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Li F, McCormick TJ, Katz AR, Whiticar PM, Wasserman GM. Patient and provider characteristics associated with retention in HIV medical care and viral suppression among in care patients in Hawaii. Int J STD AIDS 2021; 32:919-926. [PMID: 33908838 DOI: 10.1177/09564624211002403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The percentages of retention in care and viral suppression among persons living with HIV (PLWH) in the United States from 2015 to 2018 were far below the 2020 national goals. This study aims to examine disparities in retention in care and viral suppression. The study population included PLWH diagnosed through 2016, residing in Hawaii at year-end 2016 and 2017, and who were in care in 2017 defined as having ≥1 CD4/viral load tests in 2017. Care providers were categorized as "very frequent" (≥50 patients), "frequent" (25-49 patients), "occasional" (10-24 patients), and "infrequent" (<10 patients). Among the 1752 patients included, 28.0% were not retained in care in 2017 (i.e., <2 CD4/VL tests performed at least 3 months apart), of whom 89.2% had only a single viral load test. Patients receiving care from the "infrequent" group of providers were less likely to be retained in care (adjusted odds ratio (aOR) = 0.48; 95% CI = 0.33, 0.69) or virally suppressed (aOR = 0.39; 95% CI = 0.24, 0.63), than patients receiving care from the "very frequent" group of providers. Percentages of three-year (2016-2018) in care and viral suppression were lowest among patients receiving care from "infrequent" care providers. Patients <45 years old were less likely to be retained in care (aOR = 0.53; 95% CI = 0.41, 0.68) or be virally suppressed (aOR = 0.59; 95% CI = 0.40, 0.86) than those 45 years or older. Patients of multiple races were less likely to be virally suppressed than whites (aOR = 0.38, 95% CI = 0.23, 0.64). Establishing a long-term relationship with an experienced HIV provider appears beneficial to achieve sustainable viral suppression and provision of uninterrupted HIV medical care.
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Affiliation(s)
- Fenfang Li
- Communicable Disease and Public Health Nursing Division, 11147Hawaii State Department of Health, Honolulu, HI, USA
| | - Timothy J McCormick
- Harm Reduction Services Branch, Communicable Disease and Public Health Nursing Division, 11147Hawaii State Department of Health, Honolulu, HI, USA
| | - Alan R Katz
- Office of Public Health Studies, Myron B. Thompson School of Social Work, 3939University of Hawaii, Honolulu, HI, USA
| | - Peter M Whiticar
- Harm Reduction Services Branch, Communicable Disease and Public Health Nursing Division, 11147Hawaii State Department of Health, Honolulu, HI, USA
| | - Glenn M Wasserman
- Communicable Disease and Public Health Nursing Division, 11147Hawaii State Department of Health, Honolulu, HI, USA
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Monroe AK, Happ LP, Rayeed N, Ma Y, Jaurretche MJ, Terzian AS, Trac K, Horberg MA, Greenberg AE, Castel AD. Clinic-Level Factors Associated With Time to Antiretroviral Initiation and Viral Suppression in a Large, Urban Cohort. Clin Infect Dis 2020; 71:e151-e158. [PMID: 31701144 PMCID: PMC7583410 DOI: 10.1093/cid/ciz1098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/06/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Using the results of a site assessment survey performed at clinics throughout Washington, DC, we studied the impact of clinic-level factors on antiretroviral therapy (ART) initiation and viral suppression (VS) among people living with human immunodeficiency virus (HIV; PLWH). METHODS This was a retrospective analysis from the District of Columbia (DC) Cohort, an observational, clinical cohort of PLWH from 2011-2018. We included data from PLWH not on ART and not virally suppressed at enrollment. Outcomes were ART initiation and VS (HIV RNA < 200 copies/mL). A clinic survey captured information on care delivery (eg, clinical services, adherence services, patient monitoring services) and clinic characteristics (eg, types of providers, availability of evenings/weekends sessions). Multivariate marginal Cox regression models were generated to identify those factors associated with the time to ART initiation and VS. RESULTS Multiple clinic-level factors were associated with ART initiation, including retention in care monitoring and medication dispensing reviews (adjusted hazard ratios [aHRs], 1.34 to 1.40; P values < .05 for both). Furthermore, multiple factors were associated with VS, including retention in HIV care monitoring, medication dispensing reviews, and the presence of a peer interventionist (aHRs, 1.35 to 1.72; P values < .05 for all). In multivariable models evaluating different combinations of clinic-level factors, enhanced adherence services (aHR, 1.37; 95% confidence interval [CI], 1.18-1.58), medication dispensing reviews (aHR, 1.22; 95% CI, 1.10-1.36), and the availability of opioid treatment (aHR, 1.26; 95% CI, 1.01-1.57) were all associated with the time to VS. CONCLUSIONS The observed association between clinic-level factors and ART initiation/VS suggests that the presence of specific clinic services may facilitate the achievement of HIV treatment goals.
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Affiliation(s)
- Anne K Monroe
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Lindsey P Happ
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | | | - Yan Ma
- Department of Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Maria J Jaurretche
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Arpi S Terzian
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Kevin Trac
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland, USA
| | - Alan E Greenberg
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - Amanda D Castel
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
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Hawk M, Coulter RW, Egan JE, Friedman MR, Meanley S, Fisk S, Watson C, Kinsky S. Exploring the Healthcare Environment and Associations with Clinical Outcomes of People Living with HIV/AIDS. AIDS Patient Care STDS 2017; 31:495-503. [PMID: 29148966 PMCID: PMC5724582 DOI: 10.1089/apc.2017.0124] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite three decades of dramatic treatment breakthroughs in antiretroviral regimens, clinical outcomes for people living with HIV vary greatly. The HIV treatment cascade models the stages of care that people living with HIV go through toward the goal of viral suppression and demonstrates that <30% of those living with HIV/AIDS in the United States have met this goal. Although some research has focused on the ways that patient characteristics and patient-provider relationships contribute to clinical adherence and treatment success, few studies to date have examined the ways that contextual factors of care and the healthcare environment contribute to patient outcomes. Here, we present qualitative findings from a mixed-methods study to describe contextual and healthcare environment factors in a Ryan White Part C clinic that are associated with patients' abilities to achieve viral suppression. We propose a modification of Andersen's Behavioral Model of Health Services Utilization, and its more recent adaptation developed by Ulett et al., to describe the ways that clinic, system, and provider factors merge to create a system of care in which more than 86% of the patient population is virally suppressed.
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Affiliation(s)
- Mary Hawk
- Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - James E. Egan
- Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mackey Reuel Friedman
- Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Steven Meanley
- Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Stuart Fisk
- Center for Inclusion Health, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Courtney Watson
- Center for Inclusion Health, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Suzanne Kinsky
- UPMC Center for High-Value Health Care, Pittsburgh, Pennsylvania
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Lai JB, Witt MA, Pauly MP, Ready J, Allerton M, Seo S, Witt DJ. Eight- or 12-Week Treatment of Hepatitis C with Ledipasvir/Sofosbuvir: Real-World Experience in a Large Integrated Health System. Drugs 2017; 77:313-318. [PMID: 28078644 DOI: 10.1007/s40265-016-0684-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Second-generation direct-acting antiviral agents are integral to treatment of hepatitis C (HCV) infection. Eight-week courses of ledipasvir/sofosbuvir (LDV/SOF) have been supported in some studies, but data are limited on efficacy in real-world use. Controversy exists regarding applicability of clinical trials to real-world effectiveness. We report virologic responses of patients with HCV genotype 1 infection receiving LDV/SOF for 8 or 12 weeks in a large integrated healthcare system. METHODS All patients receiving LDV/SOF, without ribavirin, were identified from pharmacy records, and outcomes are reported. Only treatment-naïve patients without evidence of cirrhosis and hepatitis C viral load less than 6 million IU/ml were candidates for 8-week therapy. Treatment was at clinician discretion, but delivered by a multidisciplinary team and reviewed for appropriateness and adherence to these criteria by one of the authors, all experienced in hepatitis C treatment. Sustained viral response at 12 weeks (SVR 12) was contrasted between those receiving 8 and those receiving 12 weeks of treatment. RESULTS Completed prescriptions for LDV/SOF, without ribavirin, as of 30 September 2015 were identified in 1021 patients. Five patients discontinued therapy due to medical reasons and 35 had incomplete follow-up viral load data, thus there were 981 evaluable patients: 377 treated for 8 weeks and 604 treated for 12 weeks. SVR 12 was virtually identical at 93.6 and 93.5%, respectively. Baseline characteristics differed between the two groups, as only treatment-naïve, non-cirrhotic, non-HIV-infected patients were eligible for an 8-week course of therapy. CONCLUSIONS Eight-week courses of LDV/SOF are comparable to 12-week courses in real-world use among selected patients supported by a multidisciplinary team.
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Affiliation(s)
- Jennifer B Lai
- Division of Infectious Diseases, Kaiser Permanente, 99 Montecillo Rd, Northern California Region, San Rafael, CA, 94903, USA
- Division of Gastroenterology, Kaiser Permanente, Northern California Region, San Rafael, CA, USA
| | - Maxwell A Witt
- Division of Infectious Diseases, Kaiser Permanente, 99 Montecillo Rd, Northern California Region, San Rafael, CA, 94903, USA
| | - Mary Patricia Pauly
- Division of Gastroenterology, Kaiser Permanente, Northern California Region, San Rafael, CA, USA
| | - Joanna Ready
- Division of Gastroenterology, Kaiser Permanente, Northern California Region, San Rafael, CA, USA
| | - Michael Allerton
- Division of Infectious Diseases, Kaiser Permanente, 99 Montecillo Rd, Northern California Region, San Rafael, CA, 94903, USA
| | - Suk Seo
- Division of Gastroenterology, Kaiser Permanente, Northern California Region, San Rafael, CA, USA
| | - David J Witt
- Division of Infectious Diseases, Kaiser Permanente, 99 Montecillo Rd, Northern California Region, San Rafael, CA, 94903, USA.
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Lai JB, Witt MA, Pauly MP, Ready J, Allerton M, Seo S, Witt DJ. Eight- or 12-Week Treatment of Hepatitis C with Ledipasvir/Sofosbuvir: Real-World Experience in a Large Integrated Health System. Drugs 2017. [PMID: 28078644 DOI: 10.1007/s40265-016-0684-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Second-generation direct-acting antiviral agents are integral to treatment of hepatitis C (HCV) infection. Eight-week courses of ledipasvir/sofosbuvir (LDV/SOF) have been supported in some studies, but data are limited on efficacy in real-world use. Controversy exists regarding applicability of clinical trials to real-world effectiveness. We report virologic responses of patients with HCV genotype 1 infection receiving LDV/SOF for 8 or 12 weeks in a large integrated healthcare system. METHODS All patients receiving LDV/SOF, without ribavirin, were identified from pharmacy records, and outcomes are reported. Only treatment-naïve patients without evidence of cirrhosis and hepatitis C viral load less than 6 million IU/ml were candidates for 8-week therapy. Treatment was at clinician discretion, but delivered by a multidisciplinary team and reviewed for appropriateness and adherence to these criteria by one of the authors, all experienced in hepatitis C treatment. Sustained viral response at 12 weeks (SVR 12) was contrasted between those receiving 8 and those receiving 12 weeks of treatment. RESULTS Completed prescriptions for LDV/SOF, without ribavirin, as of 30 September 2015 were identified in 1021 patients. Five patients discontinued therapy due to medical reasons and 35 had incomplete follow-up viral load data, thus there were 981 evaluable patients: 377 treated for 8 weeks and 604 treated for 12 weeks. SVR 12 was virtually identical at 93.6 and 93.5%, respectively. Baseline characteristics differed between the two groups, as only treatment-naïve, non-cirrhotic, non-HIV-infected patients were eligible for an 8-week course of therapy. CONCLUSIONS Eight-week courses of LDV/SOF are comparable to 12-week courses in real-world use among selected patients supported by a multidisciplinary team.
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Affiliation(s)
- Jennifer B Lai
- Division of Infectious Diseases, Kaiser Permanente, 99 Montecillo Rd, Northern California Region, San Rafael, CA, 94903, USA
- Division of Gastroenterology, Kaiser Permanente, Northern California Region, San Rafael, CA, USA
| | - Maxwell A Witt
- Division of Infectious Diseases, Kaiser Permanente, 99 Montecillo Rd, Northern California Region, San Rafael, CA, 94903, USA
| | - Mary Patricia Pauly
- Division of Gastroenterology, Kaiser Permanente, Northern California Region, San Rafael, CA, USA
| | - Joanna Ready
- Division of Gastroenterology, Kaiser Permanente, Northern California Region, San Rafael, CA, USA
| | - Michael Allerton
- Division of Infectious Diseases, Kaiser Permanente, 99 Montecillo Rd, Northern California Region, San Rafael, CA, 94903, USA
| | - Suk Seo
- Division of Gastroenterology, Kaiser Permanente, Northern California Region, San Rafael, CA, USA
| | - David J Witt
- Division of Infectious Diseases, Kaiser Permanente, 99 Montecillo Rd, Northern California Region, San Rafael, CA, 94903, USA.
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Rhodes CM, Chang Y, Regan S, Singer DE, Triant VA. Human Immunodeficiency Virus (HIV) Quality Indicators Are Similar Across HIV Care Delivery Models. Open Forum Infect Dis 2017; 4:ofw240. [PMID: 28480238 DOI: 10.1093/ofid/ofw240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/31/2016] [Accepted: 11/09/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There are limited data on human immunodeficiency virus (HIV) quality indicators according to model of HIV care delivery. Comparing HIV quality indicators by HIV care model could help inform best practices because patients achieving higher levels of quality indicators may have a mortality benefit. METHODS Using the Partners HIV Cohort, we categorized 1565 patients into 3 HIV care models: infectious disease provider only (ID), generalist only (generalist), or infectious disease provider and generalist (ID plus generalist). We examined 12 HIV quality indicators used by 5 major medical and quality associations and grouped them into 4 domains: process, screening, immunization, and HIV management. We used generalized estimating equations to account for most common provider and multivariable analyses adjusted for prespecified covariates to compare composite rates of HIV quality indicator completion. RESULTS We found significant differences between HIV care models, with the ID plus generalists group achieving significantly higher quality measures than the ID group in HIV management (94.4% vs 91.7%, P = .03) and higher quality measures than generalists in immunization (87.8% vs 80.6%, P = .03) in multivariable adjusted analyses. All models achieved rates that equaled or surpassed previously reported quality indicator rates. The absolute differences between groups were small and ranged from 2% to 7%. CONCLUSIONS Our results suggest that multiple HIV care models are effective with respect to HIV quality metrics. Factors to consider when determining HIV care model include healthcare setting, feasibility, and physician and patient preference.
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Affiliation(s)
- Corinne M Rhodes
- University of Pennsylvania, Division of General Internal Medicine, Philadelphia, Pennsylvania; Massachusetts General Hospital, Divisions of
| | - Yuchiao Chang
- General Internal Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Susan Regan
- General Internal Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Daniel E Singer
- General Internal Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Virginia A Triant
- General Internal Medicine.,Infectious Diseases, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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