the lists monthly and identified out-of-care patients in need of linkage or re-engagement.

RESULTS

Between October 2015 and June 2017, of 1418 patients potentially out of care, 83 (5.9%) were confirmed to be out of care. Forty-four of those out of care (53%) received services or were re-engaged in care within 90 days, 45 (54%) were retained in care, and 40 (48%) were virally suppressed. The odds of being re-engaged or retained were lower for patients who were 6 months out-of-care (vs. those newly diagnosed). Patients with an AIDS-defining condition had increased odds of retention and viral suppression. The odds of viral suppression were reduced for patients who reported exposure categories other than men who have sex with men and were younger (30-49 years vs. ≥50 years).

CONCLUSIONS

Although rates of re-engagement, retention, and viral suppression were low, the MA P4C Data to Care procedures provided a means for accurate ascertainment of out-of-care status. Future Data to Care programs should investigate the factors that contribute to disengagement from care.

Multilevel Barriers to Engagement in the HIV Care Continuum Among Residents of the State of Rhode Island Living with HIV

An estimated 1.2 million people in the United States are living with HIV. Of those living with HIV, only 40% are engaged in HIV care, 37% are prescribed antiretroviral therapy (ART), and 30% are virally suppressed. Individual-, interpersonal-, and structural-level factors that represent barriers to engagement along the HIV care continuum are important to identify in order to inform priority areas and interventions. 296 adult residents of Rhode Island living with HIV between November 2015 and January 2016 were asked to participate in an observational study (Ryan White Part B Health Resources and Services Administration-funded consumer needs assessment) to identify the multilevel factors associated with engagement in the HIV care continuum outcomes (i.e., being retained in care, being prescribed ART, adhering to ART, and achieving viral suppression-all in the past 12 months). Multivariable logistic regression models were fit to model the four HIV care continuum outcomes. The majority of participants were over age 30 (92.5%), racial/ethnic minorities (67.1%), cisgender men (56.9%), and identified as straight/heterosexual (60.5%). Overall, 95.2% of participants were retained in care in the past 12 months, 93.0% were prescribed ART, 87.1% were currently adherent to ART, and 68.2% were virally suppressed. Factors positively associated with not being retained in HIV care in the past 12 months included having no income and challenges navigating the HIV care system. Being age 18-29 and having a provider who does not know how to treat people with HIV/AIDS were each positively associated with not being prescribed ART. Factors positively associated with not being adherent to ART included being age 18-29 and substance use in the past 12 months. Finally, having private insurance and having a provider who is not trustworthy were each positively associated with not being virally suppressed. Regardless of the fact that many of the individuals living with HIV in this sample are able to achieve an undetectable viral load, challenges with retention in HIV care and ART adherence threaten to undermine the clinical and public health benefits of treatment as prevention. Future longitudinal research conducted to better understand how to boost the effectiveness of treatment as prevention in this population should focus on examining the unique multilevel factors, polymorbidities, and conditions (mostly social determinants of health including housing, socioeconomic position, etc.) associated with suboptimal engagement across the stages of the HIV care continuum.

Detecting Social and Behavioral Determinants of Health with Structured and Free-Text Clinical Data

BACKGROUND

Social and behavioral determinants of health (SBDH) are environmental and behavioral factors that often impede disease management and result in sexually transmitted infections. Despite their importance, SBDH are inconsistently documented in electronic health records (EHRs) and typically collected only in an unstructured format. Evidence suggests that structured data elements present in EHRs can contribute further to identify SBDH in the patient record.

OBJECTIVE

Explore the automated inference of both the presence of SBDH documentation and individual SBDH risk factors in patient records. Compare the relative ability of clinical notes and structured EHR data, such as laboratory measurements and diagnoses, to support inference.

METHODS

We attempt to infer the presence of SBDH documentation in patient records, as well as patient status of 11 SBDH, including alcohol abuse, homelessness, and sexual orientation. We compare classification performance when considering clinical notes only, structured data only, and notes and structured data together. We perform an error analysis across several SBDH risk factors.

RESULTS

Classification models inferring the presence of SBDH documentation achieved good performance (F1 score: 92.7-78.7; F1 considered as the primary evaluation metric). Performance was variable for models inferring patient SBDH risk status; results ranged from F1 = 82.7 for LGBT (lesbian, gay, bisexual, and transgender) status to F1 = 28.5 for intravenous drug use. Error analysis demonstrated that lexical diversity and documentation of historical SBDH status challenge inference of patient SBDH status. Three of five classifiers inferring topic-specific SBDH documentation and 10 of 11 patient SBDH status classifiers achieved highest performance when trained using both clinical notes and structured data.

CONCLUSION

Our findings suggest that combining clinical free-text notes and structured data provide the best approach in classifying patient SBDH status. Inferring patient SBDH status is most challenging among SBDH with low prevalence and high lexical diversity.

Trends and Disparities in Mortality and Progression to AIDS in the Highly Active Antiretroviral Therapy Era: Tennessee, 1996-2016

Objectives. To use statewide surveillance data to examine trends and disparities in mortality and progression from HIV to AIDS comprehensively in Tennessee over the past 20 years.Methods. Individuals diagnosed with HIV in Tennessee from 1996 to 2016 were identified through the Tennessee Department of Health Enhanced HIV/AIDS Reporting System. Clinical AIDS and all-cause mortality were the outcomes. Cox regression yielded adjusted hazard ratios (AHRs) for death and competing risk regression yielded adjusted subhazard ratios (SHRs) for AIDS, with death as the competing event.Results. Individuals with a history of heterosexual contact (AHR = 1.20; 95% confidence interval [CI] = 1.12, 1.29) and injection drug use (AHR = 1.27; 95% CI = 1.18, 1.38) had increased hazards of death relative to those with a history of male-to-male sexual contact. Hazards of death were lower among White (AHR = 0.79; 95% CI = 0.73, 0.85) and Hispanic (AHR = 0.50; 95% CI = 0.40, 0.63) individuals than among Black individuals. Those with heterosexual contact (SHR = 1.20; 95% CI = 1.12, 1.29) and injection drug use (SHR = 1.27; 95% CI = 1.18, 1.38) had a greater risk of AIDS than those with male-to-male sexual contact. White individuals (SHR = 0.85; 95% CI = 0.81, 0.90) had a lower risk of AIDS than Black individuals, and female individuals (SHR = 0.84; 95% CI = 0.79, 0.90) had a lower risk than male individuals.Conclusions. The trends, disparities, and outcomes assessed in our study will inform HIV testing and care linkage program design and implementation in Tennessee.

Using big data analytics to improve HIV medical care utilisation in South Carolina: A study protocol

INTRODUCTION

Linkage and retention in HIV medical care remains problematic in the USA. Extensive health utilisation data collection through electronic health records (EHR) and claims data represent new opportunities for scientific discovery. Big data science (BDS) is a powerful tool for investigating HIV care utilisation patterns. The South Carolina (SC) office of Revenue and Fiscal Affairs (RFA) data warehouse captures individual-level longitudinal health utilisation data for persons living with HIV (PLWH). The data warehouse includes EHR, claims and data from private institutions, housing, prisons, mental health, Medicare, Medicaid, State Health Plan and the department of health and human services. The purpose of this study is to describe the process for creating a comprehensive database of all SC PLWH, and plans for using BDS to explore, identify, characterise and explain new predictors of missed opportunities for HIV medical care utilisation.

METHODS AND ANALYSIS

This project will create person-level profiles guided by the Gelberg-Andersen Behavioral Model and describe new patterns of HIV care utilisation. The population for the comprehensive database comes from statewide HIV surveillance data (2005-2016) for all SC PLWH (N≈18000). Surveillance data are available from the state health department's enhanced HIV/AIDS Reporting System (e-HARS). Additional data pulls for the e-HARS population will include Ryan White HIV/AIDS Program Service Reports, Health Sciences SC data and Area Health Resource Files. These data will be linked to the RFA data and serve as sources for traditional and vulnerable domain Gelberg-Anderson Behavioral Model variables. The project will use BDS techniques such as machine learning to identify new predictors of HIV care utilisation behaviour among PLWH, and 'missed opportunities' for re-engaging them back into care.

ETHICS AND DISSEMINATION

The study team applied for data from different sources and submitted individual Institutional Review Board (IRB) applications to the University of South Carolina (USC) IRB and other local authorities/agencies/state departments. This study was approved by the USC IRB (#Pro00068124) in 2017. To protect the identity of the persons living with HIV (PLWH), researchers will only receive linked deidentified data from the RFA. Study findings will be disseminated at local community forums, community advisory group meetings, meetings with our state agencies, local partners and other key stakeholders (including PLWH, policy-makers and healthcare providers), presentations at academic conferences and through publication in peer-reviewed articles. Data security and patient confidentiality are the bedrock of this study. Extensive data agreements ensuring data security and patient confidentiality for the deidentified linked data have been established and are stringently adhered to. The RFA is authorised to collect and merge data from these different sources and to ensure the privacy of all PLWH. The legislatively mandated SC data oversight council reviewed the proposed process stringently before approving it. Researchers will get only the encrypted deidentified dataset to prevent any breach of privacy in the data transfer, management and analysis processes. In addition, established secure data governance rules, data encryption and encrypted predictive techniques will be deployed. In addition to the data anonymisation as a part of privacy-preserving analytics, encryption schemes that protect running prediction algorithms on encrypted data will also be deployed. Best practices and lessons learnt about the complex processes involved in negotiating and navigating multiple data sharing agreements between different entities are being documented for dissemination.

Development of PositiveLinks: A Mobile Phone App to Promote Linkage and Retention in Care for People With HIV

Background

Linkage to and retention in HIV care are challenging, especially in the Southeastern United States. The rise in mobile phone app use and the potential for an app to deliver just in time messaging provides a new opportunity to improve linkage and retention among people living with HIV (PLWH).

Objective

This study aimed to develop an app to engage, link, and retain people in care. We evaluated the acceptability, feasibility, and impact of the app among users.

Methods

App development was informed by principles of chronic disease self-management and formative interviews with PLWH. Once developed, the app was distributed among participants, and usability feedback was incorporated in subsequent iterations. We interviewed app users after 3 weeks to identify usability issues, need for training on the phone or app, and to assess acceptability. We tracked and analyzed usage of app features for the cohort over 2 years.

Results

A total of 77 participants used the app during the pilot study. The query response rate for the first 2 years was 47.7%. Query response declined at a rate of 0.67% per month. The community message board was the most popular feature, and 77.9% (60/77) of users posted on the board at least once during the 2 years.

Conclusions

The PositiveLinks app was feasible and acceptable among nonurban PLWH. High participation on the community message board suggests that social support from peers is important for people recently diagnosed with or returning to care for HIV.

Compound Retention in Care and All-Cause Mortality Among Persons Living With Human Immunodeficiency Virus

Background

To obtain optimal health outcomes, persons living with human immunodeficiency virus (HIV) must be retained in clinical care. We examined the relationships between 4 possible combinations of 2 separate retention measures (missed visits and the Institute of Medicine [IOM] indicator) and all-cause mortality.

Methods

The sample included 4162 antiretroviral therapy (ART)-naive patients who started ART between January 2000 and July 2010 at any of 5 US sites of the Center for AIDS Research Network of Integrated Clinical Systems. The independent variable of interest was retention, captured over the 12-month period after the initiation of ART. The study outcome, all-cause mortality 1 year after ART initiation, was determined by querying the Social Security Death Index or the National Death Index. We evaluated the associations of the 4 categories of retention with all-cause mortality, using the Cox proportional hazards models.

Results

Ten percent of patients did not meet retention standards for either measure (hazard ratio [HR], 2.26; 95% confidence interval [CI], 1.59-3.21). Patients retained by the IOM but not the missed-visits measure (42%) had a higher HR for mortality (1.72; 95% CI, 1.33-2.21) than patients retained by both measures (41%). Patients retained by the missed-visits but not the IOM measure (6%) had the same mortality hazards as patients retained by both measures (HR, 1.01; 95% CI, .54-1.87).

Conclusions

Missed visits within the first 12 months of ART initiation are a major risk factor for subsequent death. Incorporating missed visits in clinical and public health retention and viral suppression programming is advised.

Level of Alcohol Use Associated with HIV Care Continuum Targets in a National U.S. Sample of Persons Living with HIV Receiving Healthcare

We evaluated associations between levels of alcohol use and HIV care continuum components using national Veterans Aging Cohort Study data for all patients with HIV and AUDIT-C screening (2/1/2008-9/30/2014). Poisson regression models evaluated associations between alcohol use levels (non-drinking, low-, medium-, high-, and very high-level drinking) and: (1) engagement with care (documented CD4 cells/µl or viral load copies/ml labs), (2) ART treatment (≥ 1 prescription), and (3) viral suppression (HIV RNA < 500 copies/ml) within one year. Among 33,224 patients, alcohol use level was inversely associated with all care continuum outcomes (all p < 0.001). Adjusted prevalence of care engagement ranged from 77.8% (95% CI 77.1-78.4%) for non-drinking to 69.1% (66.6-71.6%) for high-level drinking. The corresponding range for ART treatment was 74.0% (73.3-74.7%) to 60.1% (57.3-62.9%) and for viral suppression was 57.3% (56.5-58.1%) to 38.3% (35.6-41.1%). Greater alcohol use is associated with suboptimal HIV treatment across the HIV care continuum.

Time Spent with HIV Viral Load > 1500 Copies/mL Among Persons Engaged in Continuity HIV Care in an Urban Clinic in the United States, 2010-2015

Persons with HIV who have entered care but have viral load > 1500 copies/mL may be the source of the majority of new HIV infections in the United States. We followed patients engaged in continuity care in the Johns Hopkins HIV Clinical Cohort between January 2010 and August 2015. We estimated person-time spent with viral load > 1500 copies/mL while in care after antiretroviral therapy (ART) initiation, while in care, and while alive. Person-time was classified according to the most recent viral load measurement. Of 11,283.1 person-years in care on after ART initiation, 11,954.7 person-years in care and 13,990.0 total person-years of follow-up spent alive, 12.5, 14.8%, and between 12.6 and 27.2%, respectively (depending on assumptions about the viral load of persons lost to clinic) were spent with viral load > 1500 copies/mL. Patients with lower baseline CD4 cell count, younger age, black race, history of injection drug use, or baseline hazardous alcohol use spent more time with viral load > 1500 copies/mL after ART initiation.

Retention in HIV care during the 3 years following release from incarceration: A cohort study

BACKGROUND

Sustained retention in HIV care (RIC) and viral suppression (VS) are central to US national HIV prevention strategies, but have not been comprehensively assessed in criminal justice (CJ) populations with known health disparities. The purpose of this study is to identify predictors of RIC and VS following release from prison or jail.

METHODS AND FINDINGS

This is a retrospective cohort study of all adult people living with HIV (PLWH) incarcerated in Connecticut, US, during the period January 1, 2007, to December 31, 2011, and observed through December 31, 2014 (n = 1,094). Most cohort participants were unmarried (83.7%) men (77.0%) who were black or Hispanic (78.1%) and acquired HIV from injection drug use (72.6%). Prison-based pharmacy and custody databases were linked with community HIV surveillance monitoring and case management databases. Post-release RIC declined steadily over 3 years of follow-up (67.2% retained for year 1, 51.3% retained for years 1-2, and 42.5% retained for years 1-3). Compared with individuals who were not re-incarcerated, individuals who were re-incarcerated were more likely to meet RIC criteria (48% versus 34%; p < 0.001) but less likely to have VS (72% versus 81%; p = 0.048). Using multivariable logistic regression models (individual-level analysis for 1,001 individuals after excluding 93 deaths), both sustained RIC and VS at 3 years post-release were independently associated with older age (RIC: adjusted odds ratio [AOR] = 1.61, 95% CI = 1.22-2.12; VS: AOR = 1.37, 95% CI = 1.06-1.78), having health insurance (RIC: AOR = 2.15, 95% CI = 1.60-2.89; VS: AOR = 2.01, 95% CI = 1.53-2.64), and receiving an increased number of transitional case management visits. The same factors were significant when we assessed RIC and VS outcomes in each 6-month period using generalized estimating equations (for 1,094 individuals contributing 6,227 6-month periods prior to death or censoring). Additionally, receipt of antiretroviral therapy during incarceration (RIC: AOR = 1.33, 95% CI 1.07-1.65; VS: AOR = 1.91, 95% CI = 1.56-2.34), early linkage to care post-release (RIC: AOR = 2.64, 95% CI = 2.03-3.43; VS: AOR = 1.79; 95% CI = 1.45-2.21), and absolute time and proportion of follow-up time spent re-incarcerated were highly correlated with better treatment outcomes. Limited data were available on changes over time in injection drug use or other substance use disorders, psychiatric disorders, or housing status.

CONCLUSIONS

In a large cohort of CJ-involved PLWH with a 3-year post-release evaluation, RIC diminished significantly over time, but was associated with HIV care during incarceration, health insurance, case management services, and early linkage to care post-release. While re-incarceration and conditional release provide opportunities to engage in care, reducing recidivism and supporting community-based RIC efforts are key to improving longitudinal treatment outcomes among CJ-involved PLWH.

Beyond binary retention in HIV care: predictors of the dynamic processes of patient engagement, disengagement, and re-entry into care in a US clinical cohort

OBJECTIVES

Studies examining engagement in HIV care often capture cross-sectional patient status to estimate retention and identify predictors of attrition, which ignore longitudinal patient care-seeking behaviors. We describe the cyclical nature of (dis)engagement and re-entry into HIV care using the state transition framework.

DESIGN

We represent the dynamic patterns of patient care-retention using five states: engaged in care, missed one, two, three, or more expected visits, and deceased. Then we describe various care-seeking behaviors in terms of transitioning from one state to another (e.g. from disengaged to engaged). This analysis includes 31 009 patients enrolled in the Center for AIDS Research Network of Integrated Systems (CNICS) in the United States from 1996 to 2014.

METHOD

Multistate models for longitudinal data were used to identify barriers to retention and subgroups at higher risk of falling out of care.

RESULTS

The initial 2 years following primary engagement in care were a crucial time for improving retention. Patients who had not initiated antiretroviral therapy, with lower CD4 cell counts, higher viral load, or not having an AIDS-defining illness were less likely to be retained in care.

CONCLUSION

Beyond the individual patient characteristics typically used to characterize retention in HIV care, we identified specific periods of time and points in the care continuum associated with elevated risk of transitioning out of care. Our findings can contribute to evidence-based recommendations to enhance long-term retention in CNICS. This approach can also be applied to other cohort data to identify retention strategies tailored to each population.

Identifying Spatial Variation Along the HIV Care Continuum: The Role of Distance to Care on Retention and Viral Suppression

Distance to HIV care may be associated with retention in care (RIC) and viral suppression (VS). RIC (≥ 2 HIV visits or labs ≥ 90 days apart in 12 months), prescribed antiretroviral therapy (ART), VS (< 200 copies/mL at last visit) and distance to care were estimated among 3623 DC Cohort participants receiving HIV care in 13 outpatient clinics in Washington, DC in 2015. Logistic regression models and geospatial statistics were computed. RIC was 73%; 97% were on ART, among whom 77% had VS. ZIP code-level clusters of low RIC and high VS were found in Northwest DC, and low VS in Southeast DC. Those traveling ≥ 5 miles had 30% lower RIC (adjusted odds ratio (aOR) 0.71, 95% CI 0.58, 0.86) and lower VS (OR 0.70, 95% CI 0.52, 0.94). Geospatial clustering of RIC and VS was observed, and distance may be a barrier to optimal HIV care outcomes.

Discordance of Self-report and Laboratory Measures of HIV Viral Load Among Young Men Who Have Sex with Men and Transgender Women in Chicago: Implications for Epidemiology, Care, and Prevention

Suppressing HIV viral load through daily antiretroviral therapy (ART) substantially reduces the risk of HIV transmission, however, the potential population impact of treatment as prevention (TasP) is mitigated due to challenges with sustained care engagement and ART adherence. For an undetectable viral load (VL) to inform decision making about transmission risk, individuals must be able to accurately classify their VL as detectable or undetectable. Participants were 205 HIV-infected young men who have sex with men (YMSM) and transgender women (TGW) from a large cohort study in the Chicago area. Analyses examined correspondence among self-reported undetectable VL, study-specific VL, and most recent medical record VL. Among HIV-positive YMSM/TGW, 54% had an undetectable VL (< 200 copies/mL) via study-specific laboratory testing. Concordance between self-report and medical record VL values was 80% and between self-report and study-specific laboratory testing was 73%; 34% of participants with a detectable study-specific VL self-reported an undetectable VL at last medical visit, and another 28% reported not knowing their VL status. Periods of lapsed viral suppression between medical visits may represent a particular risk for the TasP strategy among YMSM/TGW. Strategies for frequent viral load monitoring, that are not burdensome to patients, may be necessary to optimize TasP.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Monitoring the HIV continuum of care in key populations across Europe and Central Asia

OBJECTIVES

The aim of the study was to measure and compare national continuum of HIV care estimates in Europe and Central Asia in three key subpopulations: men who have sex with men (MSM), people who inject drugs (PWID) and migrants.

METHODS

Responses to a 2016 European Centre for Disease Prevention and Control (ECDC) survey of 55 European and Central Asian countries were used to describe continuums of HIV care for the subpopulations. Data were analysed using three frameworks: Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets; breakpoint analysis identifying reductions between adjacent continuum stages; quadrant analysis categorizing countries using 90% cut-offs for continuum stages.

RESULTS

Overall, 29 of 48 countries reported national data for all HIV continuum stages (numbers living with HIV, diagnosed, receiving treatment and virally suppressed). Six countries reported all stages for MSM, seven for PWID and two for migrants. Thirty-one countries did not report data for MSM (34 for PWID and 41 for migrants). In countries that provided key-population data, overall, 63%, 40% and 41% of MSM, PWID and migrants living with HIV were virally suppressed, respectively (compared with 68%, 65% and 68% nationally, for countries reporting key-population data). Variation was observed between countries, with higher outcomes in subpopulations in Western Europe compared with Eastern Europe and Central Asia.

CONCLUSIONS

Few reporting countries can produce the continuum of HIV care for the three key populations. Where data are available, differences exist in outcomes between the general and key populations. While MSM broadly mirror national outcomes (in the West), PWID and migrants experience poorer treatment and viral suppression. Countries must develop continuum measures for key populations to identify and address inequalities.

Patient-nominated supporters as facilitators for engagement in HIV care in a referral hospital in Peru: A retrospective cohort study

Patient-nominated supporters can potentially improve the continuum of HIV care. We retrospectively determined factors associated with having a patient-nominated supporter among people living with HIV (PLWH), and its association with retention in care and viral suppression. We analysed registries of adults evaluated by social workers (n = 1345) at a referral hospital in Peru between 2011–2014. Nondisclosure of HIV status was associated with lacking supporters (aPR: 5.41, 95% CI: 3.83–7.64). Retention in care was 76.4% and 34.2% after one and two years of enrolment, respectively. PLWH with supporters were more likely to be retained in care after two years (aRR = 1.36, 95% CI: 1.02–1.81), but not after one year (aRR = 1.10, 95% CI: 0.98–1.23) compared to PLWH without supporters. Having supporters who were parents or friends was associated with an increased probability of being retained in care after one and two years of enrolment. Viral suppression after one year of enrolment was 58.7%. Having a supporter was not associated with viral suppression (aRR = 1.18, 95% CI: 0.99–1.41), but PLWH with supporters were more likely to have viral load measurements (p = 0.005). Patient-nominated supporters appear beneficial for engagement in HIV care; these benefits may be related to the nature of their relationship with PLWH.

Sexual risk taking and the HIV care continuum in an online sample of men who have sex with men

Antiretroviral Therapy (ART) suppresses HIV replication, reducing the risk of transmission. However, many people living with HIV in the US are not virally suppressed even after diagnosis and initiating ART, and may become disengaged from care at each stage of the HIV care continuum (HCC). In the current study we assessed the sexual risk behaviors of MSM by HCC stage. US MSM who completed an online survey (N = 12,995) in 2015 were categorized into 6 HCC groups. Mean age was 39.2 and a majority identified as White (49.6%). At every stage of the HCC, we found higher proportions of individuals engaged in care compared to CDC estimates. A majority of the sample was HIV-positive and engaged in care, with 67.2% of HIV-positive participants reporting viral suppression with ART. Across HCC groups, participants reported high rates of past 6-month condomless anal sex (CAS) (79.2%-84.8%) and CAS with serodiscordant or unknown status partners (38.0%-84.1%). Notably, MSM with unknown HIV serostatus reported the highest proportion of CAS and serodiscordant CAS. HIV-positive MSM not on ART were more likely to report an STI diagnosis (p < .002) compared to those unaware of their HIV status or HIV negative. Moreover, young Black MSM were less likely to be on ART (p < .002) or virally suppressed (p < .002) compared to older White MSM. Our findings highlight potentially problematic sexual risk behaviors among MSM by level of HCC engagement, which can impede the preventive impact of ART. Online platforms provide an avenue to assess the progress of MSM along the HCC, as well as other subpopulations in need of appropriate behavioral interventions to decrease HIV incidence.

Changes in Specific Substance Involvement Scores among SBIRT recipients in an HIV primary care setting

Background

Substance use is common among people living with HIV (PLHIV) and is associated with worse outcomes along the HIV care continuum. One potentially effective clinic-based approach to addressing unhealthy substance use is screening, brief intervention, and referral to treatment (SBIRT).

Methods

We conducted a two-arm randomized trial to examine the effects of a self-administered, computerized SBIRT intervention compared to a clinician-administered SBIRT intervention in an HIV primary clinic. Patients were surveyed before receiving the intervention and again at 1, 3, and 6 months. We administered the WHO Alcohol, Smoking and Substance Involvement Screening Test to determine Specific Substance Involvement Scores (SSIS) and to assign participants to categories of lower, moderate, or high risk to health and other problems for each substance. We collapsed moderate or severe risk responses into a single moderate–high risk category. Based on low rates of participation in the computerized arm, we conducted an “as treated” analysis to examine 6-month changes in mean SSIS among SBIRT intervention participants.

Results

For the overall sample (n = 208), baseline mean SSIS were in the moderate risk category for alcohol, tobacco, cannabis, cocaine, amphetamine, sedatives and opioids. Of those enrolled, 134 (64.4%) received the intervention, and 109 (52.4%) completed the 6-month follow up. There was a statistically significant decline in mean SSIS for all substances except tobacco and cannabis among participants who were at moderate–high risk at baseline. We also observed a statistically significant increase in mean SSIS for all substances except amphetamines and sedatives among participants who were at lower risk at baseline.

Conclusions

Substance use among patients in this urban, safety-net, HIV primary care clinic was near universal, and moderate risk substance use was common. Among participants who received the SBIRT intervention, mean SSISs decreased among those at moderate–high risk at baseline, but increased among those at lower risk at baseline over the 6-month study period. Additional research should examine the clinical significance of SSIS changes for PLHIV, which SBIRT components drive changes in substance use scores, and what other interventions might support those patients at lower risk to maintain health and engagement along the HIV care continuum.

Trial registration ClinicalTrials.gov study NCT01300806

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

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

Place-Based Predictors of HIV Viral Suppression and Durable Suppression Among Men Who Have Sex With Men in New York City

We explore relationships between place characteristics and HIV viral suppression among HIV-positive men who have sex with men (MSM) in New York City (NYC). We conducted multilevel analyses to examine associations of United Hospital Fund (UHF)-level characteristics to individual-level suppression and durable suppression among MSM. Individual-level independent and dependent variables came from MSM in NYC's HIV surveillance registry who had been diagnosed in 2009-2013 (N = 7159). UHF-level covariates captured demographic composition, economic disadvantage, healthcare access, social disorder, and police stop and frisk rates. 56.89% of MSM achieved suppression; 35.49% achieved durable suppression. MSM in UHFs where 5-29% of residents were Black had a greater likelihood of suppression (reference: ≥30% Black; adjusted relative risk (ARR) = 1.07, p = 0.04). MSM in UHFs with <30 MSM-headed households/10,000 households had a lower likelihood of achieving durable suppression (reference: ≥60 MSM-headed households/10,000; ARR = 0.82; p = 0.05). Place characteristics may influence viral suppression. Longitudinal research should confirm these associations.

Do Persons Living with HIV Continue to Fill Prescriptions for Antiretroviral Drugs during a Gap in Care? Analysis of a Large Commercial Claims Database

The significance of a gap in HIV care depends, at least partially, on whether patients continue to fill prescriptions for antiretroviral (ARV) drugs during the gap in care. We used a billing claims database to determine the proportion of persons who filled ≥1 prescription for ARV drugs during a gap in care (no clinic visit in >6 months). Persons were stratified into 3 groups: "never" (prescriptions never filled), "sometimes" (prescriptions filled >0%-<100% of months), and "always" (prescriptions filled monthly). Logistic regression analyses were conducted to determine factors associated with "never" filling ARV drugs. Of 14 308 persons, 69% (n = 9817), 13% (n = 1928), and 18% (n = 2563) "never," "sometimes," and "always" filled ARV drugs during the gap in care. Persons aged 18 to 29 years (odds ratio [OR] = 1.56, 95% confidence interval [CI] 1.39-1.74), women (OR = 1.67, CI 1.52-1.83), and persons from the Northeast region of the United States (OR = 1.86, CI 1.69-2.03) were more likely to never fill ARV drugs than persons aged ≥30 years, men, and persons outside the Northeast, respectively. Efforts should be made to minimize gaps in care, emphasize importance of therapy, and provide adherence support.

Prevalence of Internalized HIV-Related Stigma Among HIV-Infected Adults in Care, United States, 2011-2013

HIV-infected U.S. adults have reported internalized HIV-related stigma; however, the national prevalence of stigma is unknown. We sought to determine HIV-related stigma prevalence among adults in care, describe which socio-demographic groups bear the greatest stigma burden, and assess the association between stigma and sustained HIV viral suppression. The Medical Monitoring Project measures characteristics of U.S. HIV-infected adults receiving care using a national probability sample. We used weighted data collected from June 2011 to May 2014 and assessed self-reported internalized stigma based on agreement with six statements. Overall, 79.1% endorsed ≥1 HIV-related stigma statements (n = 13,841). The average stigma score was 2.4 (out of a possible high score of six). White males had the lowest stigma scores while Hispanic/Latina females and transgender persons who were multiracial or other race had the highest. Although stigma was associated with viral suppression, it was no longer associated after adjusting for age. Stigma was common among HIV-infected adults in care. Results suggest individual and community stigma interventions may be needed, particularly among those who are <50 years old or Hispanic/Latino. Stigma was not independently associated with viral suppression; however, this sample was limited to adults in care. Examining HIV-infected persons not in care may elucidate stigma's association with viral suppression.

Accuracy of self-report of HIV viral load among people with HIV on antiretroviral treatment

OBJECTIVES

The aim of the study was to assess, among people living with HIV, knowledge of their latest HIV viral load (VL) and CD4 count.

METHODS

Agreement between self-report and clinic record was assessed among 2771 HIV-diagnosed individuals on antiretroviral treatment (ART) in the UK Antiretrovirals, Sexual Transmission Risk and Attitudes Study (2011-2012). A confidential self-completed questionnaire collected information on demographic, socioeconomic, HIV-related and health-related factors. Participants were asked to self-report their latest VL [undetectable (≤ 50 copies/mL), detectable (> 50 copies/mL) or "don't know"] and CD4 count (< 200, 200-350, 351-500 or > 500 cells/μL, or "don't know"). Latest clinic-recorded VL and CD4 count were documented.

RESULTS

Of 2678 participants on ART, 434 (16.2%) did not accurately report whether their VL was undetectable. Of 2334 participants with clinic-recorded VL ≤ 50 copies/mL, 2061 (88.3%) correctly reported undetectable VL; 49 (2.1%) reported detectable VL; 224 (9.6%) did not know their VL. Of 344 participants with clinic-recorded VL > 50 copies/mL, 183 (53.2%) correctly reported detectable VL; 76 (22.1%) reported undetectable VL; 85 (24.7%) did not know their VL. Of 2137 participants who reported undetectable VL, clinic-recorded VL was ≤ 50 copies/mL for 2061 (96.4%) and <1000 copies/mL for 2122 (99.3%). In analyses adjusted for gender/sexual orientation, ethnicity, age and time since starting ART, factors strongly associated with inaccurate self-report of VL (including "don't know") included socioeconomic disadvantage [prevalence ratio (95% CI) for "not" vs. "always" having enough money for basic needs: 2.4 (1.9, 3.1)], poor English fluency [3.5 (2.4, 5.1) vs. UK born], nondisclosure of HIV status [1.7 (1.3, 2.1)], ART nonadherence [2.1 (1.7, 2.7) for three or more missed doses vs. none in the past 2 weeks] and depressive symptoms (PHQ-9 score ≥ 10) [1.9 (1.6, 2.2)]. Overall, 612 (22.9%) of 2667 participants on ART did not accurately self-report whether or not their CD4 count was ≤ 350 cells/μL.

CONCLUSIONS

There is a high level of accuracy of a self-report of undetectable VL in people on ART in the UK. Overall, accurate knowledge of personal VL level varied according to demographic, socioeconomic, HIV-related and health-related factors. Active identification of people who may benefit from increased levels of support and engagement in care is important.

Continuum of Care Among People Living with Perinatally Acquired HIV Infection in New York City, 2014

OBJECTIVE

The HIV care continuum outlines the steps from HIV infection to diagnosis, linkage to care, and viral suppression among people living with HIV. We examined data for steps along the HIV care continuum among people living with perinatally acquired infection in New York City using surveillance data.

METHODS

This study included data for people who acquired HIV infection perinatally and lived in New York City as of December 31, 2014. We defined "in care" as having ≥1 CD4 or viral load test in 2014, "in continuous care" as having ≥2 CD4 or viral load tests ≥3 months apart in 2014, and "virally suppressed" as having a viral load of #200 copies per milliliter in the most recent test in 2014. We estimated factors associated with viral suppression from a weighted log-binomial regression model that included sex, race/ethnicity, age, and country of birth as independent variables.

RESULTS

As of December 31, 2014, an estimated 1,596 people were living with perinatally acquired HIV infection in New York City. All were diagnosed, 96% were in care, 80% were in continuous care, and 61% were virally suppressed. The multivariable analysis showed significant differences in viral suppression by race/ethnicity and age. Black patients (59%, 534/907) were the least likely of all racial/ethnic groups examined to have a suppressed viral load. By age, compared with 73% (80/109) of children aged 0-12 years who were virally suppressed, 58% (568/987) of adults aged 20-29 years and 56% (54/96) of adults aged 30-39 years were virally suppressed; the adjusted prevalence ratio was 0.80 (95% confidence interval [CI] 0.69, 0.92) for those aged 20-29 years and 0.79 (95% CI 0.63, 0.99) for those aged 30-39 years.

CONCLUSION

The low level of viral suppression among people living with perinatally acquired infection found in this study warrants further exploration to identify the best management strategies to improve viral suppression in this population, especially those transitioning from pediatric to adult health care.

HIV Provider Experiences Engaging and Retaining Patients in HIV Care and Treatment: "A Soft Place to Fall"

Engaging and retaining persons with HIV in care and treatment is key to reducing new HIV infections in the United States. Understanding the experiences, barriers, and facilitators to engaging and retaining persons in HIV care from the perspective of HIV care providers could help provide insight into how best to achieve this goal. We present qualitative data from 30 HIV care providers in three cities. We identified three facilitators to HIV care: providing a medical home, team-based care and strategies for engaging and retaining patients in HIV care, and focus on provider-patient relationships. We identified two main barriers to care: facility-level policies and patient-level challenges. Our findings suggest that providers embrace the medical home model for engaging patients but need support to identify aspects of the model that promote engagement in long-term HIV care, improve the quality of the provider-patient relationship, and address persistent logistical barriers, such as transportation.

Disparities in the Clinical Evolution of Anal Neoplasia in an HIV-Infected Cohort

BACKGROUND

A recent meta-analysis suggested that anal intraepithelial neoplasia and invasive anal cancer are more prevalent among black men having sex with men (MSM).

METHODS

We conducted a retrospective cohort of HIV-infected adult patients under care between 2001 and 2012. Disparities in clinical evolution of anal intraepithelial neoplasia to high-grade squamous intraepithelial lesion (HSIL) and invasive anal cancer were evaluated in a three-state Markov model adjusted for cytology misclassification. We studied sociodemographic covariate effects for each state transition using multivariable models controlling for antiretroviral therapy and infrared coagulation treatment of HSIL.

RESULTS

Among 2804 patients with a median age of 40 years, 78% were MSM and 38% non-white. There were no disparities in HSIL prevalence (14%) by age, sex, race, or risk group. After 4.0 years of follow-up, 23 patients developed invasive anal cancer. Females and black patients had lower transition rates from <HSIL→HSIL (HR = 0.35 and HR = 0.55, respectively); those with age >40 had lower rates of both <HSIL→HSIL progression (HR = 0.64) and HSIL→<HSIL regression (HR = 0.56); and MSM had higher rates of progression from <HSIL→HSIL (HR = 3.30). Controlling for antiretroviral therapy and infrared coagulation (IRC) treatment as time-updated covariates, the univariable effects of sex, black race, and HIV risk factor remained significant.

CONCLUSIONS

Black race was not associated with prevalent anal intraepithelial neoplasia nor with post-baseline progression of anal intraepithelial neoplasia.

Gender Differences in HIV Care among Criminal Justice-Involved Persons: Baseline Data from the CARE+ Corrections Study

Background

HIV-infected individuals recently released from incarceration have suboptimal linkage and engagement in community HIV care. We conducted a study to evaluate an information and communication technology intervention to increase linkage to community care among HIV-infected persons recently involved in the criminal justice (CJ) system. Baseline characteristics including risk behaviors and HIV care indicators are reported and stratified by gender.

Methods

We recruited HIV-infected individuals in the District of Columbia jail and persons with a recent history of incarceration through community and street outreach. Participants completed a baseline computer-assisted personal interview regarding HIV care and antiretroviral treatment (ART) adherence, substance use, and sexual behaviors. CD4 and HIV plasma viral load testing were performed at baseline or obtained through medical records. Data were analyzed for the sample overall and stratified by gender.

Results

Of 110 individuals, 70% were community-enrolled, mean age was 40 (SD = 10.5), 85% were Black, and 58% were male, 24% female, and 18% transgender women. Nearly half (47%) had condomless sex in the three months prior to incarceration. Although drug dependence and hazardous alcohol use were highly prevalent overall, transgender women were more likely to have participated in drug treatment than men and women (90%, 61%, and 50% respectively; p = 0.01). Prior to their most recent incarceration, 80% had an HIV provider and 91% had ever taken ART. Among those, only 51% reported ≥90% ART adherence. Fewer women (67%) had received HIV medications during their last incarceration compared to men (96%) and transgender women (95%; p = 0.001). Although neither was statistically significant, transgender women and men had higher proportions of baseline HIV viral suppression compared to women (80%, 69%, and 48.0% respectively, p>0.05); a higher proportion of women had a CD4 count ≤200 compared to men and transgender women (17%, 8% and 5% respectively; p>0.05).

Conclusions

In this study, HIV-infected persons with recent incarceration in Washington, DC reported important risk factors and co-morbidities, yet the majority had access to HIV care and ART prior to, during, and after incarceration. Self-reported ART adherence was sub-optimal, and while there were not statistically significant differences, CJ-involved women appeared to be at greatest risk of poor HIV outcomes.

Trial registration

Registered on ClinicalTrials.gov on 10/16/2012. Reference number: NCT01721226.

Retention in Continuous Care and Sustained Viral Suppression

OBJECTIVES

To examine the relationship between retention in continuous care and sustained viral suppression.

METHODS

The authors retrospectively followed 653 persons who were virally suppressed and seeking care at an infectious disease clinic in Kentucky for an average of 6 years to determine the rates of retention in medical care (≥2 visits separated by ≥3 months within a 12-month period) and sustained viral suppression (<400 copies/mL). A generalized linear mixed model was used to determine an association between retention and suppression over time.

RESULTS

Approximately 61% of the study population were retained in continuous care and 75% had sustained viral suppression for all patient-years. Persons retained in care were 3 times the odds of sustaining viral suppression over time ( P < .001).

CONCLUSION

Retention is essential to achieving and maintaining viral suppression. Strategies should be set in place that emphasize increasing the rates of retention, which in turn may increase the rates of suppression.

Alcohol Use and Human Immunodeficiency Virus (HIV) Infection: Current Knowledge, Implications, and Future Directions

Alcohol use is common among people living with human immunodeficiency virus (HIV). In this narrative review, we describe literature regarding alcohol's impact on transmission, care, coinfections, and comorbidities that are common among people living with HIV (PLWH), as well as literature regarding interventions to address alcohol use and its influences among PLWH. This narrative review identifies alcohol use as a risk factor for HIV transmission, as well as a factor impacting the clinical manifestations and management of HIV. Alcohol use appears to have additive and potentially synergistic effects on common HIV-related comorbidities. We find that interventions to modify drinking and improve HIV-related risks and outcomes have had limited success to date, and we recommend research in several areas. Consistent with Office of AIDS Research/National Institutes of Health priorities, we suggest research to better understand how and at what levels alcohol influences comorbid conditions among PLWH, to elucidate the mechanisms by which alcohol use is impacting comorbidities, and to understand whether decreases in alcohol use improve HIV-relevant outcomes. This should include studies regarding whether state-of-the-art medications used to treat common coinfections are safe for PLWH who drink alcohol. We recommend that future research among PLWH include validated self-report measures of alcohol use and/or biological measurements, ideally both. Additionally, subgroup variation in associations should be identified to ensure that the risks of particularly vulnerable populations are understood. This body of research should serve as a foundation for a next generation of intervention studies to address alcohol use from transmission to treatment of HIV. Intervention studies should inform implementation efforts to improve provision of alcohol-related interventions and treatments for PLWH in healthcare settings. By making further progress on understanding how alcohol use affects PLWH in the era of HIV as a chronic condition, this research should inform how we can mitigate transmission, achieve viral suppression, and avoid exacerbating common comorbidities of HIV and alcohol use and make progress toward the 90-90-90 goals for engagement in the HIV treatment cascade.

Reported Church Attendance at the Time of Entry into HIV Care is Associated with Viral Load Suppression at 12 Months

The Southeast has high rates of church attendance and HIV infection rates. We evaluated the relationship between church attendance and HIV viremia in a Southeastern US, HIV-infected cohort. Viremia (viral load ≥200 copies/ml) was analyzed 12 months after initiation of care. Univariate and multivariable logistic regression models were fit for variables potentially related to viremia. Of 382 patients, 74 % were virally suppressed at 12 months. Protective variables included church attendance (AOR 0.5; 95 % CI 0.2, 0.9), being on antiretroviral therapy (AOR 0.01; 95 % CI 0.004, 0.04), CD4(+) T lymphocyte count 200-350 cells/mm(3) at care entry (AOR 0.3; 95 % 0.1, 0.9), and education (AOR 0.5; 95 % CI 0.2, 0.9). Variables predicting viremia included black race (AOR 3.2; 95 % CI 1.4, 7.4) and selective disclosure of HIV status (AOR 2.7; 95 % CI 1.2, 5.6). Church attendance may provide needed support for patients entering HIV care for the first time.

Linking Infectious and Narcology Care (LINC) in Russia: design, intervention and implementation protocol

BACKGROUND

Russia and Eastern Europe have one of the fastest growing HIV epidemics in the world. While countries in this region have implemented HIV testing within addiction treatment systems, linkage to HIV care from these settings is not yet standard practice. The Linking Infectious and Narcology Care (LINC) intervention utilized peer-led strengths-based case management to motivate HIV-infected patients in addiction treatment to obtain HIV care. This paper describes the protocol of a randomized controlled trial evaluating the effectiveness of the LINC intervention in St. Petersburg, Russia.

METHODS/DESIGN

Participants (n = 349) were recruited from the inpatient wards at the City Addiction Hospital in St. Petersburg, Russia. After completing a baseline assessment, participants were randomly assigned to receive either the LINC intervention or standard of care. Participants returned for research assessments 6 and 12 months post-baseline. Primary outcomes were assessed via chart review at HIV treatment locations.

DISCUSSION

LINC holds the potential to offer an effective approach to coordinating HIV care for people who inject drugs in Russia. The LINC intervention utilizes existing systems of care in Russia, minimizing adoption of substantial infrastructure for implementation. Trial Registration NCT01612455.

Identifying Best Practices for Increasing Linkage to, Retention, and Re-engagement in HIV Medical Care: Findings from a Systematic Review, 1996-2014

A systematic review was conducted to identify best practices for increasing linkage, retention and re-engagement in HIV care (LRC) for persons living with HIV (PLWH). Our search strategy consisted of automated searches of electronic databases and hand searches of journals, reference lists and listservs. We developed two sets of criteria: evidence-based to identify evidence-based interventions (EBIs) tested with a comparison group and evidence-informed to identify evidence-informed interventions (EIs) tested with a one-group design. Eligible interventions included being published between 1996 and 2014, U.S.-based studies with a comparison or one-group designs with pre-post data, international randomized controlled trials, and having objective measures of LRC-relevant outcomes. We identified 10 best practices: 5 EBIs and 5 EIs. None focused on re-engagement. Providers and prevention planners can use the review findings to identify best practices suitable for their clinics, agencies, or communities to increase engagement in care for PLWH, ultimately leading to viral suppression.

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

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

Assessing the HIV Care Continuum in Latin America: progress in clinical retention, cART use and viral suppression

Introduction

We assessed trends in HIV Care Continuum outcomes associated with delayed disease progression and reduced transmission within a large Latin American cohort over a decade: clinical retention, combination antiretroviral therapy (cART) use and viral suppression (VS).

Methods

Adults from Caribbean, Central and South America network for HIV epidemiology clinical cohorts in seven countries contributed data between 2003 and 2012. Retention was defined as two or more HIV care visits annually, >90 days apart. cART was defined as prescription of three or more antiretroviral agents annually. VS was defined as HIV-1 RNA <200 copies/mL at last measurement annually. cART and VS denominators were subjects with at least one visit annually. Multivariable modified Poisson regression was used to assess temporal trends and examine associations between age, sex, HIV transmission mode, cohort, calendar year and time in care.

Results

Among 18,799 individuals in retention analyses, 14,380 in cART analyses and 13,330 in VS analyses, differences existed between those meeting indicator definitions versus those not by most characteristics. Retention, cART and VS significantly improved from 2003 to 2012 (63 to 77%, 74 to 91% and 53 to 82%, respectively; p<0.05, each). Female sex (risk ratio (RR)=0.97 vs. males) and injection drug use as HIV transmission mode (RR=0.83 vs. male sexual contact with males (MSM)) were significantly associated with lower retention, but unrelated with cART or VS. MSM (RR=0.96) significantly decreased the probability of cART compared with heterosexual transmission.

Conclusions

HIV Care Continuum outcomes improved over time in Latin America, though disparities for vulnerable groups remain. Efforts must be made to increase retention, cART and VS, while engaging in additional research to sustain progress in these settings.

Measuring the HIV Care Continuum Using Public Health Surveillance Data in the United States

The HIV care continuum is a critical framework for situational awareness of the HIV epidemic; yet challenges to accurate enumeration of continuum components hamper continuum estimation in practice. We describe local surveillance-based estimation of the HIV continuum in the United States, reviewing common practices as recommended by the Centers for Disease Control and Prevention. Furthermore, we review some challenges and biases likely to threaten existing continuum estimates. Current estimates rely heavily on the use of CD4 cell count and HIV viral load laboratory results reported to surveillance programs as a proxy for receipt of HIV-related outpatient care. As such, continuum estimates are susceptible to bias because of incomplete laboratory reporting and imperfect sensitivity and specificity of laboratory tests as a proxy for routine HIV care. Migration of HIV-infected persons between jurisdictions also threatens the validity of continuum estimates. Data triangulation may improve but not fully alleviate biases.

Systematic Assessment of Linkage to Care for Persons with HIV Released from Corrections Facilities Using Existing Datasets

Populations in corrections continue to have high prevalence of HIV. Expanded testing and treatment programs allow persons to be identified and stabilized on treatment while incarcerated. However, these gains and frequently lost on reentry. Systemic frameworks are needed to monitor linkage to care to guide programs supporting linkage to care. To assess the adequacy of linkage to care on reentry, incarceration data from the National Corrections Reporting Program and data from the Ryan White Services Report from 2010 to 2012 were linked using an encrypted client identification (eUCI). Time from release to the first visit and presence of detectable HIV RNA at linkage were assessed. Multivariate survival analyses were performed to identify associations between patient characteristics and time to linkage. Among those linking, only 43% in Rhode Island and 49% in North Carolina linked within 90 days, and 33% in both states had detectable viremia at the first visit. Those not previously in care and with shorter incarceration experiences longer linkage times. Persons identified as black, had median times greater than 1 year. Using existing datasets, significant gaps in linkage to care for persons with HIV on release from corrections were demonstrated in Rhode Island and North Carolina. Systemically implementing this monitoring to evaluate changes over time would provide important information to support interventions to improve linkage in high-risk populations. Using national datasets for both corrections and clinical data, this framework equally could be used to evaluate experiences of persons with HIV linking to care on release from corrections facilities nationwide.

Achieving Core Indicators for HIV Clinical Care Among New Patients at an Urban HIV Clinic

Following the release of the 2010 National HIV/AIDS Strategy for the United States, the Institute of Medicine (IOM) issued core clinical indicators for measuring health outcomes in HIV-positive persons. As early retention in HIV primary care is associated with improved long-term health outcomes, we employed IOM indicators as a guide to examine a cohort of persons initiating HIV outpatient medical care at a university-affiliated HIV clinic in the Southern United States (January 2007-July 2012). Using indicators for visit attendance, CD4 and viral load laboratory testing frequency, and antiretroviral therapy initiation, we evaluated factors associated with achieving IOM core indicators among care- and treatment-naïve patients during the first year of HIV care. Of 448 patients (mean age = 35 years, 35.7% white, 79.0% male, 58.4% education beyond high school, 35.9% monthly income > $1,000 US, 47.3% uninsured), 84.6% achieved at least four of five IOM indicators. In multivariable analyses, persons with monthly income > $1,000 (ORadj. = 3.71; 95% CI: 1.68-8.19; p = 0.001) and depressive symptoms (ORadj. = 2.13; 95% CI: 1.02-4.45; p = 0.04) were significantly more likely to achieve at least four of the five core indicators, while patients with anxiety symptoms were significantly less likely to achieve these indicators (ORadj. = 0.50; 95% CI: 0.26-0.97; p = 0.04). Age, sex, race, education, insurance status, transportation barriers, alcohol use, and HIV status disclosure to family were not associated with achieving core indicators. Evaluating and addressing financial barriers and anxiety symptoms during the first year of HIV outpatient care may improve individual health outcomes and subsequent achievement of the National HIV/AIDS Strategy.

Impact of defined clinical population and missing data on temporal trends in HIV viral load estimation within a health care system

OBJECTIVES

Community viral load (CVL) estimates vary based on analytic methods. We extended the CVL concept and used data from the Veterans Health Administration (VA) to determine trends in the health care system viral load (HSVL) and its sensitivity to varying definitions of the clinical population and assumptions regarding missing data.

METHODS

We included HIV-infected patients in the Veterans Aging Cohort Study, 2000-2010, with at least one documented CD4 count, HIV-1 RNA or antiretroviral prescription (n = 37 318). We created 6-month intervals including patients with at least one visit in the past 2 years. We assessed temporal trends in clinical population size, patient clinical status and mean HSVL and explored the impact of varying definitions of the clinical population and assumptions about missing viral load.

RESULTS

The clinical population size varied by definition, increasing from 16 000-19 000 patients in 2000 to 23 000-26 000 in 2010. The proportion of patients with suppressed HIV-1 RNA increased over time. Over 20% of patients had no viral load measured in a given interval or the past 2 years. Among patients with a current HIV-1 RNA, mean HSVL decreased from 97 800 HIV-1 RNA copies/mL in 2000 to 2000 copies/mL in 2010. When current HIV-1 RNA data were unavailable and the HSVL was recalculated using the last available HIV-1 RNA, HSVL decreased from 322 300 to 9900 copies/mL. HSVL was underestimated when using only current data in each interval.

CONCLUSIONS

The CVL concept can be applied to a health care system, providing a measure of health care quality. Like CVL, HSVL estimates depend on definitions of the clinical population and assumptions about missing data.

Association of individual and systemic barriers to optimal medical care in people living with HIV/AIDS in Miami-Dade County

Barriers to retention in HIV care are detrimental to patients' progress along the HIV continuum of care. Previous literature has focused on individual, client-level barriers, and interventions to address them. In contrast, less work has examined the role of system-level barriers on HIV care outcomes. This study seeks to understand how individual and systemic barriers individually are associated with clinic appointment attendance and virologic suppression in HIV-infected patients attending the largest HIV clinic in Miami-Dade, FL. In addition, we examined the synergistic effects of these barriers as potential syndemic factors on these health outcomes. Barriers to clinic attendance were determined in a face-to-face study interview with 444 HIV-infected outpatients (187 regular attenders, 191 irregular attenders, and 66 nonattenders) identified from electronic medical records. Compared with the other attendance groups, nonattenders had higher viral loads, were less likely to be virologically suppressed, had lower CD4 counts, had higher depressive symptoms, life chaos, lower quality of life, and higher rates of food insecurity, and recent drug use. Additionally, nonattenders compared with regular attenders had lower physician relationship ratings, had lower medical information clarity and more often reported transportation as a barrier to clinic attendance. When viewed as a syndemic, compared with patients not reporting any barriers, patients with 3 or more individual-level barriers were more likely to have a detectable viral load (odds ratio = 3.60, 95% CI: 1.71 to 7.61). Our findings suggest that patients presenting to the clinic with multiple barriers should be prioritized for assistance and future interventions to improve retention in care. Interventions should address multiple individual and system-level barriers simultaneously with particular attention to addressing depressive symptoms, organizational skills, relationship with the physician, and HIV-related health education.

Impact of age on retention in care and viral suppression

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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