Developing and validating a clinical risk score to predict losses in the PISCIS cohort of people with HIV

BACKGROUND

People lost to follow-up (LTFU) from HIV care have an increased risk of worse health. The objective of this study is to create and validate a risk score to predict LTFU among PLWH in Catalonia and the Balearic Islands.

METHODS

6661 PLWH were included. LTFU were those without contact with HIV care for 12 months or more. Logistic regression models were used to assess the role of independent factors on LTFU. The validation included a 10-fold iteration to predict the performance of the regression model and the Area under the ROC Curve (AUC). Regression coefficients were rounded and summed to construct the score.

RESULTS

Determinants of LTFU included being younger than 34 years (OR: 1.80, CI, 1.44-2.23), not having been born in Spain (OR: 1.32, 1.11-1.58), men who inject drugs (OR: 2.10, 1.38-3.19), having a detectable viral load (OR: 3.14, 2.47-3.99), and ≤2.5 years since HIV diagnosis (OR: 3.84, 3.10-4.75). The validation of determinants resulted in a mean AUC of 0.69 and the risk-score revealed that 28.8% had a medium and 3.4% a high risk of LTFU respectively.

CONCLUSIONS

Findings can be used to prevent LTFU in HIV care.

Who is lost to follow-up in HIV care? Assessment of care retention over time and the impact of COVID-19. Longitudinal analysis of the PISCIS cohort

INTRODUCTION

People living with HIV who are lost to follow-up have a greater risk of health deterioration, mortality, and community transmission.

OBJECTIVE

Our aim was to analyse both how rates of loss to follow-up (LTFU) changed between 2006 and 2020 and how the COVID-19 pandemic affected these rates in the PISCIS cohort study of Catalonia and the Balearic Islands.

METHODS

We analysed socio-demographic and clinical characteristics of LTFU yearly and with adjusted odds ratios to assess the impact of these determinants on LTFU in 2020 (the year of COVID-19). We used latent class analysis to categorize classes of LTFU based on their socio-demographic and clinical characteristics at each year.

RESULTS

In total, 16.7% of the cohort were lost to follow-up at any time in the 15 years (n = 19 417). Of people living with HIV who were receiving follow-up, 81.5% were male and 19.5% were female; of those who were lost to follow-up, 79.6% and 20.4% were male and female, respectively (p < 0.001). Although rates of LTFU increased during COVID-19 (1.11% vs. 0.86%, p = 0.024), socio-demographic and clinical factors were similar. Eight classes of people living with HIV who were lost to follow-up were identified: six for men and two for women. Classes of men (n = 3) differed in terms of their country of birth, viral load (VL), and antiretroviral therapy (ART); classes of people who inject drugs (n = 2) differed in terms of VL, AIDS diagnosis, and ART. Changes in rates of LTFU included higher CD4 cell count and undetectable VL.

CONCLUSIONS

The socio-demographic and clinical characteristics of people living with HIV changed over time. Although the circumstances of the COVID-19 pandemic increased the rates of LTFU, the characteristics of these people were similar. Epidemiological trends among people who were lost to follow-up can be used to prevent new losses of care and to reduce barriers to achieve Joint United Nations Programme on HIV/AIDS 95-95-95 targets.

Five-Year Mortality for Adults Entering Human Immunodeficiency Virus Care Under Universal Early Treatment Compared With the General US Population

BACKGROUND

Mortality among adults with human immunodeficiency virus (HIV) remains elevated over those in the US general population, even in the years after entry into HIV care. We explore whether the elevation in 5-year mortality would have persisted if all adults with HIV had initiated antiretroviral therapy within 3 months of entering care.

METHODS

Among 82 766 adults entering HIV care at North American AIDS Cohort Collaboration clinical sites in the United States, we computed mortality over 5 years since entry into HIV care under observed treatment patterns. We then used inverse probability weights to estimate mortality under universal early treatment. To compare mortality with those for similar individuals in the general population, we used National Center for Health Statistics data to construct a cohort representing the subset of the US population matched to study participants on key characteristics.

RESULTS

For the entire study period (1999-2017), the 5-year mortality among adults with HIV was 7.9% (95% confidence interval [CI]: 7.6%-8.2%) higher than expected based on the US general population. Under universal early treatment, the elevation in mortality for people with HIV would have been 7.2% (95% CI: 5.8%-8.6%). In the most recent calendar period examined (2011-2017), the elevation in mortality for people with HIV was 2.6% (95% CI: 2.0%-3.3%) under observed treatment patterns and 2.1% (.0%-4.2%) under universal early treatment.

CONCLUSIONS

Expanding early treatment may modestly reduce, but not eliminate, the elevation in mortality for people with HIV.

Survival probability and factors associated with time to loss to follow-up and mortality among patients on antiretroviral treatment in central Kenya

BACKGROUND

Retention of patients who are receiving antiretroviral therapy (ART) remains a challenge especially in the setting of rapid expansion of HIV services. Retention in care remains vital to the HIV care continuum, and has been associated with viral suppression and improved survival. This study aimed to ascertain survival rates, time to loss to follow-up (LTFU) or mortality events and factors associated with time to LTFU or mortality among patients enrolled on antiretroviral therapy at health facilities in central Kenya.

METHODS

This was a retrospective cohort study among patients initiated on ART between 2004 and 2012 in central Kenya. Demographic characteristics, clinical characteristics and outcomes data were analyzed using Stata version 15.1. Competing risks regression analysis and cummulative incidence functions were used to estimate survival.

RESULTS

A total of 31,346 patients were included, of whom 65.6% were female, 76.0% were aged between 20 and 50 years old, and 38.9% were diagnosed at WHO stage III. At 36 months, overall retention was 68.8%, LTFU was 27.1%, and mortality was 4.1%. The total person-years of follow up was 74,986. The incidence rate of LTFU was 9.99 per 100 person years for a total of 9383.25 person-years of follow up. The mortality rate was 1.25 per 100 person years for a total of 875.5 person-years among those who died. The median time to LTFU was 11 months (IQR 3-22) while median time to death was 3 months (IQR 0-13). Men, unmarried patients, patients presenting with advanced HIV, not on TB treatment, and enrolled into the HIV program in later cohorts, had a shorter time to mortality and LTFU.

CONCLUSION

Our study demonstrated evidence of scale-up of HIV treatment programs in central Kenya. While most patients were enrolled at an advanced WHO clinical stage, overall 36-month mortality remained low, but occurred earlier during follow-up. Cohort LTFU at 36-months reduced in later years with the losses occurring within the 1st year of follow-up. Predictors of early mortality and LTFU included being male, single, separated or divorced, advanced WHO clinical stage, and among patients not on TB treatment.

Disengagement and reengagement of HIV continuum of care in a single center cohort in northern Italy

Background: Despite the progress in HIV care, adherence to follow up remains critical. Disengagement impairs the benefit of HIV care and the increasing number of data that associates failed retention with worse outcomes has led public health institutions to consider retention in care as a new tool to fight against HIV pandemic. Objective: The aim of this retrospective, observational study was to estimate the burden of disengagement and reengagement in care in our HIV cohort and to identify the characteristics of our LTFU and reengaged patients. Moreover, we build our cascade of care to explore how closely our center aligned with the "90-90-90" targets. Methods: From the local electronic database we extracted all HIV-infected patients with at least one contact with HIV Clinic between 2012 and 2018 excluding deceased and transferred patients. Our definition of LTFU was based on the lack of any visit during at least 1 year after the last visit. Patients re-engaged were defined as those firstly considered as LTFU patients who subsequently were newly linked to HIV care. Results: About 8% of patients were lost to follow up during the period of study, with a rate of less than 2% per year and 14.1% of them were re-engaged in care. The cascade of care shows, among HIV cases diagnosed between 2011 and 2018, 86.7% patients retained in care, 94.1% of whom were on cART and 95.6% of whom were virologically suppressed. A higher attrition was found among infections diagnosed since 2011 than before 2011, such as women, patients coming from foreign countries and those with poor virological control. Conclusions: The retention rate found in our cohort is high and is in accordance with the 90-90-90 strategy. Nevertheless, understanding disengagement and re-engagement determinants is important to strengthen retention in care in the most fragile population.

Co-morbid Non-communicable Diseases and Associated Health Service Use in African and Caribbean Immigrants with HIV

We sought to characterize non-communicable disease (NCD)-related and overall health service use among African and Caribbean immigrants living with HIV between April 1, 2010 and March 31, 2013. We conducted two population-based analyses using Ontario's linked administrative health databases. We studied 1525 persons with HIV originally from Africa and the Caribbean. Compared with non-immigrants with HIV (n = 11,931), African and Caribbean immigrants had lower rates of hospital admissions, emergency department visits and non-HIV specific ambulatory care visits, and higher rates of health service use for hypertension and diabetes. Compared with HIV-negative individuals from these regions (n = 228,925), African and Caribbean immigrants with HIV had higher rates of health service use for chronic obstructive pulmonary disease [rate ratio (RR) 1.78; 95% confidence interval (CI) 1.36-2.34] and malignancy (RR 1.20; 95% CI 1.19-1.43), and greater frequency of hospitalizations for mental health illness (RR 3.33; 95% CI 2.44-4.56), diabetes (RR 1.37; 95% CI 1.09-1.71) and hypertension (RR 1.85; 95% CI 1.46-2.34). African and Caribbean immigrants with HIV have higher rates of health service use for certain NCDs than non-immigrants with HIV. The evaluation of health services for African and Caribbean immigrants with HIV should include indicators of NCD care that disproportionately affect this population.

Predictors associated with HIV/AIDS patients dropout from antiretroviral therapy at Mettu Karl Hospital, southwest Ethiopia

OBJECTIVE

The aim of this study was to determine the major risk factors of antiretroviral therapy dropout. The retrospective cohort research design was applied. 1512 HIV patients were included from Mettu Karl Hospital in Illubabor Zone, southwest part of Ethiopia from September 2005 to January 2018. Kaplan-Meier comparison and log-logistic regression accelerated failure time model were used.

RESULTS

From the log-logistic regression result, the risk of dropout for patients with primary education status was 10.58% greater as compared to illiterate (p < 0.0110). The probability of dropout for patients with marital status separated was about 16.82% higher than those patients with marital status divorced (p < 0.0070). Being merchant, farmer and daily labour had a greater risk of dropout as compared to a housewife. Most of the HIV/AIDS patients on ART were dropout in a short period due to patients separated marital status, primary education, CD4, being merchants, farmer and daily labour. Investigation on the cause of antiretroviral therapy dropout from a number of AIDS clinics in the country is highly appreciated.

Incidence of and risk factors for medical care interruption in people living with HIV in recent years

Objectives

With HIV treatment as a prevention strategy, retention in care remains a key for sustained viral suppression. We sought to identify HIV-infected patients at risk for medical care interruption (MCI) in a high-income country.

Methods

The HIV-infected patients enrolled had to attend the clinic at least twice between January 2010 and October 2014 and were followed up until May 2016. MCI was defined as patients not seeking care in or outside the clinic for at least 18 months, regardless of whether they returned to care after the interruption. The association between MCI and sociodemographic, clinical, and immuno-virological characteristics at HIV diagnosis and during follow-up was assessed using Cox models.

Results

The incidence rate of MCI was 2.5 per 100 persons-years (95% confidence interval [CI] = 2.3–2.7). MCI was more likely in patients who accessed care >6 months after diagnosis (hazard ratio [HR] = 1.30, 95% CI = 1.10–1.54 vs. ≤6 months) or did not report a primary care physician (HR = 2.40; 95% CI = 2.03–2.84). MCI was less likely in patients born in sub-Saharan Africa (HR = 0.75, 95% CI = 0.62–0.91 vs. born in France). During follow-up, the risk of MCI increased when the last CD4 count was ≤350 (HR = 2.85, 95% CI = 2.02–4.04 vs. >500 cells/mm³) and when the patient was not on antiretroviral therapy (HR = 3.67, 95% CI = 2.90–4.66).

Conclusions

The incidence of MCI is low in this hospital that serves a large proportion of migrants. Low or no recorded CD4 counts for a medical visit could alert of a higher risk of MCI, even more in patients who accessed HIV care late or did not report a primary care physician.

Predictors of Mortality among Patients Lost to Follow up Antiretroviral Therapy

Introduction: The death of HIV/AIDS patients after receiving therapy in Bali is the seventh highest percentage of deaths in Indonesia. LTFU increases the risk of death in PLHA, given the saturation of people with HIV taking medication. The level of consistency in the treatment is very important to maintain the resilience and quality of life of people living with HIV. This study aims to determine the incidence rate, median time and predictors of death occurring in LTFU patients as seen from their sociodemographic and clinical characteristics.Methods: This study used an analytical longitudinal approach with retrospective secondary data analysis in a cohort of HIV-positive patients receiving ARV therapy at the Buleleng District Hospital in the period 2006-2015. The study used the survival analysis available within the STATA SE 12 softwareResults: The result showed that the incidence rate of death in LTFU patients was 65.9 per 100 persons, with the median time occurrence of 0.2 years (2.53 months). The NNRTI-class antiretroviral evapirens agents were shown to increase the risk of incidence of death in LTFU patients 3.92 times greater than the nevirapine group (HR 3.92; p = 0.007 (CI 1.46-10.51). Each 1 kg increase in body weight decreased the risk of death in LTFU patients by 6% (HR 0.94; p = 0.035 (CI 0.89-0.99).Conclusion: An evaluation and the monitoring of patient tracking with LTFU should be undertaken to improve sustainability. Furthermore, an observation of the LTFU patient's final condition with primary data and qualitative research needs to be done so then it can explore more deeply the reasons behind LTFU.

Loss to follow-up in anti-HCV-positive patients in a Brazilian regional outpatient clinic

Loss to follow-up (LF), which refers to patients who started care but voluntary stopped it, is a problem for patients with chronic disease. We aimed to estimate the rate of LF among patients seropositive for hepatitis C virus (HCV) and identify possible demographic and lifestyle risk factors associated with LF. From January 2009 through December 2012, 1010 anti-HCV-positive patients were included in the study. Among participants, 223 (22.1%) met the case definition for LF (more than 1-year elapsed since the last clinical appointment). Among 787 patients who remained in follow-up, 372 (47.2%) were discharged after undetectable HCV RNA, 88 (11.1%) were transferred (and remained on regular follow-up at the destination), and 25 (3.1%) died. According to univariate analysis, male gender, absence of a life partner, black race, psychiatric illness, previous alcohol abuse, previous or current recreational drug use, and previous or current smoking were significantly associated with LF. In multivariate analysis, absence of a life partner (adjusted odds ratio (AOR)=1.44; 95% confidence interval (95%CI)=1.03–2.02), black race (AOR=1.81, 95%CI=1.12–2.89), psychiatric illness (AOR=1.77, 95%CI=1.14–2.73), and the presence of at least one lifestyle risk factor (pertaining to substance abuse) (AOR=1.95, 95%CI=1.29–2.94) were independently associated with LF. Our study provides an estimate of the incidence of LF among anti-HCV-positive patients and identifies risk factors associated with this outcome. In addition, these results can help clinicians recognize patients at risk for LF, who require additional support for the continuity of care.

The Effect of Timing of Initiation of Antiretroviral Therapy on Loss to Follow-up in HIV-Tuberculosis Coinfected Patients in South Africa: An Open-Label, Randomized, Controlled Trial

OBJECTIVE

To evaluate the effect of early integrated, late-integrated, and delayed antiretroviral therapy (ART) initiation during tuberculosis (TB) treatment on the incidence rates of loss to follow-up (LTFU) and to evaluate the effect of ART initiation on LTFU rates within trial arms in patients coinfected with TB and HIV.

METHODS

A substudy within a 3-armed, open label, randomized, controlled trial. Patients were randomized to initiate ART either early or late during TB treatment or after the TB treatment completion. We reported the incidence and predictors of LTFU from TB treatment initiation during the 24 months of follow-up. LTFU was defined as having missed 4 consecutive monthly visits with the inability to make contact.

RESULTS

Of the 642 patients randomized, a total of 96 (15.0%) were LTFU at a median of 6.0 [interquartile range (IQR), 1.1-11.3] months after TB treatment initiation. Incidence rates of LTFU were 7.5 per 100 person-years (PY) [95% confidence interval (CI): 4.9 to 11], 10.9 per 100 PY (95% CI: 7.6 to 15.1), and 11.0 per 100 PY (95% CI: 7.6 to 15.4) in the early integrated, late-integrated, and delayed treatment arms (P = 0.313). Incidence rate of LTFU before and after ART initiation was 31.7 per 100 PY (95% CI: 11.6 to 69.0) vs. 6.1 per 100 PY (95% CI: 3.7 to 9.4); incidence rate ratio (IRR) was 5.2 (95% CI: 2.1 to 13.0; P < 0.001) in the early integrated arm; 31.9 per 100 PY (95% CI: 20.4 to 47.5) vs. 4.7 per 10 PY (95% CI: 2.4 to 8.2) and IRR was 6.8 (95% CI: 3.4 to 13.6; P < 0.0001) in the late-integrated arm; and 21.9 per 100 PY (95% CI: 14.6 to 31.5) vs. 2.8 per 100 PY (95% CI: 0.9 to 6.6) and IRR was 7.7 (95% CI: 3.0 to 19.9; P < 0.0001) in the sequential arm.

CONCLUSION

LTFU rates were not significantly different between the 3 trials arms. However, ART initiation within each trial arm resulted in a significant reduction in LTFU rates among TB patients.

Characteristics and consequences of medical care interruptions in HIV-infected patients in France

To describe the consequences of medical care interruptions (MCIs) we selected patients with at least two medical encounters between January 2006 and June 2013 in the Dat'AIDS cohort. Patients with any time interval >15 months between two visits were defined as having a MCI, as opposed to uninterrupted follow-up (UFU). Patients' characteristics at the time of HIV diagnosis and at the censoring date were compared between groups. Cox proportional hazards models were built to assess the role of interruptions on survival (total and AIDS-free). Of 11 116 patients, 824 had at least one MCI. These patients were younger at the time of HIV diagnosis (30 vs. 33 years, P < 0·0001). MCI was less frequent in men having sex with men vs. heterosexual patients [odds ratio (OR) 0·81, 95% confidence interval (CI) 0·69-0·96)], and a centre effect was described. MCI was independently associated with AIDS (OR 2·54, 95% CI 2·10-3·09) and death (OR 2·65, 95% CI 1·94-3·61). At the censoring date, 52·2% of patients with at least one MCI had viral load below detection vs. 85·3% of the UFU group (P < 0·0001). In conclusion, MCIs were associated with patients' survival and with the proportion of viral loads below detection in our cohort, compromising individual and collective treatment benefits.

Implementation and Operational Research: Engagement in HIV Care Among Persons Enrolled in a Clinical HIV Cohort in Ontario, Canada, 2001-2011

Supplemental Digital Content is Available in the Text.

Ensuring that people living with HIV are accessing and staying in care is vital to achieving optimal health outcomes including antiretroviral therapy (ART) success. We sought to characterize engagement in HIV care among participants of a large clinical cohort in Ontario, Canada, from 2001 to 2011.

Effect of Health Literacy on Research Follow-Up

Previous research has not examined the effect of health literacy on research subjects' completion of scheduled research follow-up. This article evaluates patient factors associated with incomplete research follow-up at three time points after enrollment in a large, hospital-based prospective cohort study. Predictor variables included health literacy, age, race, gender, education, employment status, difficulty paying bills, hospital diagnosis, length of stay, self-reported global health status, depression, perceived health competence, medication adherence, and health care system distrust. In a sample of 2,042 patients, multivariable models demonstrated that lower health literacy and younger age were significantly associated with a lower likelihood of completing research follow-up interviews at 2-3 days, 30 days, and 90 days after hospital discharge. In addition, patients who had less education, were currently employed, and had moderate financial stress were less likely to complete 90-day follow-up. This study is the first to demonstrate that lower health literacy is a significant predictor of incomplete research follow-up.