The impact of transfer patients on the local cascade of HIV care continuum

Transfer of primary care patients receiving chronic care: the next step in the continuum of care

The burden of chronic conditions is increasing rapidly in low- and middle-income countries. Chronic conditions require long-term and continuous care, including for patients transferring between facilities. Patient transfer is particularly important in the context of health service decentralization, which has led to increasing numbers of primary care facilities at which patients can access care, and high levels of migration, which suggest that patients might require care at multiple facilities. This article provides a critical review of existing evidence regarding transfer of stable patients receiving primary care for chronic conditions. Patient transfer has received limited consideration in people living with HIV, with growing concern that patients who transfer are at risk of poor outcomes; this appears similar for people with TB, although studies are few. There are minimal data on transfer of patients with non-communicable diseases, including diabetes. Patient transfer for chronic conditions has thus received surprisingly little attention from researchers; considering the potential risks, more research is urgently required regarding reasons for and outcomes of transfers, transfer processes and interventions to optimize transfers, for different chronic conditions. Ultimately, it is the responsibility of health systems to facilitate successful transfers, and this issue requires increased attention from researchers and policy-makers.

Association between engagement in-care and mortality in HIV-positive persons

Objective:

To assess associations between engagement in-care and future mortality.

Design:

UK-based observational cohort study.

Methods:

HIV-positive participants with more than one visit after 1 January 2000 were identified. Each person-month was classified as being in or out-of-care based on the dates of the expected and observed next care visits. Cox models investigated associations between mortality and the cumulative proportion of months spent in-care (% IC, lagged by 1 year), and cumulative %IC prior to antiretroviral therapy (ART) in those attending clinic for more than 1 year, with adjustment for age, CD4⁺/viral load, year, sex, infection mode, ethnicity, and receipt/type of ART.

Results:

The 44 432 individuals (27.8% women; 50.5% homosexual, 28.9% black African; median age 36 years) were followed for a median of 5.5 years, over which time 2279 (5.1%) people died. Higher %IC was associated with lower mortality both before [relative hazard 0.91 (95% confidence interval 0.88–0.95)/10% higher, P = 0.0001] and after [0.90 (0.87–0.93), P = 0.0001] adjustment. Adjustment for future CD4⁺ changes revealed that the association was explained by poorer CD4⁺ cell counts in those with lower %IC. In total 8730 participants under follow-up for more than 1 year initiated ART of whom 237 (2.7%) died. Higher values of %IC prior to ART initiation were associated with a reduced risk of mortality before [0.29 (0.17–0.47)/10%, P = 0.0001] and after [0.36 (0.21–0.61)/10%, P = 0.0002] adjustment; the association was again explained by poorer post-ART CD4⁺/ viral load in those with lower pre-ART %IC.

Conclusions:

Higher levels of engagement in-care are associated with reduced mortality at all stages of infection, including in those who initiate ART.

The South Carolina rural-urban HIV continuum of care

The HIV continuum of care model is widely used by various agencies to describe the HIV epidemic in stages from diagnosis through to virologic suppression. It identifies the various points at which persons living with HIV (PLWHIV) within a population fail to reach their next step in HIV care. The rural population in the Southern United States is disproportionally affected by the HIV epidemic. The purpose of this study was to examine these rural-urban disparities using the HIV care continuum model and determine at what stages these differences become apparent. PLWHIV aged 13 years and older in South Carolina (SC) were identified using data from the enhanced HIV/AIDS Reporting System. The percentages of PLWHIV linked to care, retained in care, and virologically suppressed were determined. Rural versus urban residence was determined using the Office of Management and Budget classification. There were 14,523 PLWHIV in SC at the end of 2012; 11,193 (77%) of whom were categorized as urban and 3305 (22%) as rural. There was no difference between urban and rural for those who had received any care: 64% versus 64% (p = .61); retention in care 53% versus 53% (p = .71); and virologic suppression 49% versus 48% (p = .35), respectively. The SC rural-urban HIV cascade represents the first published cascade of care model using rural versus urban residence. Although significant health care disparities exist between rural and urban residents, there were no major differences between rural and urban residents at the various stages of engagement in HIV care using the HIV continuum of care model.