The association of clinical follow-up intervals in HIV-infected persons with viral suppression on subsequent viral suppression

A Comparative Analysis of Different HIV Viral Load Suppression Definitions Among Clients Receiving Care in the Miami-Dade Ryan White HIV/AIDS Program

The study's objective was to examine variations in viral load (VL) suppression definitions among clients in the Ryan White Program (RWP). Data from clients enrolled in the RWP during 2017 were examined to calculate the proportion of virally suppressed clients using three definitions: recent viral suppression, defined as having a suppressed VL (< 200 copies/mL) in the last test in 2017; maintained viral suppression, having a suppressed VL for both the first and last tests in 2017; and sustained viral suppression, having all tests in 2017 showing suppression. Relative differences across all three definitions were computed. Recent viral suppression measures were higher than maintained and sustained viral suppression measures by 7.0% and 10.1%, respectively. Significant relative differences in definitions by demographic, socioeconomic and clinical status were observed. It may be beneficial for care planning to report not only estimates of recent viral suppression but maintained and sustained viral suppression as well.

The Management of HIV Care Services in Central and Eastern Europe: Data from the Euroguidelines in Central and Eastern Europe Network Group

Introduction: The COVID-19 pandemic has been challenging time for medical care, especially in the field of infectious diseases (ID), but it has also provided an opportunity to introduce new solutions in HIV management. Here, we investigated the changes in HIV service provision across Central and Eastern European (CEE) countries before and after the COVID-19 outbreak. Methods: The Euroguidelines in Central and Eastern Europe Network Group consists of experts in the field of ID from 24 countries within the CEE region. Between 11 September and 29 September 2021, the group produced an on-line survey, consisting of 32 questions on models of care among HIV clinics before and after the SARS-CoV-2 outbreak. Results: Twenty-three HIV centers from 19 countries (79.2% of all countries invited) participated in the survey. In 69.5% of the countries, there were more than four HIV centers, in three countries there were four centers (21%), and in four countries there was only one HIV center in each country. HIV care was based in ID hospitals plus out-patient clinics (52%), was centralized in big cities (52%), and was publicly financed (96%). Integrated services were available in 21 clinics (91%) with access to specialists other than ID, including psychologists in 71.5% of the centers, psychiatrists in 43%, gynecologists in 47.5%, dermatologists in 52.5%, and social workers in 62% of all clinics. Patient-centered care was provided in 17 centers (74%), allowing consultations and tests to be planned for the same day. Telehealth tools were used in 11 centers (47%) before the COVID-19 pandemic outbreak, and in 18 (78%) after (p = 0.36), but were represented mostly by consultations over the telephone or via e-mail. After the COVID-19 outbreak, telehealth was introduced as a new medical tool in nine centers (39%). In five centers (28%), no new services or tools were introduced. Conclusions: As a consequence of the COVID-19 pandemic, tools such as telehealth have become popularized in CEE countries, challenging the traditional approach to HIV care. These implications need to be further evaluated in order to ascertain the best adaptations, especially for HIV medicine.

A Midwestern Academic HIV Clinic Operation during the COVID-19 Pandemic: Implementation Strategy and Preliminary Outcomes

During the COVID-19 pandemic, HIV clinics had to transform care delivery for people with HIV (PWH). We developed a multifaceted telehealth implementation strategy and monitored number of out of care patients (OOC), medical visit frequency (MVF), gap in care (GiC) and viral suppression (VS), and compared measures to baseline data. Between April and October 2020, 1559 visits were scheduled; 328 (21%) were missed, and 63 (4%) were new to care. Of the remaining 1168 follow-up visits, 412 (35%) were telehealth visits. As of October 2020, there were 53 patients OOC, MVF was 55% and GiC was 24% compared to 34, 69% and 14% at baseline, respectively. Overall VS rate remained high at 93% (97% for telehealth and 91% for in-person visits, p = 0.0001). Our implementation strategy facilitated quick provision of telehealth to a third of PWH receiving care in our clinic. While MVF decreased and GiC increased, VS rates remained high.

Trends in Follow-Up Visits Among People Living With HIV: Results From the TREAT Asia and Australian HIV Observational Databases

BACKGROUND

Less frequent follow-up visits may reduce the burden on people living with HIV (PLHIV) and health care facilities. We aimed to assess trends in follow-up visits and survival outcomes among PLHIV in Asia and Australasia.

SETTINGS

PLHIV enrolled in TREAT Asia HIV Observational Database (TAHOD) or Australian HIV Observational Database (AHOD) from 2008 to 2017 were included.

METHODS

Follow-up visits included laboratory testing and clinic visit dates. Visit rates and survival were analyzed using repeated measure Poisson regression and competing risk regression, respectively. Additional analyses were limited to stable PLHIV with viral load <1000 copies/mL and self-reported adherence ≥95%.

RESULTS

We included 7707 PLHIV from TAHOD and 3289 PLHIV from AHOD. Visit rates were 4.33 per person-years (/PYS) in TAHOD and 3.68/PYS in AHOD. Both TAHOD and AHOD showed decreasing visit rates in later calendar years compared with that in years 2008-2009 (P < 0.001 for both cohorts). Compared with PLHIV with 2 visits, those with ≥4 visits had poorer survival: TAHOD ≥4 visits, subhazard ratio (SHR) = 1.88, 95% confidence interval (CI): 1.16 to 3.03, P = 0.010; AHOD ≥4 visits, SHR = 1.80, 95% CI: 1.10 to 2.97, P = 0.020; whereas those with ≤1 visit showed no differences in mortality. The association remained evident among stable PLHIV: TAHOD ≥4 visits, SHR = 5.79, 95% CI: 1.84 to 18.24, P = 0.003; AHOD ≥4 visits, SHR = 2.15, 95% CI: 1.20 to 3.85, P = 0.010, compared with 2 visits.

CONCLUSIONS

Both TAHOD and AHOD visit rates have declined. Less frequent visits did not affect survival outcomes; however, poorer health possibly leads to increased follow-up and higher mortality. Reducing visit frequency may be achievable among PLHIV with no other medical complications.

Gaps Up To 9 Months Between HIV Primary Care Visits Do Not Worsen Viral Load

Current guidelines specify that visit intervals with viral monitoring should not exceed 6 months for HIV patients. Yet, gaps in care exceeding 6 months are common. In an observational cohort using US patients, we examined the association between gap length and changes in viral load status and sought to determine the length of the gap at which significant increases in viral load occur. We identified patients with gaps in care greater than 6 months from 6399 patients from six US HIV clinics. Gap strata were >6 to <7, 7 to <8, 8 to <9, 9 to <12, and ≥12 months, with viral load measurements matched to the opening and closing dates for the gaps. We examined visit gap lengths in association with two viral load measurements: continuous (log10 viral load at gap opening and closing) and dichotomous (whether patients initially suppressed but lost viral suppression by close of the care gap). Viral load increases were nonsignificant or modest when gap length was <9 months, corresponding to 10% or fewer patients who lost viral suppression. For gaps ≥12 months, there was a significant increase in viral load as well as a much larger loss of viral suppression (in 23% of patients). Detrimental effects on viral load after a care gap were greater in young patients, black patients, and those without private health insurance. On average, shorter gaps in care were not detrimental to patient viral load status. HIV primary care visit intervals of 6 to 9 months for select patients may be appropriate.

Effect of frequency of clinic visits and medication pick-up on antiretroviral treatment outcomes: a systematic literature review and meta-analysis

Introduction: Expanding and sustaining antiretroviral therapy (ART) coverage may require simplified HIV service delivery strategies that concomitantly reduce the burden of care on the health system and patients while ensuring optimal outcomes. We conducted a systematic review to assess the impact of reduced frequency of clinic visits and drug dispensing on patient outcomes.

Methods: As part of the development process of the World Health Organization antiretroviral (ARV) guidelines, we systematically searched medical literature databases for publications up to 30 August 2016. Information was extracted on trial characteristics, patient characteristics and the following outcomes: mortality, morbidity, treatment adherence, retention, patient and provider acceptability, cost and patients exiting the programme. When feasible, conventional pairwise meta‐analyses were conducted.

Results and discussion: Of 6443 identified citations, 21 papers, pertaining to 16 studies, were included in this review, with 11 studies contributing to analyses. Although analyses were feasible, they were limited by the sparse evidence base, despite the importance of the research area, and relatively low quality. Comparative analyses of eight studies reporting on frequency of clinic visits showed that less frequent clinic visits led to higher odds of being retained in care (odds ratio [OR]: 1.90; 95% CI: 1.21–2.99). No differences were found with respect to viral failure, morbidity or mortality; however, most estimates were favourable to reduced clinic visits. Reduced frequency of ARVs pick‐ups showed a trend towards better retention (OR: 1.93; 95% CI: 0.62–6.04). Strategies using community support tended to have better outcomes; however, their implementation varied, particularly by location. External validity may be questionable.

Conclusions: Our systematic review suggests that reduction of clinical visits (and likely ARVs pick‐ups) may improve clinical outcomes, and that they are a viable option to relieve health systems and reduce burden of care for PLHIV. Strategies aimed at reducing clinic visits or drug refill services should focus on stable patients who are virally suppressed, tolerant to their drug regimen and fully adherent. These strategies may be critical to the current changes taking place in HIV treatment policy; thus, due to the data limitations, further high quality research is needed to inform policy and programmatic interventions.

Assessing Antiretroviral Use During Gaps in HIV Primary Care Using Multisite Medicaid Claims and Clinical Data

BACKGROUND

Some individuals who appear poorly retained by clinic visit-based retention measures are using antiretroviral therapy (ART) and maintaining viral suppression. We examined whether individuals with a gap in HIV primary care (≥180 days between HIV outpatient clinic visits) obtained ART during that gap after 180 days.

SETTING

HIV Research Network data from 5 sites and Medicaid Analytic Extract eligibility and pharmacy data were combined.

METHODS

Factors associated with having both an HIV primary care gap and a new (ie, nonrefill) ART prescription during a gap were evaluated with multinomial logistic regression.

RESULTS

Of 6892 HIV Research Network patients, 6196 (90%) were linked to Medicaid data, and 4275 had any Medicaid ART prescription. Over half (54%) had occasional gaps in HIV primary care. Women, older people, and those with suppressed viral load were less likely to have a gap. Among those with occasional gaps (n = 2282), 51% received a new ART prescription in a gap. Viral load suppression before gap was associated with receiving a new ART prescription in a gap (odds ratio = 1.91, 95% confidence interval: 1.57 to 2.32), as was number of days in a gap (odds ratio = 1.04, 95% confidence interval: 1.02 to 1.05), and the proportion of months in the gap enrolled in Medicaid.

CONCLUSIONS

Medicaid-insured individuals commonly receive ART during gaps in HIV primary care, but almost half do not. Retention measures based on visit frequency data that do not incorporate receipt of ART and/or viral suppression may misclassify individuals who remain suppressed on ART as not retained.

HIV Nurse Navigation: Charting the Course to Improve Engagement in Care and HIV Virologic Suppression

This study represents one of the few exploring the effectiveness of an integrated HIV nurse navigation program on engagement and virologic outcomes. A navigator provided individualized care management (eg, pillbox renewals), intensive outreach, and collaboration with existing support systems (eg, families, community programs). Clinical data from the Veterans Affairs (VA) Medical Center site of a longitudinal, observational study of HIV in the District of Columbia (DC) cohort were used for comparison (N = 706). Navigation patients (n = 84) were less likely to have permanent housing, and more likely to be disabled, have detectable viral load, comorbid depressive, and substance use disorders. Navigation patients showed improvements in clinic visits (doubled), rate of medication renewal (40.91% to 80.61%), CD4 count and CD4%, and viral rates of Veterans with <200 copies/mL increased from 47.6% to 69.0% after one year. Integration of nurse navigation into a HIV primary care setting shows promise in improving engagement and virologic suppression in a high-risk population.

Evaluating patterns in retention, continuation, gaps, and re-engagement in HIV care in a Medicaid-insured population, 2006-2012, United States

We used the US-based MarketScan(®) Medicaid Multi-state Databases to determine the un-weighted proportion of publically insured persons with HIV that were retained, continued, and re-engaged in care. Persons were followed for up to 84 months. Cox proportional hazards models were conducted to determine factors associated with gaps in care. Of the 6463 HIV cases identified in 2006, 61% were retained during the first 24 months, and 53% continued in care through 78 months. Between 8% and 30% experienced a gap in care, and 59% of persons who experienced a gap in care later re-engaged in care. Persons with one or more Charlson co-morbidities (HR 0.72, 95% CI 0.64-0.81), ages 40-59 (0.79, 0.71-0.88), mental illness diagnosis (0.79, 0.72-0.87), hepatitis C co-infection (0.83, 0.75-0.93), and female sex (0.86, 0.78-0.94) were less likely to experience a gap in care. Between 27% and 38% of those not retained in care continued to receive HIV-related laboratory services. This Medicaid claims database combines features of both clinic visits-based and surveillance lab-based surrogate measures to give a more complete picture of engagement in care than single-facility-based studies.

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.

Trends and Determinants of Antiretroviral Therapy Patient Monitoring Practices in Kenya and Uganda

Introduction

Patients receiving antiretroviral therapy (ART) require routine monitoring to track response to treatment and assess for treatment failure. This study aims to identify gaps in monitoring practices in Kenya and Uganda.

Methods

We conducted a systematic retrospective chart review of adults who initiated ART between 2007 and 2012. We assessed the availability of baseline measurements (CD4 count, weight, and WHO stage) and ongoing CD4 and weight monitoring according to national guidelines in place at the time. Mixed-effects logistic regression models were used to analyze facility and patient factors associated with meeting monitoring guidelines.

Results

From 2007 to 2012, at least 88% of patients per year in Uganda had a recorded weight at initiation, while in Kenya there was a notable increase from 69% to 90%. Patients with a documented baseline CD4 count increased from 69% to about 80% in both countries. In 2012, 83% and 86% of established patients received the recommended quarterly weight monitoring in Kenya and Uganda, respectively, while semiannual CD4 monitoring was less common (49% in Kenya and 38% in Uganda). Initiating at a more advanced WHO stage was associated with a lower odds of baseline CD4 testing. On-site CD4 analysis capacity was associated with increased odds of CD4 testing at baseline and in the future.

Discussion

Substantial gaps were noted in ongoing CD4 monitoring of patients on ART. Although guidelines have since changed, limited laboratory capacity is likely to remain a significant issue in monitoring patients on ART, with important implications for ensuring quality care.

Antiretroviral treatment use, co-morbidities and clinical outcomes among Aboriginal participants in the Australian HIV Observational Database (AHOD)

Background

There are few data regarding clinical care and outcomes of Indigenous Australians living with HIV and it is unknown if these differ from non-Indigenous HIV-positive Australians.

Methods

AHOD commenced enrolment in 1999 and is a prospective cohort of HIV-positive participants attending HIV outpatient services throughout Australia, of which 20 (74 %) sites report Indigenous status. Data were collected up until March 2013 and compared between Indigenous and non-Indigenous participants. Person-year methods were used to compare death rates, rates of loss to follow-up and rates of laboratory testing during follow-up between Indigenous and non-Indigenous participants. Factors associated with time to first combination antiretroviral therapy (cART) regimen change were assessed using Kaplan Meier and Cox Proportional hazards methods.

Results

Forty-two of 2197 (1.9 %) participants were Indigenous. Follow-up amongst Indigenous and non-Indigenous participants was 332 & 16270 person-years, respectively. HIV virological suppression was achieved in similar proportions of Indigenous and non-Indigenous participants 2 years after initiation of cART (81.0 % vs 76.5 %, p = 0.635). Indigenous status was not independently associated with shorter time to change from first- to second-line cART (aHR 0.95, 95 % CI 0.51-1.76, p = 0.957). Compared with non-Indigenous participants, Indigenous participants had significantly less frequent laboratory monitoring of CD4 count (rate:2.76 tests/year vs 2.97 tests/year, p = 0.025) and HIV viral load (rate:2.53 tests/year vs 2.93 tests/year, p < 0.001), while testing rates for lipids and blood glucose were almost half that of non-indigenous participants (rate:0.43/year vs 0.71 tests/year, p < 0.001). Loss to follow-up (23.8 % vs 29.8 %, p = 0.496) and death (2.4 % vs 7.1 %, p = 0.361) occurred in similar proportions of indigenous and non-Indigenous participants, respectively, although causes of death in both groups were mostly non-HIV-related.

Conclusions

As far as we are aware, these are the first data comparing clinical outcomes between Indigenous and non-Indigenous HIV-positive Australians. The forty-two Indigenous participants represent over 10 % of all Indigenous Australians ever diagnosed with HIV. Although outcomes were not significantly different, Indigenous patients had lower rates of laboratory testing for HIV and lipid/glucose parameters. Given the elevated risk of cardiovascular disease in the general Indigenous community, the additional risk factor of HIV infection warrants further focus on modifiable risk factors to maximise life expectancy in this population.

Patient Perspectives on Leaving, Disengaging, and Returning to HIV Care

Continuity of care is the cornerstone of all modern HIV disease management guidelines. Interruptions in care due to disengagement or moving between HIV care centers are common occurrences often contributing to poorer health. In order to understand why patients disengage from HIV care we first document movement into and out of our regional population since 2001 and then interview returning patients about their underlying motivations leaving or transferring care. Overall, 47% of all patients either disengaged (i.e., lost-to-follow-up) or moved away from local HIV care; 16% returned. Motivations and underlying reasons stated by patients who moved were different than for patients who disengaged from care. "Feeling well' and 'loss of interest' most often led to dropping out of care, whereas as employment or family issues predicated more formal moves. Reengaging to HIV care was commonly related to health concerns. Understanding patient's motivations underlying discontinuation of care will help provide insight into the reasons that patients themselves find important thus improving outcomes.

A Comparison of Methods for Analyzing Viral Load Data in Studies of HIV Patients

HIV RNA viral load (VL) is a pivotal outcome variable in studies of HIV infected persons. We propose and investigate two frameworks for analyzing VL: (1) a single-measure VL (SMVL) per participant and (2) repeated measures of VL (RMVL) per participant. We compared these frameworks using a cohort of 720 HIV patients in care (4,679 post-enrollment VL measurements). The SMVL framework analyzes a single VL per participant, generally captured within a “window” of time. We analyzed three SMVL methods where the VL binary outcome is defined as suppressed or not suppressed. The omit-participant method uses a 8-month “window” (-6/+2 months) around month 24 to select the participant’s VL closest to month 24 and removes participants from the analysis without a VL in the “window”. The set-to-failure method expands on the omit-participant method by including participants without a VL within the “window” and analyzes them as not suppressed. The closest-VL method analyzes each participant’s VL measurement closest to month 24. We investigated two RMVL methods: (1) repeat-binary classifies each VL measurement as suppressed or not suppressed and estimates the proportion of participants suppressed at month 24, and (2) repeat-continuous analyzes VL as a continuous variable to estimate the change in VL across time, and geometric mean (GM) VL and proportion of participants virally suppressed at month 24. Results indicated the RMVL methods have more precision than the SMVL methods, as evidenced by narrower confidence intervals for estimates of proportion suppressed and risk ratios (RR) comparing demographic strata. The repeat-continuous method had the most precision and provides more information than other considered methods. We generally recommend using the RMVL framework when there are repeated VL measurements per participant because it utilizes all available VL data, provides additional information, has more statistical power, and avoids the subjectivity of defining a “window.”

Monitoring of HIV treatment in seven countries in the WHO Region of the Americas

OBJECTIVE

To determine the prevalence of adequate monitoring and the costs of measuring CD4+ T-lymphocytes (CD4+ cell) and human immunodeficiency virus (HIV) viral load in people receiving antiretroviral therapy (ART) in seven countries in the WHO Region of the Americas.

METHODS

We obtained retrospective, longitudinal data for 14 476 adults who started a first ART regimen at seven HIV clinics in Argentina, Brazil, Chile, Haiti, Honduras, Mexico and Peru between 2000 and 2011. We estimated the proportion of 180-day periods with adequate monitoring, which we defined as at least one CD4+ cell count and one viral load measurement. Factors associated with adequate monitoring were analysed using regression methods. The costs of the tests were estimated.

FINDINGS

The median follow-up time was 50.4 months; the proportion of 180-day periods with adequate CD4+ cell counts was 69% while the proportion with adequate monitoring was 62%. Adequate monitoring was more likely in participants who were older, who started ART more recently, whose first regimen included a non-nucleoside reverse transcriptase inhibitor or who had a CD4+ cell count less than 200 cells/µl at ART initiation. The cost of one CD4+ cell count ranged from 7.37 United States dollars (US$) in Argentina to US$ 64.09 in Chile; the cost of one viral load measurement ranged from US$ 20.34 in Brazil to US$ 186.28 in Haiti.

CONCLUSION

In HIV-infected participants receiving ART in the WHO Region of the Americas, CD4+ cell count and viral load monitoring was often carried out less frequently than regional guidelines recommend. The laboratory costs of monitoring varied greatly.

Patterns of HIV service use and HIV viral suppression among patients treated in an academic infectious diseases clinic in North Carolina

Irregular participation in HIV medical care hinders HIV RNA suppression and impacts health among people living with HIV. Cluster analysis of clinical data from 1,748 patients attending a large academic medical center yielded three HIV service usage patterns, namely: 'engaged in care', 'sporadic care', and 'frequent use'. Patients 'engaged in care' exhibited most consistent retention (on average, >88 % of each patient's observation years had ≥2 visits 90 days apart), annualized visit use (2.9 mean visits/year) and viral suppression (>73 % HIV RNA tests <400 c/mL). Patients in 'sporadic care' demonstrated lower retention (46-52 %), visit use (1.7 visits/year) and viral suppression (56 % <400 c/mL). Patients with 'frequent use' (5.2 visits/year) had more inpatient and emergency visits. Female, out-of-state residence, low attendance during the first observation year and detectable first-observed HIV RNA were early predictors of subsequent service usage. Patients 'engaged in care' were more likely to have HIV RNA <400 than those receiving sporadic care. Results confirm earlier findings that under-utilization of services predicts poorer viral suppression and health outcomes and support recommendations for 2-3 visits/year.

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

BACKGROUND

Ongoing HIV medical care is vital in achieving and maintaining viral suppression. We examined viral suppression applying retention in care definitions used by various federal agencies.

METHODS

Using National HIV Surveillance System data from 19 US jurisdictions with complete CD4 and viral load reporting, we determined viral suppression among persons who met the National HIV/AIDS Strategy retention in care definition (≥2 visits ≥3 months apart; "retained in continuous care") and among those who had evidence of care but did not meet the definition ("engaged in care"). We also examined viral suppression among persons who met the Health and Human Services Core Indicator definition for retention.

RESULTS

Of 338,959 persons living with diagnosed HIV infection in 19 areas in 2010, 63.7% received any care; of these, 19.7% were "engaged in care" and 80.3% were "retained in continuous care." Of those "engaged in care," 47.7% achieved viral suppression compared with 73.6% of persons "retained in continuous care." Significant differences were evident for all subpopulations within each care category; younger persons and blacks/African Americans had lower levels of viral suppression than their counterparts. Persons "engaged in care," regardless of sex, age, race/ethnicity, and transmission category, had significantly lower percentages of viral suppression than persons "retained in continuous care." Similar patterns of viral suppression were found for persons meeting the Health and Human Services definition compared with persons "retained in continuous care."

CONCLUSIONS

Higher levels of engagement in care, including more frequent monitoring of CD4 and viral load, were associated with viral suppression.

Engagement-in-care during the first 5 years after HIV diagnosis: data from a cohort of newly HIV-diagnosed individuals in a large US city

Initial descriptions of the HIV engagement continuum are limited by short-term follow-up and incomplete data. We evaluated engagement in a newly HIV-diagnosed cohort. Our goals were to assess long-term engagement-in-care, evaluate the effects of out-of-state migration on engagement estimates, and determine whether engagement has improved in more recently diagnosed individuals. This is a retrospective cohort study of individuals newly HIV-diagnosed at two large HIV care centers in the Denver metropolitan area from 2005 to 2009. Clinical data were obtained from three public HIV providers and two clinical trial groups. For statewide evaluation, we used mandated laboratory reporting databases for CD4 lymphocyte counts and HIV-1 RNA levels. From 2005 to 2009, 615 individuals were diagnosed with HIV. By 18 months after HIV diagnosis, 84% of the cohort had linked to care, 73% were retained in care, 49% were prescribed antiretroviral therapy, and 36% had viral suppression. By 5 years after HIV diagnosis, 55% of the cohort were retained in care, 37% had viral suppression, 15% had moved out of state, and 3% were deceased. When censoring for outmigration and death, 66% of the cohort were retained in care and 45% of the cohort had viral suppression 5 years after HIV diagnosis. Engagement-in-care 18 months after diagnosis was better in individuals diagnosed more recently. Retention in care declined while viral suppression increased over time after HIV diagnosis. Accounting for outmigration and death significantly increased estimates of engagement-in-care. Performance in the engagement continuum 18 months after diagnosis improved significantly in individuals more recently diagnosed with HIV.

Enhanced personal contact with HIV patients improves retention in primary care: a randomized trial in 6 US HIV clinics

BACKGROUND

The aim of the study was to determine whether enhanced personal contact with human immunodeficiency virus (HIV)-infected patients across time improves retention in care compared with existing standard of care (SOC) practices, and whether brief skills training improves retention beyond enhanced contact.

METHODS

The study, conducted at 6 HIV clinics in the United States, included 1838 patients with a recent history of inconsistent clinic attendance, and new patients. Each clinic randomized participants to 1 of 3 arms and continued to provide SOC practices to all enrollees: enhanced contact with interventionist (EC) (brief face-to-face meeting upon returning for care visit, interim visit call, appointment reminder calls, missed visit call); EC + skills (organization, problem solving, and communication skills); or SOC only. The intervention was delivered by project staff for 12 months following randomization. The outcomes during that 12-month period were (1) percentage of participants attending at least 1 primary care visit in 3 consecutive 4-month intervals (visit constancy), and (2) proportion of kept/scheduled primary care visits (visit adherence).

RESULTS

Log-binomial risk ratios comparing intervention arms against the SOC arm demonstrated better outcomes in both the EC and EC + skills arms (visit constancy: risk ratio [RR], 1.22 [95% confidence interval {CI}, 1.09-1.36] and 1.22 [95% CI, 1.09-1.36], respectively; visit adherence: RR, 1.08 [95% CI, 1.05-1.11] and 1.06 [95% CI, 1.02-1.09], respectively; all Ps < .01). Intervention effects were observed in numerous patient subgroups, although they were lower in patients reporting unmet needs or illicit drug use.

CONCLUSIONS

Enhanced contact with patients improved retention in HIV primary care compared with existing SOC practices. A brief patient skill-building component did not improve retention further. Additional intervention elements may be needed for patients reporting illicit drug use or who have unmet needs.

CLINICAL TRIALS REGISTRATION

CDCHRSA9272007.

Assessing the overall quality of health care in persons living with HIV in an urban environment

Ensuring high quality primary care for people living with HIV (PLWH) is important. We studied factors associated with meeting Health Resources and Services Administration-identified HIV performance measures, among a population-based sample of 376 PLWH in care at 24 Philadelphia clinics. Quality of care was assessed by a patient-level composite of 15 performance measures, focusing on HIV-specific care, vaccinations, and co-morbid condition screening. Adjusted incidence rate ratios (IRR) demonstrated relationships between patient and clinic factors and the performance measures score. The mean number of measures met was 8.52. Older age groups met more measures than 18- to 29-year-olds (age 40-49: adjusted IRR: 1.19, 95% CI: 1.05-1.35; age ≥50: adjusted IRR: 1.19, 95% CI: 1.03-1.35). Higher CD4 counts were associated with meeting more measures compared to CD4 <200 cells/μL (CD4 350-499 cells/μL: adjusted IRR: 1.14, 95% CI: 1.02-1.28; ≥500 cells/μL: adjusted IRR: 1.12, 95% CI: 1.01-1.26). PLWH attending clinics that provide adherence counseling or case management met more measures (adjusted IRR: 1.12, 95% CI: 1.04-1.21; adjusted IRR: 1.08, 95% CI: 1.02-1.14; respectively) than those attending clinics without these services. Limitations include potentially poor performance measure documentation and equal treatment of measures. Future work should focus on improving compliance with performance measures.