Trends in HIV Continuum of Care Outcomes over Ten Years of Follow-Up at a Large HIV Primary Medical Home in the Southeastern United States

Syndemic of Substance Abuse, Depression, and Type 2 Diabetes and Their Association with Retention in Care Among People Living with HIV

Substance abuse (SA), depression, and type 2 diabetes (DM2) often co-occur among people living with HIV (PLHIV). Guided by a syndemic framework, this cross-sectional retrospective study examined the cumulative and interaction effects of SA, depression, and DM2 on retention in HIV care (RIC) among 621 PLHIV receiving medical care in central Pennsylvania. We performed logistic regression analysis to test the associations between SA, depression, and DM2 and RIC. To test the "syndemic" model, we assessed additive and multiplicative interactions. In an unadjusted model, a dose-response pattern between the syndemic index (total number of health conditions) and RIC was detected (OR for 1 syndemic factor vs. none: 1.01, 95% CI: 0.69-1.47; 2 syndemic factors: 1.59, 0.89-2.84; 3 syndemic factors: 1.62, 0.44-5.94), but no group reached statistical significance. Interactions on both additive and multiplicative scales were not significant, demonstrating no syndemic effect of SA, depression, and DM2 on RIC among our study sample. Our findings highlight that comorbid conditions may, in some populations, facilitate RIC rather than act as barriers, which may be due to higher levels of engagement with medical care.

Intersectional Stigma, Fear of Negative Evaluation, Depression, and ART Adherence Among Women Living with HIV Who Engage in Substance Use: A Latent Class Serial Mediation Analysis

Women Living with HIV (WLHIV) who use substances face stigma related to HIV and substance use (SU). The relationship between the intersection of these stigmas and adherence to antiretroviral therapy (ART), as well as the underlying mechanisms, remains poorly understood. This study aimed to examine the association between intersectional HIV and SU stigma and ART adherence, while also exploring the potential role of depression and fear of negative evaluation (FNE) by other people in explaining this association. We analyzed data from 409 WLHIV collected between April 2016 and April 2017, Using Multidimensional Latent Class Item Response Theory analysis. We identified five subgroups (i.e., latent classes [C]) of WLHIV with different combinations of experienced SU and HIV stigma levels: (C1) low HIV and SU stigma; (C2) moderate SU stigma; (C3) higher HIV and lower SU stigma; (C4) moderate HIV and high SU stigma; and (C5) high HIV and moderate SU stigma. Medication adherence differed significantly among these classes. Women in the class with moderate HIV and high SU stigma had lower adherence than other classes. A serial mediation analysis suggested that FNE and depression symptoms are mechanisms that contribute to explaining the differences in ART adherence among WLHIV who experience different combinations of intersectional HIV and SU stigma. We suggest that FNE is a key intervention target to attenuate the effect of intersectional stigma on depression symptoms and ART adherence, and ultimately improve health outcomes among WLHIV.

Durable viral suppression among persons with HIV in the deep south: an observational study

This study assessed predictors of stable HIV viral suppression in a racially diverse sample of persons living with HIV (PWH) in the southern US. A total of 700 PWH were recruited from one of four HIV clinics in Metro Atlanta, GA. Data were collected from September 2012 to July 2017, and HIV viral loads were retrieved from EMR for 18 months. The baseline visits and EMR data were used for current analyses. Durable viral suppression was categorized as 1. Remain suppressed, 2. Remain unsuppressed, and 3. Unstable suppression. The number of antiretroviral medications and age were significantly associated with durable viral suppression. Older age, fewer ART medications and availability of social support were positively associated with durable viral suppression over the 18-month observation period. Findings suggest that regimen complexity is potentially a better predictor of viral suppression than self-reported medication adherence. The need for consensus on the definition of durable viral suppression is also urged.

Electronic Patient Portal Access, Retention in Care, and Viral Suppression Among People Living With HIV in Southeastern United States: Observational Study

BACKGROUND

Approximately 1.1 million people living with HIV live in the United States, and the incidence is highest in Southeastern United States. Electronic patient portal prevalence is increasing and can improve engagement in primary medical care. Retention in care and viral suppression-measures of engagement in HIV care-are associated with decreased HIV transmission, morbidity, and mortality.

OBJECTIVE

We aimed to determine if patient portal access among people living with HIV was associated with retention and viral suppression.

METHODS

We conducted an observational cohort study among people living with HIV in care at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee) from 2011-2016. Individual access was defined as patient portal account registration at any point in the year prior. Retention was defined as ≥2 kept appointments or HIV lab measurements ≥3 months apart within a 12-month period. Viral suppression was defined as the last viral load in the calendar year <200 copies/mL. We calculated adjusted prevalence ratios (aPRs) and 95% CIs using modified Poisson regression with generalized estimating equations to estimate the association of portal access with retention and viral suppression.

RESULTS

We included 4237 people living with HIV contributing 16,951 person-years of follow-up (median 5, IQR 3-5 person-years). The median age was 43 (IQR 33-50) years. Of the 4237 people living with HIV, 78.1% (n=4237) were male, 40.8% (n=1727) were Black non-Hispanic, and 56.5% (n=2395) had access. Access was independently associated with retention (aPR 1.13, 95% CI 1.10-1.17) and viral suppression (aPR 1.18, 95% CI 1.14-1.22).

CONCLUSIONS

In this population, patient portal access was associated with retention and viral suppression. Future prospective studies should assess the impact of increasing portal access among people living with HIV on these HIV outcomes.

Differential Role of Psychosocial, Health Care System and Neighborhood Factors on the Retention in HIV Care of Women and Men in the Ryan White Program

We investigated potential differential impact of barriers to HIV care retention among women relative to men. Client intake, health assessment, service, and laboratory information among clients receiving medical case management during 2017 in the Miami-Dade County Ryan White Program (RWP) were obtained and linked to American Community Survey data by ZIP code. Cross-classified multilevel logistic regression analysis was conducted. Among 1609 women and 5330 men, 84.6% and 83.7% were retained in care. While simultaneously controlling for all demographic characteristics, vulnerable/enabling factors, and neighborhood indices in the model, younger age, being US born, not working, and having a medical provider with low volume (<10) of clients remained associated with non-retention in care among women and men; while having ≥3 minors in the household and being perinatally infected were additionally associated with retention only for women. Both gender-specific and gender-non-specific barriers should be considered in efforts to achieve higher retention rates.

Annual and durable HIV retention in care and viral suppression among patients of Peter Ho Clinic, 2013-2017

Objectives

To determine rates of annual and durable retention in medical care and viral suppression among patients enrolled in the Peter Ho Clinic, from 2013–2017.

Methods

This is a retrospective review of medical record data in an urban clinic, located in Newark, New Jersey, a high prevalence area of persons living with HIV. Viral load data were electronically downloaded, in rolling 1-year intervals, in two-month increments, from January 1, 2013 to December 31, 2019. Three teams were established, and every two months, they were provided with an updated list of patients with virologic failure. Retention and viral suppression rates were first calculated for each calendar-year. After patients were determined to be retained/suppressed annually, the proportion of patients with durable retention and viral suppression were calculated in two, three, four, five and six-year periods. Descriptive statistics were used to summarize sample characteristics by retention in care, virologic failure and viral suppression with Pearson Chi-square; p-value <0.05 was statistically significant. Multiple logistic regression models identified patient characteristics associated with retention in medical care, virologic failure and suppression.

Results

As of December 31, 2017, 1000 (57%) patients were retained in medical care of whom 870 (87%) were suppressed. Between 2013 and 2016, decreases in annual (85% to 77%) and durable retention in care were noted: two-year (72% to 70%) and three-year (63% to 59%) periods. However, increases were noted for 2017, in annual (89%) and durable retention in the two-year period (79%). In the adjusted model, when compared to current patients, retention in care was less likely among patients reengaging in medical care (adjusted Odds Ratio (aOR): 0.77, 95% CI: 0.61–0.98) but more likely among those newly diagnosed from 2014–2017 (aOR: 1.57, 95% CI: 1.08–2.29), compared to those in care since 2013. A higher proportion of patients re-engaging in medical care had virologic failure than current patients (56% vs. 47%, p < 0.0001). As age decreased, virologic failure was more likely (p<0.0001). Between 2013 and 2017, increases in annual (74% to 87%) and durable viral suppression were noted: two-year (59% to 73%) and three-year (49% to 58%) periods. Viral suppression was more likely among patients retained in medical care up to 2017 versus those who were not (aOR: 5.52, 95% CI: 4.08–7.46). Those less likely to be suppressed were 20–29 vs. 60 years or older (aOR: 0.52, 95% CI: 0.28–0.97), had public vs. private insurance (aOR: 0.29, 95% CI: 0.15–0.55) and public vs. private housing (aOR: 0.59, 95% CI: 0.40–0.87).

Conclusions

Restructuring clinical services at this urban clinic was associated with improved viral suppression. However, concurrent interventions to ensure retention in medical care were not implemented. Both retention in care and viral suppression interventions should be implemented in tandem to achieve an end to the epidemic. Retention in care and viral suppression should be measured longitudinally, instead of cross-sectional yearly evaluations, to capture dynamic changes in these indicators.

Disparities in Retention in Care Among Adults Living with HIV/AIDS: A Systematic Review

As national HIV prevention goals aim to increase the proportion of persons living with HIV, determining existing disparities in retention in care will allow for targeted intervention. The purpose of this systematic review was to identify existing disparities in retention in care. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) 2015 guided this systematic review. Electronic databases, including PubMed/MEDLINE, CINAHL, Sociological Collection, PsychInfo, and Cab Direct/Global Health, were systematically searched and twenty studies were included. This review identified disparities in retention in care that have been documented by race, gender, age, HIV exposure, incarceration history, place of birth, and U.S. geographic location. Research is necessary to further identify existing disparities in retention in care and to better understand determinants of health disparities. Additionally, interventions must be tailored to meet the needs of health disparate populations and should be assessed to determine their effectiveness in reducing health disparities.

Predictors of disparities in retention in care among African Americans living with HIV

Limited health literacy may contribute to racial disparities in retention in HIV care. The purpose of this study was to evaluate the effects of health literacy and patient and social-level factors on retention in care among African Americans living with HIV. This study included 699 participants recruited from outpatient HIV clinics and retention in care was defined as visit adherence. Multivariable logistic regression models were used to assess predictors of visit adherence among persons with 100% visit adherence compared to less than 100% visit adherence. Controlling for demographic factors, the odds of 100% visit adherence was greater among non-African Americans compared to African Americans. In models that included health literacy, race was no longer significant and health literacy was a significant predictor of 100% visit adherence. Among participants with less than 100% visit adherence, health literacy was not a significant predictor of visit adherence; however, age, marital status, and patient attitudes towards the health care provider were significant predictors. Findings suggest that health literacy may mediate the relationship between race and visit adherence. Future studies should further examine these relationships and develop interventions that target modifiable factors, with a goal of improving health equity and minimizing disparities.

Do Symptoms of Depression Interact with Substance Use to Affect HIV Continuum of Care Outcomes?

Few studies examine how depression and substance use interact to affect HIV control. In 14,380 persons with HIV (PWH), we used logistic regression and generalized estimating equations to evaluate how symptoms of depression interact with alcohol, cocaine, opioid, and methamphetamine use to affect subsequent retention in care, maintaining an active prescription for ART, and consistent virologic suppression. Among PWH with no or mild depressive symptoms, heavy alcohol use had no association with virologic suppression (OR 1.00 [0.95-1.06]); among those with moderate or severe symptoms, it was associated with reduced viral suppression (OR 0.80 [0.74-0.87]). We found no interactions with heavy alcohol use on retention in care or maintaining ART prescription or with other substances for any outcome. These results highlight the importance of treating moderate or severe depression in PWH, especially with comorbid heavy alcohol use, and support multifaceted interventions targeting alcohol use and depression.

Role of Gay Neighborhood Status and Other Neighborhood Factors in Racial/Ethnic Disparities in Retention in Care and Viral Load Suppression Among Men Who Have Sex with Men, Florida, 2015

This study's objective was to examine the role of gay neighborhood residence and other neighborhood factors in racial/ethnic disparities in retention in HIV care and viral load suppression during 2015. Florida residents diagnosed 2000-2014 with HIV infection and with transmission mode of men who have sex with men (MSM) were included in multi-level logistic regression models. Of 29,156 MSM, 29.4% were not retained and 34.2% were not virally suppressed. Non-Hispanic Blacks (NHB) had a higher likelihood of not being retained (adjusted prevalence ratio [aPR] 1.31, 95% confidence interval [CI] 1.24-1.38, p value < 0.0001) and not being virally suppressed (aPR 1.82, 95% CI 1.67-1.98, p value < 0.0001) compared with non-Hispanic Whites. Among NHBs, rural residence was protective for both outcomes. Although gay neighborhood residence was not associated with either outcome, the role of other neighborhood factors suggests that individual and neighborhood barriers to HIV care and treatment should be addressed among MSM.