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Masters MC, Rivera J, Calamari M, Wright K, Janulis P, Rusie L, Bannon J, Milne P, Galvin SR, Molina EG, Hirschhorn LR, Palella FJ, Kumar R, Brown C, Hawkins C. Telemedicine and HIV Care Quality Measures During the COVID-19 Pandemic. J Acquir Immune Defic Syndr 2023; 94:46-52. [PMID: 37368925 PMCID: PMC10526734 DOI: 10.1097/qai.0000000000003238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/08/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND During the COVID-19 pandemic, telemedicine was adopted to ensure continuity of HIV care. We examined how introducing televisits affected technical quality of care for people with HIV (PWH) during this time. METHODS PWH receiving HIV care at Howard Brown Health Centers and Northwestern University in Chicago, Illinois were included. HIV care quality indicators were calculated using data extracted from electronic medical records during 4 timepoints every 6 months from March, March 1, 2020 to September 1, 2021. Generalized linear mixed models estimated differences in indicators across timepoints within each site while controlling for multiple observations of individuals. Generalized linear mixed models were also used to compare differences in outcomes among PWH who attended all versus a combination of in-person and televisits versus no televisits across the study time periods. RESULTS 6447 PWH were included in the analysis. Compared with prepandemic levels, there were significant declines in care utilization and processes of care measures. Measures of HIV virologic suppression, blood pressure control, and HbA1C <7% (in both people with and without diabetes) were stable with no significant differences noted across the study timepoints. Similar trends were observed across all age, race, and sex subgroups. In multivariable models, televisits were not associated with decreased HIV viral suppression. CONCLUSIONS During the COVID-19 pandemic and rapid implementation of televisits, indicators of care utilization and processes of care decreased compared with prepandemic levels. Among PWH who remained in care, televisits were not associated with worse virologic, blood pressure, and glycemic control in PWH.
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Affiliation(s)
| | | | - Mia Calamari
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Patrick Janulis
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Jacqueline Bannon
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Patrick Milne
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Shannon R. Galvin
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | | | - Frank J. Palella
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | | | - Claudia Hawkins
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Kumbhakar RG, Budak JZ, Tao Y, Beste J, Lake E, Navabi N, Mose E, Barker G, Lee J, Hara K, Khosropour C, Dhanireddy S, Dombrowski JC. The Impact of a Walk-in Human Immunodeficiency Virus Care Model for People Who Are Incompletely Engaged in Care: The Moderate Needs (MOD) Clinic. Open Forum Infect Dis 2023; 10:ofac670. [PMID: 36628059 PMCID: PMC9825197 DOI: 10.1093/ofid/ofac670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Background The Moderate Needs (MOD) Clinic in Seattle, Washington provides walk-in primary care for people with human immunodeficiency virus (HIV) who are incompletely engaged in standard care. Methods We evaluated HIV outcomes among patients enrolled in the MOD Clinic (within group analysis) and, separately, among MOD patients versus patients who were MOD-eligible but did not enroll (comparison group analysis) during January 1, 2018-September 30, 2021. The primary outcome was viral suppression ([VS] viral load <200 copies/mL); secondary outcomes care engagement (≥2 visits ≥60 days apart) and sustained VS (≥2 consecutive suppressed viral loads ≥60 days apart). In the within group analysis, we examined outcomes at time of MOD enrollment versus 12 months postenrollment. In the comparison group analysis, we examined outcomes at the time of MOD eligibility versus 12 months posteligibility. Both analyses used modified Poisson regression. Results Most patients in MOD (N = 213) were unstably housed (52%) and had psychiatric comorbidities (86%) or hazardous substance use (81%). Among patients enrolled ≥12 months (N = 164), VS did not increase significantly from baseline to postenrollment (63% to 71%, P = .11), but care engagement and sustained VS both improved (37% to 86%, P < .001 and 20% to 53%, P < .001, respectively) from pre-enrollment to 12 months postenrollment. In the comparison group analysis, VS worsened in nonenrolled patients (N = 517) from baseline to 12 months posteligibility (82% to 75%, P < .001). Patients in the MOD Clinic who met criteria for the comparison group analysis (N = 68) were more likely than nonenrolled patients to be engaged in care at 12 months posteligibility (relative risk, 1.29; 95% confidence interval, 1.03-1.63). Conclusions The MOD Clinic enrollment was associated with improved engagement in care. This model adds to the spectrum of differentiated HIV care services.
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Affiliation(s)
- Raaka G Kumbhakar
- Correspondence: Raaka G. Kumbhakar, MD, Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, 325 9th Ave., Box 358061, Seattle, WA 98104 (). Julia C. Dombrowski, MD, MPH, 325 9th Ave., Box 359777, Seattle, WA 98104 ()
| | - Jehan Z Budak
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Yuan Tao
- Harborview Medical Center, Seattle, Washington, USA
| | - Jason Beste
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Eve Lake
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Nazlee Navabi
- Present Affiliation: Wise Patient Internal Medicine, Seattle, Washington, USA
| | - Eric Mose
- Harborview Medical Center, Seattle, Washington, USA
| | - Gwen Barker
- Harborview Medical Center, Seattle, Washington, USA
| | - Ji Lee
- Harborview Medical Center, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Katie Hara
- Present Affiliation: Bailey-Boushay House, Seattle, Washington, USA
| | | | - Shireesha Dhanireddy
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Julia C Dombrowski
- Correspondence: Raaka G. Kumbhakar, MD, Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, 325 9th Ave., Box 358061, Seattle, WA 98104 (). Julia C. Dombrowski, MD, MPH, 325 9th Ave., Box 359777, Seattle, WA 98104 ()
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Chyten-Brennan J, Patel VV, Anastos K, Hanna DB. Brief Report: Role of Gender-Affirming Hormonal Care in HIV Care Continuum Outcomes When Comparing Transgender Women With Cisgender Sexual Minority Men. J Acquir Immune Defic Syndr 2022; 91:255-260. [PMID: 36252240 PMCID: PMC9577885 DOI: 10.1097/qai.0000000000003056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 06/28/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transgender women (transwomen) are frequently conflated with cisgender sexual minority men (cis-SMM) in HIV research. We examined the impact of socioeconomic and health conditions, and gender-affirming hormones in comparing HIV-related outcomes between cis-SMM and transwomen. SETTING Large tertiary care health system in the Bronx, NY. METHODS Retrospective cohort study of people with HIV receiving care in 2008-2017. We compared retention in care, antiretroviral therapy (ART) prescription, and viral suppression between cis-SMM and transwomen, using modified Poisson regression, adjusting for demographic and clinical factors. Transwomen were further stratified by receipt of estrogen prescription. RESULTS We included 166 transwomen (1.4%), 1936 cis-SMM (17%), 4715 other cisgender men (41%), and 4745 cisgender women (41%). Transwomen were more likely to have public insurance (78% vs 65%) and mental health (49% vs 39%) or substance use (43% vs 33%) diagnoses than cis-SMM. Compared with cis-SMM, transwomen prescribed estrogen (67% of transwomen) were more likely to be retained [adjusted risk ratio (aRR) 1.15, 95% confidence interval (CI) 1.08 to 1.23), prescribed ART (aRR 1.06, CI 1.01 to 1.11), and virally suppressed (aRR 1.08, CI 1.01 to 1.16). Transwomen not prescribed estrogen were less likely to be retained (aRR 0.92, CI 0.83 to 1.02), prescribed ART (aRR 0.90, CI 0.82 to 0.98), or virally suppressed (aRR 0.85, CI 0.76 to 0.95). CONCLUSIONS In the context of HIV, socioeconomic factors, comorbidities, and gender-affirming care distinguish transwomen from cis-SMM. Compared with cis-SMM, transwomen who were prescribed estrogen had better HIV care continuum outcomes; transwomen not prescribed estrogen had worse outcomes. These differences should be accounted for in HIV-related research.
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Affiliation(s)
- Jules Chyten-Brennan
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center-Albert Einstein College of Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, United States
| | - Viraj V. Patel
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center-Albert Einstein College of Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, United States
| | - Kathryn Anastos
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center-Albert Einstein College of Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, United States
| | - David B. Hanna
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, United States
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Liu Y, Rich SN, Siddiqi KA, Chen Z, Prosperi M, Spencer E, Cook RL. Longitudinal trajectories of HIV care engagement since diagnosis among persons with HIV in the Florida Ryan White program. AIDS Behav 2022; 26:3164-3173. [PMID: 35362911 PMCID: PMC10080894 DOI: 10.1007/s10461-022-03659-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2022] [Indexed: 11/30/2022]
Abstract
HIV care engagement is a dynamic process. We employed group-based trajectory modeling to examine longitudinal patterns in care engagement among people who were newly diagnosed with HIV and enrolled in the Ryan White program in Florida (n = 9,755) between 2010 and 2015. Five trajectories were identified (47.9% "in care" with 1-2 care visit(s) per 6 months, 18.0% "frequent care" with 3 or more care visits per 6 months, 11.0% "re-engage", 11.0% "gradual drop out", 12.6% "early dropout") based on the number of care attendances (including outpatient/case management visits, viral load or CD4 test) for each six-month during the first five years since diagnosis. Relative to "in care", people in the "frequent care" trajectory were more likely to be Hispanic/Latino and older at HIV diagnosis, whereas people in the three suboptimal care retention trajectories were more likely to be younger. Area deprivation index, rurality, and county health rankings were also strongly associated with care trajectories. Individual- and community-level factors associated to the three suboptimal care retention trajectories, if confirmed to be causative and actionable, could be prioritized to improve HIV care engagement.
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Affiliation(s)
- Yiyang Liu
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, 2004 Mowry Road, PO Box 100231, 32610-0231, Gainesville, FL, United States.
| | - Shannan N Rich
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, 2004 Mowry Road, PO Box 100231, 32610-0231, Gainesville, FL, United States
| | - Khairul A Siddiqi
- Department of Health Outcome and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Zhaoyi Chen
- Department of Health Outcome and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Mattia Prosperi
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, 2004 Mowry Road, PO Box 100231, 32610-0231, Gainesville, FL, United States
| | - Emma Spencer
- Florida Department of Health, Bureau of Communicable Diseases, Tallahassee, FL, United States
| | - Robert L Cook
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, 2004 Mowry Road, PO Box 100231, 32610-0231, Gainesville, FL, United States
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Lesko CR, Hutton HE, Edwards JK, McCaul ME, Fojo AT, Keruly JC, Moore RD, Chander G. Alcohol Use Disorder and Recent Alcohol Use and HIV Viral Non-Suppression Among People Engaged in HIV Care in an Urban Clinic, 2014-2018. AIDS Behav 2022; 26:1299-1307. [PMID: 34626264 PMCID: PMC8940688 DOI: 10.1007/s10461-021-03487-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 01/28/2023]
Abstract
We estimated joint associations between having history of alcohol use disorder (AUD) (based on prior ICD-9/ICD-10 codes) and recent self-reported alcohol use and viral non-suppression (≥ 1 viral load measurement > 20 copies/mL in the same calendar year as alcohol consumption was reported) among patients on ART enrolled in routine care, 2014-2018, in an urban specialty clinic. Among 1690 patients, 26% had an AUD, 21% reported high-risk alcohol use, and 39% had viral non-suppression. Relative to person-years in which people without AUD reported not drinking, prevalence of viral non-suppression was higher in person-years when people with AUD reported drinking at any level; prevalence of viral non-suppression was not significantly higher in person-years when people with AUD reported not drinking or person-years when people without AUD reported drinking at any level. No level of alcohol use may be "safe" for people with a prior AUD with regard to maintaining viral suppression.
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Affiliation(s)
- Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA.
| | - Heidi E Hutton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jessie K Edwards
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - Mary E McCaul
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Anthony T Fojo
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jeanne C Keruly
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Richard D Moore
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Geetanjali Chander
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Management of CMV, EBV, and HIV viral load quality control data using Unity Real Time. J Clin Microbiol 2021; 60:e0167521. [PMID: 34669458 PMCID: PMC8769726 DOI: 10.1128/jcm.01675-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Quality control (QC) rules (Westgard rules) are applied to viral load testing to identify runs that should be reviewed or repeated, but this requires balancing the patient safety benefits of error detection with the cost and inefficiency of false rejection. In this study, we identified the total allowable errors (TEa) from the literature and utilized a commercially available software program (Unity Real Time; Bio-Rad Laboratories) to manage QC data, assess assay performance, and provide QC decision support for both FDA-approved/cleared (Abbott cytomegalovirus [CMV] and HIV viral load) as well as laboratory-developed (Epstein-Barr virus [EBV] viral load) assays. Unity Real Time was used to calculate means, standard deviations (SDs), and coefficient of variation (CV; in percent) of negative, low-positive, and high-positive control data from 73 to 83 days of testing. Sigma values were calculated to measure the test performance relative to a TEa of 0.5 log10. The sigma value of 5.06 for EBV predicts ∼230 erroneous results per million individual patient tests (0.02% frequency), whereas sigma values of >6 for CMV (11.32) and HIV (7.66) indicate <4 erroneous results per million individual patient tests. The Unity Real Time QC Design module utilized these sigma values to recommend QC rules and provided objective evidence for loosening the laboratory’s existing QC rules for run acceptability, potentially reducing false rejection rates by 10-fold for the assay with the most variation (EBV viral load). This study provides a framework for laboratories, with Unity Real Time as a tool, to evaluate assay performance relative to clinical decision points and establish optimal rules for routine monitoring of molecular viral load assay performance.
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7
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Chen S, Owolabi Y, Dulin M, Robinson P, Witt B, Samoff E. Applying a machine learning modelling framework to predict delayed linkage to care in patients newly diagnosed with HIV in Mecklenburg County, North Carolina, USA. AIDS 2021; 35:S29-S38. [PMID: 33867487 DOI: 10.1097/qad.0000000000002830] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Machine learning has the potential to help researchers better understand and close the gap in HIV care delivery in large metropolitan regions such as Mecklenburg County, North Carolina, USA. OBJECTIVES We aim to identify important risk factors associated with delayed linkage to care for HIV patients with novel machine learning models and identify high-risk regions of the delay. METHODS Deidentified 2013-2017 Mecklenburg County surveillance data in eHARS format were requested. Both univariate analyses and machine learning random forest model (developed in R 3.5.0) were applied to quantify associations between delayed linkage to care (>30 days after diagnosis) and various risk factors for individual HIV patients. We also aggregated linkage to care by zip codes to identify high-risk communities within the county. RESULTS Types of HIV-diagnosing facility significantly influenced time to linkage; first diagnosis in hospital was associated with the shortest time to linkage. HIV patients with lower CD4+ cell counts (<200/ml) were twice as likely to link to care within 30 days than those with higher CD4+ cell count. Random forest model achieved high accuracy (>80% without CD4+ cell count data and >95% with CD4+ cell count data) to predict risk of delay in linkage to care. In addition, we also identified top high-risk zip codes of delayed linkage. CONCLUSION The findings helped public health teams identify high-risk communities of delayed HIV care continuum across Mecklenburg County. The methodology framework can be applied to other regions with HIV epidemic and challenge of delayed linkage to care.
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Affiliation(s)
- Shi Chen
- Department of Public Health Sciences, College of Health and Human Services
- School of Data Science, UNC Charlotte, Charlotte, North Carolina
| | - Yakubu Owolabi
- Department of Public Health Sciences, College of Health and Human Services
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Michael Dulin
- Department of Public Health Sciences, College of Health and Human Services
- Academy for Population Health Innovation, UNC Charlotte
| | - Patrick Robinson
- Academy for Population Health Innovation, UNC Charlotte
- Mecklenburg County Health Department, Charlotte
| | - Brian Witt
- Academy for Population Health Innovation, UNC Charlotte
- Mecklenburg County Health Department, Charlotte
| | - Erika Samoff
- HIV/STD Prevention and Care Branch, North Carolina Department of Health and Human Services, Raleigh, North Carolina, USA
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Oduguwa E, Dongarwar D, Salihu HM. Trends in Premature Deaths among Women Living with HIV/AIDS and Cervical Cancer. South Med J 2021; 113:651-658. [PMID: 33263137 DOI: 10.14423/smj.0000000000001184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES There is a lack of updated information on premature death and years of potential life lost (YPLL) among human immunodeficiency (HIV)-positive women with cervical cancer. We hypothesize that increased access to preventive resources such as antiretroviral therapy, preexposure prophylaxis, and human papillomavirus vaccines has reduced premature mortality and YPLL in these women in the previous decades. METHODS We used data from the National Inpatient Sample database from 2003 to the third quarter of 2015, and restricted the analysis to HIV-positive women with or without cervical cancer. Joinpoint regression models were run to identify trends in the rates of HIV and cervical cancer. Overall and age-stratified YPLL were calculated for HIV-positive women with cervical cancer. Adjusted survey logistic regression models were built to determine the predictive factors of in-hospital mortality among women living with HIV. RESULTS Among hospitalized women, low-income, non-Hispanic Blacks, and patients aged 40 to 59 years experienced greater frequencies of HIV/cervical cancer comorbidity. The prevalence of HIV hospitalizations increased by an average annual percentage of 0.9% (95% confidence interval 0.3-1.6). YPLL decreased in HIV-positive women living with and without cervical cancer by 4.9% and 4.3%, respectively. The trajectory for YPLL was not uniform across age groups. YPLL decreased substantially in women aged 20 to 29 years with HIV/cervical cancer comorbidity. Cervical cancer remained a significant predictor of mortality among HIV-positive women when adjusted for age, race, and insurance coverage. CONCLUSIONS Within a large, national sample from 2003 to 2015, we found an overall declining trend in YPLL in women living with HIV/cervical cancer comorbidity. In-hospital mortality among HIV-positive women was associated with cervical cancer, age, race, and insurance coverage. We recommend further investigation into the quality of HIV and cervical cancer treatment and prevention services for the sociodemographic groups described.
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Affiliation(s)
- Emmanuella Oduguwa
- From the Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas
| | - Deepa Dongarwar
- From the Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas
| | - Hamisu M Salihu
- From the Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas
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Horberg MA, Certa JM, Rubenstein KB, Hurley LB, Satre DD, Kadlecik PM, Silverberg MJ. Beyond the HIV Care Continuum and Viral Suppression: Broadening the Scope of Quality Metrics for Total HIV Patient Care. AIDS Patient Care STDS 2020; 34:461-469. [PMID: 33147087 PMCID: PMC7698986 DOI: 10.1089/apc.2020.0145] [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] [Indexed: 12/27/2022] Open
Abstract
Assessing quality care for people with HIV (PWH) should not be limited to reporting on HIV Care Continuum benchmarks, particularly viral suppression rates. At Kaiser Permanente Mid-Atlantic States (KPMAS), an integrated health system providing HIV care in the District of Columbia, Maryland, and Virginia, we created a comprehensive measure of HIV quality care, including both preventative measures and clinical outcomes. We included PWH ≥18 years old with ≥6 months KPMAS membership between 2015 and 2018. Process quality metrics (QMs) include: pneumococcal vaccination and influenza vaccination; primary care physician (PCP) and/or HIV/infectious disease (HIV/ID) visits with additional HIV/ID visit; antiretroviral treatment medication fills; and syphilis and gonorrhea/chlamydia screenings. Outcome QMs include HIV RNA <200/mL and other measurements within normal range [blood pressure, body mass index (BMI), hemoglobin, blood sugar, alanine transaminase, low-density lipoproteins, estimated glomerular filtration rate]; no hospitalization/emergency department visit; no new depression diagnosis; remaining or becoming a nonsmoker. Logistic models estimated odds of achieving QMs associated with sex, age, race/ethnicity, insurance type, and HIV risk. A total of 4996 observations were analyzed. 45.6% met all process QMs, while 19.6% met all outcome QMs. Least frequently met process QM was PCP or HIV/ID visit (74.5%); least met outcome QM was BMI (60.2%). Significantly lower odds of achieving all QMs among women {odds ratio (OR) = 0.63 [95% confidence interval (CI): 0.49-0.81]} and those with Medicaid and Medicare [vs. commercial; OR = 0.48 (95% CI: 0.30-0.76) and 0.47 (95% CI: 0.31-0.71)]. Broadening the scope of HIV patient care QMs beyond viral suppression helps identify opportunities for improvement. Successful process metrics do not necessarily coincide with greater outcome metrics.
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Affiliation(s)
- Michael A. Horberg
- Kaiser Permanente Mid-Atlantic States Mid-Atlantic Permanente Research Institute, Rockville, Maryland, USA
- Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
| | - Julia M. Certa
- Kaiser Permanente Mid-Atlantic States Mid-Atlantic Permanente Research Institute, Rockville, Maryland, USA
| | - Kevin B. Rubenstein
- Kaiser Permanente Mid-Atlantic States Mid-Atlantic Permanente Research Institute, Rockville, Maryland, USA
| | - Leo B. Hurley
- Kaiser Permanente Northern California Division of Research, Oakland, California, USA
| | - Derek D. Satre
- Kaiser Permanente Northern California Division of Research, Oakland, California, USA
- Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| | - Peter M. Kadlecik
- Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
| | - Michael J. Silverberg
- Kaiser Permanente Northern California Division of Research, Oakland, California, USA
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Thompson J, Onyenaka C, Oduguwa E, Dongarwar D, Gendra S, Coker V, Kutse S, Blanco M, Nwangwu O, King C, Enamorado E, Bakare O, Ajewole VB, Spooner KK, Salemi JL, Aliyu MH, Salihu HM, Olaleye OA. Trends and Racial/Ethnic Disparities in the Rates of Pre-eclampsia by HIV Status in the US. J Racial Ethn Health Disparities 2020; 8:670-677. [PMID: 32754847 DOI: 10.1007/s40615-020-00826-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/06/2020] [Accepted: 07/14/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Preeclampsia and HIV account for a significant proportion of the global burden of disease and pose severe maternal-fetal risks. There is a dearth of literature regarding racial/ethnic disparities in preeclampsia associated with HIV/AIDS in the US. METHODS We retrospectively analyzed data from the National Inpatient Sample (NIS) database from 2002 to 2015 on a cohort of hospitalized pregnant women with or without preeclampsia and HIV. Joinpoint regression models were used to identify trends in the rates of preeclampsia among pregnant women living with or without HIV, stratified by race/ethnicity over the study period. We also assessed the association between preeclampsia and various socio-demographic factors. RESULTS We analyzed over 60 million pregnancy-related hospitalizations, of which 3665 had diagnoses of preeclampsia and HIV, corresponding to a rate of 0.61 per 10,000. There was an increasing trend in the diagnosis of preeclampsia among hospitalized, pregnant women without HIV across each racial/ethnic category. The highest prevalence of preeclampsia was among non-Hispanic (NH) Blacks, regardless of HIV status. CONCLUSION The increase in rates of pre-eclampsia between 2002 and 2015 was mostly noted among pregnant women without HIV. Regardless of HIV status, NH-Blacks experienced the highest discharge prevalence of preeclampsia.
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Affiliation(s)
- Jamalena Thompson
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Collins Onyenaka
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Emmanuella Oduguwa
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77098, USA.
| | - Deepa Dongarwar
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77098, USA
| | - Sumaya Gendra
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Vidella Coker
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Seun Kutse
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Mayra Blanco
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Onyinye Nwangwu
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Charlee King
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Elza Enamorado
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Oluwatoyin Bakare
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Veronica B Ajewole
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Kiara K Spooner
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jason L Salemi
- College of Public Health, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Muktar H Aliyu
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hamisu M Salihu
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77098, USA.,Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Omonike A Olaleye
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
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11
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Association between quality-of-care indicators for HIV infection and healthcare resource utilization and costs. AIDS 2020; 34:291-300. [PMID: 31714351 DOI: 10.1097/qad.0000000000002418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Multiple care quality indicators for HIV infection exist but few studies examine their impact on health outcomes. This study assessed which HIV care quality indicators were associated with healthcare resource utilization and costs. DESIGN Retrospective analysis of Texas Medicaid claims data (01 January 2012 to 31 September 2016). METHODS Included patients had at least two HIV-related medical claims during the identification period (01 July 2012 to 31 August 2014) (index = date of first HIV claim), were 18-62 years at index, and were continuously enrolled in the 6-month pre-index and 1-year post-index periods. Dependent variables included emergency department (ED) visits, inpatient hospitalizations, prescription count, and all-cause healthcare costs. Independent variables included CD4 cell count monitoring, syphilis, chlamydia, gonorrhea, hepatitis B, hepatitis C, and tuberculosis screenings, influenza and pneumococcal vaccinations, retention in care, and HAART initiation. Covariates included age, chronic hepatitis C virus infection, AIDS diagnosis, sex, and baseline healthcare cost. The study objective was addressed using generalized linear modeling. RESULTS CD4 cell count monitoring and HAART initiation were significantly associated with reduced emergency department visits (P < 0.0001 for each). Influenza vaccination was significantly associated with reduced inpatient hospitalization (P < 0.0001). CD4 cell count monitoring (P < 0.0001), TB screening (P = 0.0006), influenza vaccination (P < 0.0001), and HAART initiation (P < 0.0001) were significantly associated with increase prescription claims. CD4 cell count monitoring, TB screening, and HAART initiation (P < 0.0001 for each) were significantly associated with all-cause healthcare costs. CONCLUSION HAART may reduce use of emergency care services as early as 1 year following initiation.
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Levy ME, Monroe AK, Horberg MA, Benator DA, Molock S, Doshi RK, Powers Happ L, Castel AD. Pharmacologic Treatment of Psychiatric Disorders and Time With Unsuppressed HIV Viral Load in a Clinical HIV Cohort. J Acquir Immune Defic Syndr 2019; 82:329-341. [PMID: 31356466 PMCID: PMC6791752 DOI: 10.1097/qai.0000000000002138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate associations of mood, anxiety, stress-/trauma-related, and psychotic disorders, both treated and untreated, with duration of unsuppressed HIV viral load (VL) among persons living with HIV (PLWH). SETTING The DC Cohort, an observational clinical cohort of PLWH followed from 2011 to 2018 at 14 sites in Washington, DC. METHODS Among PLWH ≥18 years old who received primary care at their HIV clinic, we determined in a time-updated manner whether participants had diagnoses and pharmacologic prescriptions for mood, anxiety, stress-/trauma-related, and/or psychotic disorders. Associations between psychiatric disorders/treatments and the proportion of subsequent days with VL ≥200 copies/mL were assessed using multivariable Poisson regression with generalized estimating equations. RESULTS Among 5904 participants (median age 51; 70% men; 82% Black), 45% had ≥1 psychiatric disorder, including 38% with mood disorders (50% treated), 18% with anxiety or stress-/trauma-related disorders (64% treated), and 4% with psychotic disorders (52% treated). Untreated major depressive disorder (adjusted rate ratio = 1.17; 95% confidence interval: 1.00 to 1.37), untreated other/unspecified depressive disorder (1.23; 1.01 to 1.49), untreated bipolar disorder (1.39; 1.15 to 1.69), and treated bipolar disorder (1.25; 1.02 to 1.53) (vs. no mood disorder) predicted more time with VL ≥200 copies/mL. Treated anxiety disorders (vs. no anxiety disorder) predicted less time (0.78; 0.62 to 0.99). Associations were weaker and nonsignificant for treated depressive disorders (vs. no mood disorder) and untreated anxiety disorders (vs. no anxiety disorder). CONCLUSIONS PLWH with depressive and bipolar disorders, particularly when untreated, spent more time with unsuppressed VL than PLWH without a mood disorder. Treatment of mood disorders may be important for promoting sustained viral suppression.
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Affiliation(s)
- Matthew E Levy
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC
| | - Anne K Monroe
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | - Debra A Benator
- Infectious Diseases Section, Veterans Affairs Medical Center, Washington, DC
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Sherry Molock
- Department of Psychology, The George Washington University, Washington, DC
| | - Rupali K Doshi
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC
| | - Lindsey Powers Happ
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC
| | - Amanda D Castel
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC
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13
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Heglar R, Mood R, Priest JL, Schulman KL, Fusco GP. Benchmarking HIV Quality Measures in the US OPERA HIV Cohort. Open Forum Infect Dis 2019; 6:ofz418. [PMID: 31660374 PMCID: PMC6800831 DOI: 10.1093/ofid/ofz418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Quality measures are effective tools to improve patient outreach, retention in care, adherence, and outcomes. This study benchmarks National Quality Forum-endorsed HIV quality measures in a US clinical cohort. Methods This observational study utilized prospectively captured data from the Observational Pharmaco-Epidemiology Research and Analysis (OPERA) database over 2014-2016 to assess quality measure achievement among patients with HIV in terms of medical visit frequency (#2079), medical visit gaps (#2080), viral suppression (#2082), and antiretroviral therapy (ART) prescriptions (#2083). The proportion of patients meeting each measure was calculated. Generalized estimating equations assessed trends in measure achievement. Results The OPERA sample included 23 059-42 285 patients with similar demographics and characteristics across measurement periods. Overall, 62%-66% of patients met the visit frequency measure (#2079), 81%-85% had no gaps between visits (#2080), 71%-73% achieved viral suppression (#2082), and 92%-94% were prescribed ART (#2083). The adjusted odds of achieving viral suppression and being prescribed ART increased over time by 3% and 19%, respectively, despite a significant decline in patient engagement (16% for #2079, 25% for #2080). Patients <30 years of age were significantly less likely to meet all measures than older patients (P < .0001), with particularly low levels of engagement. Measure achievement also varied by gender, ethnicity, region, and select clinical characteristics. Conclusions Despite gains in the rate of ART prescription and viral suppression, there remains room for improvement in the care of patients with HIV. Strategies for quality improvement may be more effective if tailored by age group.
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Affiliation(s)
- Robert Heglar
- Familiy Medicine, AIDS Healthcare Foundation, Fort Lauderdale, Florida, USA
| | - Rodney Mood
- Health Economics and Outcomes Research, Epividian Inc., Durham, North Carolina, USA
| | - Julie L Priest
- US Health Outcomes, ViiV Healthcare, Durham, North Carolina, USA
| | - Kathy L Schulman
- Health Economics and Outcomes Research, Epividian Inc., Durham, North Carolina, USA
| | - Gregory P Fusco
- Health Economics and Outcomes Research, Epividian Inc., Durham, North Carolina, USA
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14
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Wirtz AL, Poteat T, Radix A, Althoff KN, Cannon CM, Wawrzyniak AJ, Cooney E, Mayer KH, Beyrer C, Rodriguez AE, Reisner SL. American Cohort to Study HIV Acquisition Among Transgender Women in High-Risk Areas (The LITE Study): Protocol for a Multisite Prospective Cohort Study in the Eastern and Southern United States. JMIR Res Protoc 2019; 8:e14704. [PMID: 31584005 PMCID: PMC6802485 DOI: 10.2196/14704] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/31/2019] [Accepted: 08/07/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND In the United States, transgender women (TW) are disproportionately burdened by HIV infection. Cohort studies are needed to evaluate factors driving HIV acquisition among TW over time. These will require implementation strategies that are acceptable to the TW community and feasible to implement. OBJECTIVE This study aims to investigate the rate and correlates of HIV acquisition and other health outcomes among TW in eastern and southern United States. METHODS LITE is a multisite prospective cohort in 6 eastern and southern US cities, which will be followed across 24 months of technology-enhanced biobehavioral follow-up. Adult TW, regardless of HIV status, are recruited via convenience sampling (eg, peer referrals, social media, and dating apps). Participants are enrolled in a baseline study visit, complete a sociobehavioral survey, and test for HIV and sexually transmitted infections. Participants who are not living with HIV at baseline are offered enrollment into the cohort (N=1100); follow-up assessments occur quarterly. RESULTS Cohort assembly was informed by synchronous Web-based focus group discussions with TW (n=41) and by continuing engagement with community advisory board members from each site. Enrollment launched in March 2018. The study is underway in the Atlanta; Baltimore; Boston; Miami; New York City; and Washington, DC, metro areas. As of March 2019, 795 TW completed a baseline visit (mean age 35 years). The majority of the participants are racial/ethnic minorities, with 45% of the TW identifying as black and 28% of the TW identifying as Hispanic/Latinx. More than one-quarter (28%) of the TW are living with HIV infection (laboratory-confirmed). Online recruitment methods support engagement with TW, although peer referral and referral through trusted health facilities and organizations remain most effective. CONCLUSIONS This study is responsive to increasing research interest in technology-enhanced methods for cohort research, particularly for hard-to-reach populations. Importantly, the diversity of literacy, technology use, and overall socioeconomic situations in this sample of TW highlights the need to leverage technology to permit a flexible, adaptive methodology that enhances engagement of potential participants living in marginalized contexts while still ensuring rigorous and sound study design. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/14704.
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Affiliation(s)
- Andrea L Wirtz
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Tonia Poteat
- University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Asa Radix
- Callen-Lorde Community Health Center, New York, NY, United States
| | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - Andrew J Wawrzyniak
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Erin Cooney
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - Chris Beyrer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Allan E Rodriguez
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Sari L Reisner
- The Fenway Institute, Boston, MA, United States
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA, United States
- Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, United States
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15
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Chang EJ, Fleming M, Nunez A, Dombrowski JC. Predictors of Successful HIV Care Re-engagement Among Persons Poorly Engaged in HIV Care. AIDS Behav 2019; 23:2490-2497. [PMID: 30980279 DOI: 10.1007/s10461-019-02491-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Data to Care (D2C) strategy uses HIV surveillance data to identify persons living with HIV (PLWH) who are poorly engaged in care and offers assistance with care re-engagement. We evaluated HIV care re-engagement among PLWH in Seattle & King County, Washington after participation in a D2C program and determined whether variables available at the time of the D2C interview predicted subsequent re-engagement in care. We defined successful re-engagement as surveillance evidence of either continuous care engagement (≥ 2 CD4 counts or HIV RNA results ≥ 60 days apart) or viral suppression (≥ 1 HIV RNA < 200 copies/mL) in the year following the D2C interview. Predictor variables included client characteristics, beliefs about HIV care, and scores on psychosocial assessment scales. Half of participants successfully re-engaged in care. We did not find any significant predictors of re-engagement except viral suppression at the time of the D2C interview. Close follow-up is needed to identify which D2C participants need additional assistance re-engaging in care.
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Affiliation(s)
| | - Mark Fleming
- Public Health - Seattle & King County HIV/STD Program, Seattle, WA, USA
| | - Angela Nunez
- Public Health - Seattle & King County HIV/STD Program, Seattle, WA, USA
| | - Julia C Dombrowski
- Public Health - Seattle & King County HIV/STD Program, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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16
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Dombrowski JC, Galagan SR, Ramchandani M, Dhanireddy S, Harrington RD, Moore A, Hara K, Eastment M, Golden MR. HIV Care for Patients With Complex Needs: A Controlled Evaluation of a Walk-In, Incentivized Care Model. Open Forum Infect Dis 2019; 6:ofz294. [PMID: 31341930 PMCID: PMC6641789 DOI: 10.1093/ofid/ofz294] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/21/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND New approaches are needed to provide care to persons with HIV who do not engage in conventionally organized HIV clinics. The Max Clinic in Seattle, Washington, is a walk-in, incentivized HIV care model located in a public health STD clinic that provides care in collaboration with a comprehensive HIV primary care clinic (the Madison Clinic). METHODS We compared outcomes in the first 50 patients enrolled in Max Clinic and 100 randomly selected matched Madison Clinic control patients; patients in both groups were virally unsuppressed (viral load [VL] >200 copies/mL) at baseline. The primary outcome was any VL indicating viral suppression (≥1 VL <200 copies/mL) during the 12 months postbaseline. Secondary outcomes were continuous viral suppression (≥2 consecutive suppressed VLs ≥60 days apart) and engagement in care (≥2 medical visits ≥60 days apart). We compared outcomes in the 12 months pre- and postbaseline and used generalized estimating equations to compare changes in Max vs control patients, adjusting for unstable housing, substance use, and psychiatric disorders. RESULTS Viral suppression improved in both groups pre-to-post (20% to 82% Max patients; P < .001; and 51% to 65% controls; P = .04), with a larger improvement in Max patients (adjusted relative risk ratio [aRRR], 3.2; 95% confidence interval [CI], 1.8-5.9). Continuous viral suppression and engagement in care increased in both groups but did not differ significantly (continuous viral suppression: aRRR, 1.5; 95% CI, 0.5-5.2; engagement: aRRR, 1.3; 95% CI, 0.9-1.9). CONCLUSIONS The Max Clinic improved viral suppression among patients with complex medical and social needs.
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Affiliation(s)
- Julia C Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Public Health – Seattle & King County HIV/STD Program, Seattle, Washington
| | - Sean R Galagan
- Department of Global Health, University of Washington, Seattle, Washington
| | - Meena Ramchandani
- Department of Medicine, University of Washington, Seattle, Washington
- Public Health – Seattle & King County HIV/STD Program, Seattle, Washington
| | | | | | - Allison Moore
- Public Health – Seattle & King County HIV/STD Program, Seattle, Washington
| | - Katie Hara
- Social Work, Harborview Medical Center, Seattle, Washington
| | - Mckenna Eastment
- Department of Medicine, University of Washington, Seattle, Washington
| | - Matthew R Golden
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Public Health – Seattle & King County HIV/STD Program, Seattle, Washington
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17
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Desir FA, Lesko CR, Moore RD, Horberg MA, Wong C, Crane HM, Silverberg M, Thorne JE, Rachlis B, Rabkin C, Mayor AM, Mathews WC, Althoff KN. One Size Fits (n)One: The Influence of Sex, Age, and Sexual Human Immunodeficiency Virus (HIV) Acquisition Risk on Racial/Ethnic Disparities in the HIV Care Continuum in the United States. Clin Infect Dis 2019; 68:795-802. [PMID: 30169624 PMCID: PMC6376102 DOI: 10.1093/cid/ciy556] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 07/13/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The United States National HIV/AIDS Strategy established goals to reduce disparities in retention in human immunodeficiency virus (HIV) care, antiretroviral therapy (ART) use, and viral suppression. The impact of sex, age, and sexual HIV acquisition risk (ie, heterosexual vs same-sex contact) on the magnitude of HIV-related racial/ethnic disparities is not well understood. METHODS We estimated age-stratified racial/ethnic differences in the 5-year restricted mean percentage of person-time spent in care, on ART, and virally suppressed among 19 521 women (21.4%), men who have sex with men (MSM; 59.0%), and men who have sex with women (MSW; 19.6%) entering HIV care in the North American AIDS Cohort Collaboration on Research and Design between 2004 and 2014. RESULTS Among women aged 18-29 years, whites spent 12.0% (95% confidence interval [CI], 1.1%-20.2%), 9.2% (95% CI, .4%-20.4%), and 13.5% (95% CI, 2.7%-22.5%) less person-time in care, on ART, and virally suppressed, respectively, than Hispanics. Black MSM aged ≥50 years spent 6.3% (95% CI, 1.3%-11.7%), 11.0% (95% CI, 4.6%-18.1%), and 9.7% (95% CI, 3.6%-16.8%) less person-time in these stages, respectively, than white MSM ≥50 years of age. Among MSM aged 40-49 years, blacks spent 9.8% (95% CI, 2.4%-16.5%) and 11.9% (95% CI, 3.8%-19.3%) less person-time on ART and virally suppressed, respectively, than whites. CONCLUSIONS Racial/ethnic differences in HIV care persist in specific populations defined by sex, age, and sexual HIV acquisition risk. Clinical and public health interventions that jointly target these demographic factors are needed.
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Affiliation(s)
- Fidel A Desir
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore
| | - Michael A Horberg
- Division of Research, Kaiser Permanente Mid-Atlantic Research Group, Rockville, Maryland
| | - Cherise Wong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - Heidi M Crane
- Division of Allergy and Infectious Diseases, University of Washington, Seattle
| | | | - Jennifer E Thorne
- Division of Ocular Immunology, Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland
| | - Beth Rachlis
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Charles Rabkin
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Angel M Mayor
- Department of Internal Medicine, Universidad Central del Caribe, Bayamon, Puerto Rico
| | | | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore
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18
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Brooks RB, Feldman KA, Blythe D, Flynn C. Completeness of HIV nucleotide sequence ascertainment and its potential impact on understanding HIV transmission - Maryland, 2011-2013 .. AIDS Care 2018; 31:621-628. [PMID: 30430842 DOI: 10.1080/09540121.2018.1545983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
HIV nucleotide sequences generated through routine drug resistance testing (DRT) and reported to Maryland's Molecular HIV Surveillance system are most effective for elucidating transmission patterns and identifying outbreaks if DRT is ordered promptly and sequences are reported completely. Among reported cases of HIV infection newly diagnosed during 2011-2013 in Maryland residents aged ≥13 years, we assessed sequence ascertainment completeness. To better understand which populations were most likely to have a sequence, we examined associations between sequence ascertainment and clinical and demographic characteristics. During 2011-2013, 4423 new HIV infection diagnoses were reported; sequences were ascertained for 1282 (29.0%). Among 3267 cases with complete data, odds for having a sequence ascertained were highest for cases in persons living inside Maryland's Central Region with initial CD4 counts ≤500 cells/mm3 (adjusted odds ratio [aOR] 2.4, 95% confidence interval [CI] 1.9-3.1). Sequence ascertainment did not vary significantly by patient age, sex, race/ethnicity or HIV transmission category. Educational interventions, policy changes and improved processes to increase timely DRT and subsequent sequence reporting with a focus on testing at entry to care, particularly for those with higher CD4 counts and those living outside the Central Region, might improve ascertainment completeness.
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Affiliation(s)
- Richard B Brooks
- a Epidemic Intelligence Service, Division of Scientific Education and Professional Development , Centers for Disease Control and Prevention , Atlanta , GA , USA.,b Infectious Disease Epidemiology and Outbreak Response Bureau , Maryland Department of Health , Baltimore , MD , USA
| | - Katherine A Feldman
- b Infectious Disease Epidemiology and Outbreak Response Bureau , Maryland Department of Health , Baltimore , MD , USA
| | - David Blythe
- b Infectious Disease Epidemiology and Outbreak Response Bureau , Maryland Department of Health , Baltimore , MD , USA
| | - Colin Flynn
- b Infectious Disease Epidemiology and Outbreak Response Bureau , Maryland Department of Health , Baltimore , MD , USA
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Horberg MA, Blank JG, Rubenstein KB, Certa JM, Hurley LB, Kadlecik PM, Klein DB, Silverberg MJ. Impact of Alternative Encounter Types on HIV Viral Suppression Rates in an Integrated Health System. AIDS Patient Care STDS 2018; 32:425-431. [PMID: 30398954 DOI: 10.1089/apc.2018.0079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Kaiser Permanente Mid-Atlantic States (KPMAS) members are increasingly utilizing electronic encounter types, such as telephone appointments and secure messaging for healthcare purposes, although their impact on health outcomes is unknown. We evaluated whether use of alternative encounters by adult human immunodeficiency virus (HIV)-infected patients affected the likelihood of achieving viral suppression (VS). Our study population of 3114 patients contributed 6520 patient-years between 2014 and 2016. We compared VS (HIV RNA <200 copies/mL) by number of in-person visits (1 or ≥2), with further stratification for additional phone and/or e-mail encounters (none, phone only, e-mail only, and both phone and e-mail). Rate ratios (RRs) for VS by number of in-person visits and encounter types were obtained from Poisson modeling, adjusting for age, sex, race/ethnicity, and HIV risk. Compared to those with ≥2 visits, patients with one in-person visit alone were significantly less likely to achieve VS (RR = 0.93; 95% confidence interval, CI: [0.87-1.00]), as were those with one in-person visit plus a telephone encounter (0.93; [0.90-0.97]). We did not find significant differences in VS comparing patients with one in-person visit plus e-mail only (RR = 1.00; 95% CI: [0.97-1.02]) or plus e-mail and telephone (0.99; [0.97-1.01]) to those with ≥2 in-person visits. If supplemented by e-mail communications (with or without telephone contact), patients with one in-person visit per year had similar estimated rates of VS compared with ≥2 in-person visits. More research is needed to know if these findings apply to other care systems.
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Affiliation(s)
- Michael A. Horberg
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
- Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland
| | - Jackie G. Blank
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Kevin B. Rubenstein
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Julia M. Certa
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Leo B. Hurley
- Kaiser Permanente Northern California, Division of Research, Oakland, California
| | - Peter M. Kadlecik
- Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, Maryland
| | - Daniel B. Klein
- Kaiser Permanente Northern California, San Leandro, California
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20
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Kim SS, Darwish S, Lee SA, Sprague C, DeMarco RF. A randomized controlled pilot trial of a smoking cessation intervention for US women living with HIV: telephone-based video call vs voice call. Int J Womens Health 2018; 10:545-555. [PMID: 30288127 PMCID: PMC6161719 DOI: 10.2147/ijwh.s172669] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background People living with HIV smoke at a rate three times that of the general population. This randomized controlled pilot trial tested the feasibility and acceptability of a video-call smoking cessation intervention in women living with HIV and its preliminary efficacy compared with a voice-call smoking cessation intervention. The study focused on women due to a paucity of studies among this population, and women are less likely than men to quit smoking when provided with conventional treatment. Methods Participants in both arms received an HIV-tailored smoking cessation intervention comprising eight 30-minute weekly counseling sessions in conjunction with active nicotine patches for 8 weeks. The only difference between the two arms was the delivery mode of the intervention: via either telephone-based video or voice call. Survival analysis and a Cox proportional hazard regression model were performed to identify factors predicting 6-month prolonged abstinence from smoking. Results A video-call intervention was almost 30% less feasible than a voice-call intervention because women in their 50s and 60s or poorer women living in some southern states did not have access to video-call equipment. However, those who received the video-call intervention were more likely to complete the study than those who had the voice-call intervention. There was no difference in the acceptability of the two interventions. A survival analysis revealed that those in the video arm were significantly more likely to maintain smoking abstinence over the 6-month follow-up period than those in the voice arm (log rank χ2=4.02, P<0.05). Conclusion Although a video-call intervention is less feasible than a voice-call intervention, the former seems to outperform the latter in achieving long-term smoking abstinence for women living with HIV, which may offer an advantage over establishing therapeutic alliance and visually monitoring their adherence to nicotine patches. Clinical trial registration ClinicalTrials.gov NCT02898597.
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Affiliation(s)
- Sun S Kim
- Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA,
| | - Sabreen Darwish
- Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA,
| | - Sang A Lee
- Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA,
| | - Courtenay Sprague
- Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA, .,Department of Conflict Resolution, Global Governance and Human Security, John W. McCormack Graduate School of Policy and Global Studies, Boston, MA, USA.,Wits Reproductive Health and HIV Institute, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rosanna F DeMarco
- Department of Nursing, College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA,
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21
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Terzian AS, Younes N, Greenberg AE, Opoku J, Hubbard J, Happ LP, Kumar P, Jones RR, Castel AD. Identifying Spatial Variation Along the HIV Care Continuum: The Role of Distance to Care on Retention and Viral Suppression. AIDS Behav 2018; 22:3009-3023. [PMID: 29603112 DOI: 10.1007/s10461-018-2103-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Distance to HIV care may be associated with retention in care (RIC) and viral suppression (VS). RIC (≥ 2 HIV visits or labs ≥ 90 days apart in 12 months), prescribed antiretroviral therapy (ART), VS (< 200 copies/mL at last visit) and distance to care were estimated among 3623 DC Cohort participants receiving HIV care in 13 outpatient clinics in Washington, DC in 2015. Logistic regression models and geospatial statistics were computed. RIC was 73%; 97% were on ART, among whom 77% had VS. ZIP code-level clusters of low RIC and high VS were found in Northwest DC, and low VS in Southeast DC. Those traveling ≥ 5 miles had 30% lower RIC (adjusted odds ratio (aOR) 0.71, 95% CI 0.58, 0.86) and lower VS (OR 0.70, 95% CI 0.52, 0.94). Geospatial clustering of RIC and VS was observed, and distance may be a barrier to optimal HIV care outcomes.
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Affiliation(s)
- A S Terzian
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC, 20052, USA.
| | - N Younes
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC, 20052, USA
| | - A E Greenberg
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC, 20052, USA
| | - J Opoku
- District of Columbia Department of Health, HIV/AIDS, Hepatitis, STD, and TB Administration, Washington, DC, USA
| | - J Hubbard
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC, 20052, USA
| | - L P Happ
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC, 20052, USA
| | - P Kumar
- School of Medicine, Georgetown University, Washington, DC, USA
| | - R R Jones
- Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - A D Castel
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC, 20052, USA
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Rebeiro PF, McPherson TD, Goggins KM, Turner M, Bebawy SS, Rogers WB, Brinkley-Rubinstein L, Person AK, Sterling TR, Kripalani S, Pettit AC. Health Literacy and Demographic Disparities in HIV Care Continuum Outcomes. AIDS Behav 2018; 22:2604-2614. [PMID: 29560569 PMCID: PMC6051900 DOI: 10.1007/s10461-018-2092-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Studies evaluating the association between human immunodeficiency virus (HIV) infection continuum of care outcomes [antiretroviral (ART) adherence, retention in care, viral suppression] and health literacy have yielded conflicting results. Moreover, studies from the southern United States, a region of the country disproportionately affected by the HIV epidemic and low health literacy, are lacking. We conducted an observational cohort study among 575 people living with HIV (PLWH) at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee). Health literacy was measured using the brief health literacy screen, a short tool which can be administered verbally by trained clinical personnel. Low health literacy was associated with a lack of viral suppression, but not with poor ART adherence or poor retention. Age and racial disparities in continuum of care outcomes persisted after accounting for health literacy, suggesting that factors in addition to health literacy must be addressed in order to improve outcomes for PLWH.
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Affiliation(s)
- Peter F Rebeiro
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, 1161 21st Avenue S., A-2200 MCN, Nashville, TN, 37232, USA.
| | - Tristan D McPherson
- Division of Infectious Diseases, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Kathryn M Goggins
- Institute for Medicine and Public Health, Center for Effective Health Communication, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Megan Turner
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, 1161 21st Avenue S., A-2200 MCN, Nashville, TN, 37232, USA
| | - Sally S Bebawy
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, 1161 21st Avenue S., A-2200 MCN, Nashville, TN, 37232, USA
| | | | | | - Anna K Person
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, 1161 21st Avenue S., A-2200 MCN, Nashville, TN, 37232, USA
| | - Timothy R Sterling
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, 1161 21st Avenue S., A-2200 MCN, Nashville, TN, 37232, USA
| | - Sunil Kripalani
- Institute for Medicine and Public Health, Center for Effective Health Communication, Vanderbilt University School of Medicine, Nashville, TN, USA
- Division of General Internal Medicine and Public Health, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - April C Pettit
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, 1161 21st Avenue S., A-2200 MCN, Nashville, TN, 37232, USA
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23
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Dale R, Guo B. Estimating epidemiological parameters of a stochastic differential model of HIV dynamics using hierarchical Bayesian statistics. PLoS One 2018; 13:e0200126. [PMID: 30044818 PMCID: PMC6059410 DOI: 10.1371/journal.pone.0200126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 04/29/2018] [Indexed: 11/19/2022] Open
Abstract
Current estimates of the HIV epidemic indicate a decrease in the incidence of the disease in the undiagnosed subpopulation over the past 10 years. However, a lack of access to care has not been considered when modeling the population. Populations at high risk for contracting HIV are twice as likely to lack access to reliable medical care. In this paper, we consider three contributors to the HIV population dynamics: at-risk population exhaustion, lack of access to care, and usage of anti-retroviral therapy (ART) by diagnosed individuals. An extant problem in the mathematical study of this system is deriving parameter estimates due to a portion of the population being unobserved. We approach this problem by looking at the proportional change in the infected subpopulations. We obtain conservative estimates for the proportional change of the infected subpopulations using hierarchical Bayesian statistics. The estimated proportional change is used to derive epidemic parameter estimates for a system of stochastic differential equations (SDEs). Model fit is quantified to determine the best parametric explanation for the observed dynamics in the infected subpopulations. Parameter estimates derived using these methods produce simulations that closely follow the dynamics observed in the data, as well as values that are generally in agreement with prior understanding of transmission and diagnosis rates. Simulations suggest that the undiagnosed population may be larger than currently estimated without significantly affecting the population dynamics.
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Affiliation(s)
- Renee Dale
- Department of Experimental Statistics, Louisiana State University, Baton Rouge, Louisiana, United States of America
- Department of Biological Sciences, Louisiana State University, Baton Rouge, Louisiana, United States of America
- * E-mail:
| | - BeiBei Guo
- Department of Experimental Statistics, Louisiana State University, Baton Rouge, Louisiana, United States of America
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24
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Rebeiro PF, Howe CJ, Rogers WB, Bebawy SS, Turner M, Kheshti A, McGowan CC, Raffanti SP, Sterling TR. The relationship between adverse neighborhood socioeconomic context and HIV continuum of care outcomes in a diverse HIV clinic cohort in the Southern United States. AIDS Care 2018; 30:1426-1434. [PMID: 29678121 DOI: 10.1080/09540121.2018.1465526] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Retention in care and viral suppression are critical to delaying HIV progression and reducing transmission. Neighborhood socioeconomic context (NSEC) may affect HIV care receipt. We therefore assessed NSEC's impact on retention and viral suppression in a diverse HIV clinical cohort. HIV-positive adults with ≥1 visit at the Vanderbilt Comprehensive Care Clinic and 5-digit ZIP code tabulation area (ZCTA) information between 2008 and 2012 contributed. NSEC z-score indices used neighborhood-level socioeconomic indicators for poverty, education, labor-force participation, proportion of males, median age, and proportion of residents of black race by ZCTA. Retention was defined as ≥2 HIV care visits per calendar year, >90 days apart. Viral suppression was defined as an HIV-1 RNA <200 copies/mL at last measurement per calendar year. Modified Poisson regression was used to estimate risk ratios (RR) and 95% confidence intervals (CI). Among 2272 and 2541 adults included for retention and viral suppression analyses, respectively, median age and CD4 count at enrollment were approximately 38 (1st and 3rd quartile: 30, 44) years and 351 (176, 540) cells/μL, respectively, while 24% were female, and 39% were black. Across 243 ZCTAs, median NSEC z-score was 0.09 (-0.66, 0.48). Overall, 79% of person-time contributed was retained and 74% was virally suppressed. In adjusted models, NSEC was not associated with retention, though being in the 4th vs. 1st NSEC quartile was associated with lack of viral suppression (RR = 0.88; 95% CI: 0.80-0.97). Residing in the most adverse NSEC was associated with lack of viral suppression. Future studies are needed to confirm this finding.
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Affiliation(s)
- Peter F Rebeiro
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Chanelle J Howe
- b Epidemiology , Brown University School of Public Health , Providence , RI , USA
| | - William B Rogers
- c Medicine , Indiana University School of Medicine , Indianapolis , IN , USA
| | - Sally S Bebawy
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Megan Turner
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Asghar Kheshti
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Catherine C McGowan
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Stephen P Raffanti
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Timothy R Sterling
- a Medicine, Infectious Diseases , Vanderbilt University School of Medicine , Nashville , TN , USA
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Quality of HIV Testing Data Before and After the Implementation of a National Data Quality Assessment and Feedback System. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2018; 23:269-275. [PMID: 26672404 DOI: 10.1097/phh.0000000000000376] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT In 2010, the Centers for Disease Control and Prevention (CDC) implemented a national data quality assessment and feedback system for CDC-funded HIV testing program data. OBJECTIVE Our objective was to analyze data quality before and after feedback. DESIGN Coinciding with required quarterly data submissions to CDC, each health department received data quality feedback reports and a call with CDC to discuss the reports. Data from 2008 to 2011 were analyzed. SETTING Fifty-nine state and local health departments that were funded for comprehensive HIV prevention services. PARTICIPANTS Data collected by a service provider in conjunction with a client receiving HIV testing. INTERVENTION National data quality assessment and feedback system. MAIN OUTCOME MEASURES Before and after intervention implementation, quality was assessed through the number of new test records reported and the percentage of data values that were neither missing nor invalid. Generalized estimating equations were used to assess the effect of feedback in improving the completeness of variables. RESULTS Data were included from 44 health departments. The average number of new records per submission period increased from 197 907 before feedback implementation to 497 753 afterward. Completeness was high before and after feedback for race/ethnicity (99.3% vs 99.3%), current test results (99.1% vs 99.7%), prior testing and results (97.4% vs 97.7%), and receipt of results (91.4% vs 91.2%). Completeness improved for HIV risk (83.6% vs 89.5%), linkage to HIV care (56.0% vs 64.0%), referral to HIV partner services (58.9% vs 62.8%), and referral to HIV prevention services (55.3% vs 63.9%). Calls as part of feedback were associated with improved completeness for HIV risk (adjusted odds ratio [AOR] = 2.28; 95% confidence interval [CI], 1.75-2.96), linkage to HIV care (AOR = 1.60; 95% CI, 1.31-1.96), referral to HIV partner services (AOR = 1.73; 95% CI, 1.43-2.09), and referral to HIV prevention services (AOR = 1.74; 95% CI, 1.43-2.10). CONCLUSIONS Feedback contributed to increased data quality. CDC and health departments should continue monitoring the data and implement measures to improve variables of low completeness.
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Prochazka M, Otero L, Konda KA, González-Lagos E, Echevarría J, Gotuzzo E. Patient-nominated supporters as facilitators for engagement in HIV care in a referral hospital in Peru: A retrospective cohort study. PLoS One 2018; 13:e0195389. [PMID: 29617437 PMCID: PMC5884557 DOI: 10.1371/journal.pone.0195389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 03/21/2018] [Indexed: 11/19/2022] Open
Abstract
Patient-nominated supporters can potentially improve the continuum of HIV care. We retrospectively determined factors associated with having a patient-nominated supporter among people living with HIV (PLWH), and its association with retention in care and viral suppression. We analysed registries of adults evaluated by social workers (n = 1345) at a referral hospital in Peru between 2011–2014. Nondisclosure of HIV status was associated with lacking supporters (aPR: 5.41, 95% CI: 3.83–7.64). Retention in care was 76.4% and 34.2% after one and two years of enrolment, respectively. PLWH with supporters were more likely to be retained in care after two years (aRR = 1.36, 95% CI: 1.02–1.81), but not after one year (aRR = 1.10, 95% CI: 0.98–1.23) compared to PLWH without supporters. Having supporters who were parents or friends was associated with an increased probability of being retained in care after one and two years of enrolment. Viral suppression after one year of enrolment was 58.7%. Having a supporter was not associated with viral suppression (aRR = 1.18, 95% CI: 0.99–1.41), but PLWH with supporters were more likely to have viral load measurements (p = 0.005). Patient-nominated supporters appear beneficial for engagement in HIV care; these benefits may be related to the nature of their relationship with PLWH.
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Affiliation(s)
- Mateo Prochazka
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
- Carlos Vidal Layseca School of Public Health and Management, Universidad Peruana Cayetano Heredia, Lima, Peru
- * E-mail:
| | - Larissa Otero
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
- Alberto Hurtado School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Kelika A. Konda
- Carlos Vidal Layseca School of Public Health and Management, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, Division of Infectious Diseases and Center for World Health, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, California, United States of America
| | - Elsa González-Lagos
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
- Alberto Hurtado School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Juan Echevarría
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
- Alberto Hurtado School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Infectious, Tropical and Dermatological Diseases, Hospital Cayetano Heredia, Ministry of Health, Lima, Peru
| | - Eduardo Gotuzzo
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
- Alberto Hurtado School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Infectious, Tropical and Dermatological Diseases, Hospital Cayetano Heredia, Ministry of Health, Lima, Peru
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27
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Dombrowski JC, Ramchandani M, Dhanireddy S, Harrington RD, Moore A, Golden MR. The Max Clinic: Medical Care Designed to Engage the Hardest-to-Reach Persons Living with HIV in Seattle and King County, Washington. AIDS Patient Care STDS 2018; 32:149-156. [PMID: 29630852 DOI: 10.1089/apc.2017.0313] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The Max Clinic in Seattle, Washington is designed to engage patients who have extensive barriers to HIV care. In this article, we describe the clinic's evolution and outcomes of patients enrolled in the first 2 years. The clinic is a high-intensity, low-threshold, incentivized care model that includes walk-in access to primary care in a Sexually Transmitted Disease Clinic. Patients who have failed to engage in care and achieve viral suppression with lower intensity support are referred by clinicians, case managers, and the health department Data to Care program. The clinic offers food vouchers, cash incentives, no-cost bus passes, and cell phones, as well as intensive case management with cross-agency coordinated care. The primary evaluation outcome was the percentage of patients who achieved viral suppression (HIV RNA <200 copies/mL) at least once after enrollment. Secondary outcomes were continuous viral suppression (≥2 suppressed results in a row ≥60 days apart) and engagement in care (≥2 completed medical visits ≥60 days apart). During January 2015-December 2016, 263 patients were referred; 170 (65%) were eligible, and 95 (56% of eligible) were enrolled. Most patients used illicit drugs or hazardous levels of alcohol (86%) and had diagnosed psychiatric illness (72%) and unstable housing (65%). During the year after enrollment, 90 (95%) patients engaged in care. As of the end of 2016, 76 (80%) had achieved viral suppression, and 54% had continuous viral suppression. The Max Clinic successfully treated HIV in high-need patients and, to date, has been sustainable through a combination of federal, state, and local funding.
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Affiliation(s)
- Julia C. Dombrowski
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Public Health–Seattle & King County HIV/STD Program, Seattle, Washington
| | - Meena Ramchandani
- Department of Medicine, University of Washington, Seattle, Washington
- Public Health–Seattle & King County HIV/STD Program, Seattle, Washington
| | | | | | - Allison Moore
- Public Health–Seattle & King County HIV/STD Program, Seattle, Washington
| | - Matthew R. Golden
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Public Health–Seattle & King County HIV/STD Program, Seattle, Washington
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28
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Kidman R, Violari A. Dating Violence Against HIV-Infected Youth in South Africa: Associations With Sexual Risk Behavior, Medication Adherence, and Mental Health. J Acquir Immune Defic Syndr 2018; 77:64-71. [PMID: 29040165 PMCID: PMC5720896 DOI: 10.1097/qai.0000000000001569] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND As perinatal HIV-infected youth become sexually active, the potential for onward transmission becomes an increasing concern. In other populations, intimate partner violence (IPV) is a risk factor for HIV acquisition. We build on this critical work by studying the role of IPV in facilitating onward transmission among HIV-infected youth-an important step toward effective intervention. SETTING Soweto, South Africa. METHODS Self-report surveys were completed by 129 perinatal HIV-infected female youth (aged 13-24 years). We calculated the IPV prevalence and used logistic models to capture the association between IPV and health outcomes known to facilitate onward HIV transmission (eg, risky sex, poor medication adherence, depression, and substance abuse). RESULTS A fifth of perinatal HIV-infected participants reported physical and/or sexual IPV in the past year; one-third reported lifetime IPV. Childhood adversity was common and positively associated with IPV. Past-year physical and/or sexual IPV was positively correlated with high-risk sex [odds ratio (OR) = 8.96; 95% confidence interval (CI): 2.78 to 28.90], pregnancy (OR = 6.56; 95% CI: 1.91 to 22.54), poor medication adherence to antiretroviral therapy (OR = 5.37; 95% CI: 1.37 to 21.08), depression (OR = 4.25; 95% CI: 1.64 to 11.00), and substance abuse (OR = 4.11; 95% CI: 1.42 to 11.86). Neither past-year nor lifetime IPV was associated with viral load or HIV status disclosure to a partner. CONCLUSIONS We find that IPV may increase risk for onward HIV transmission in perinatal HIV-infected youth by both increasing engagement in risky sexual behaviors and lowering medication adherence. HIV clinics should consider integrating primary IPV prevention interventions, instituting routine IPV screening, and collocating services for victims of violence.
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Affiliation(s)
- Rachel Kidman
- Program in Public Health and Department of Family, Population and Preventative Medicine, Stony Brook University, Health Sciences Center, Stony Brook, NY
| | - Avy Violari
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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29
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Castel AD, Terzian A, Hart R, Rayeed N, Kalmin MM, Young H, Greenberg AE. Use of national standards to monitor HIV care and treatment in a high prevalence city-Washington, DC. PLoS One 2017; 12:e0186036. [PMID: 28982127 PMCID: PMC5628915 DOI: 10.1371/journal.pone.0186036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 09/22/2017] [Indexed: 12/25/2022] Open
Abstract
We sought to benchmark the quality of HIV care being received by persons living with HIV in care in Washington, DC and identify individual-level and structural-level differences. Data from the DC Cohort, an observational HIV cohort of persons receiving outpatient care in DC, were used to estimate the Institute of Medicine (IOM) and Department of Health and Human Services (HHS) quality of care measures. Differences in care by demographics and clinic type were assessed using χ2 tests and multivariable regression models. Among 8,047 participants, by HHS standards, 69% of participants were retained in care (RIC), 95% were prescribed antiretroviral therapy (ART), and 84% were virally suppressed (VS). By IOM standards, 84% were in continuous care; and 78% and 80% underwent regular CD4 and VL monitoring, respectively. Screening for syphilis, chlamydia, and gonorrhea was 51%, 31%, and 26%, respectively. Older participants were 1.5 times more likely to be RIC compared to younger participants (OR: 1.5; 95% CI: 1.3, 1.8). Participants enrolled in community-based clinics were more likely to be RIC (OR: 1.7; 95% CI: 1.4, 2.0) versus those enrolled at hospital-based clinics. Older participants were more likely to achieve VS than younger participants (OR: 1.8; 95% CI: 1.5, 2.2) while Black participants were less likely compared to white participants (OR: 0.4; 95% CI: 0.3, 0.5). Despite high measures of quality of care, disparities remain. Continued monitoring of the quality of HIV care and treatment can inform the development of public health programs and interventions to optimize care delivery.
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Affiliation(s)
- Amanda D. Castel
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, Washington, DC., United States of America
| | - Arpi Terzian
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, Washington, DC., United States of America
| | - Rachel Hart
- Cerner Corporation, Kansas City, Missouri, United States of America
| | - Nabil Rayeed
- Cerner Corporation, Kansas City, Missouri, United States of America
| | - Mariah M. Kalmin
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, Washington, DC., United States of America
| | - Heather Young
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, Washington, DC., United States of America
| | - Alan E. Greenberg
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, Washington, DC., United States of America
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30
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Ross J, Felsen UR, Cunningham CO, Patel VV, Hanna DB. Outcomes Along the HIV Care Continuum Among Undocumented Immigrants in Clinical Care. AIDS Res Hum Retroviruses 2017; 33:1038-1044. [PMID: 28443678 DOI: 10.1089/aid.2017.0015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
HIV-infected undocumented immigrants face unique barriers to care yet little is known about their clinical outcomes. We performed a retrospective cohort study of HIV-infected adults in clinical care from 2006 to 2014 at a large academic medical center in a setting where medical insurance is available to HIV-infected undocumented immigrants. Undocumented status was assessed based on Social Security number and insurance status and verified through medical chart review. Using Poisson regression models, we compared undocumented and documented patients with respect to retention in care (≥2 HIV-related laboratory tests ≥90 days apart), antiretroviral therapy (ART) prescription (≥3 active antiretroviral agents prescribed in a year), and viral suppression (HIV RNA <200 copies/ml for the last measured viral load) for each year in care. Of 7,551 patients included in the analysis, we classified 173 (2.3%) as undocumented. For each year of the analysis, higher proportions of undocumented patients were retained in care, prescribed ART, and virally suppressed. In adjusted models, undocumented status was associated with increased probability of retention in care [risk ratio (RR) 1.05, confidence interval (95% CI) 1.01-1.09], ART prescription (RR 1.05, 95% CI 1.01-1.08), and viral suppression (RR 1.13, 95% CI 1.08-1.19) compared to documented status. Undocumented patients achieved clinical outcomes at modestly higher rates than documented patients, despite entering care with more advanced disease. In a setting where insurance is available to undocumented patients, similar outcomes along the HIV care continuum may be achieved regardless of immigration status.
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Affiliation(s)
- Jonathan Ross
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Uriel R. Felsen
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Chinazo O. Cunningham
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - Viraj V. Patel
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center, Bronx, New York
| | - David B. Hanna
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
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31
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Wolff MJ, Cortes CP, Mejìa FA, Padgett D, Belaunzarán-Zamudio P, Grinsztejn B, Giganti MJ, McGowan CC, Rebeiro PF. Evaluating the care cascade after antiretroviral therapy initiation in Latin America. Int J STD AIDS 2017; 29:4-12. [PMID: 28618980 DOI: 10.1177/0956462417714094] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Accelerating antiretroviral therapy (ART) administration, improving retention, and achieving viral suppression in low- and middle-income countries must be prioritized. We evaluated trends and disparities in these milestones in a large Latin American cohort. Adults starting ART (ARTstart) from 2003 to 2014 at Caribbean, Central, and South America network for HIV epidemiology sites were assessed for care cascade outcomes: CD4 cell count >200 cells/mm3 at ARTstart; retention (≥1 visit at one year after ARTstart); viral suppression (≥1 HIV-1 RNA <200 copies/ml at one year after ARTstart). Modified Poisson regression provided adjusted prevalence ratios by age, gender, and HIV transmission risk, accounting for site and year of ARTstart. Proportions achieving ARTstart and suppression improved over time (p < 0.05). Older age was associated with better retention and viral suppression, but not ARTstart at CD4 cell count >200 cells/mm3. Females and men who have sex with men (MSM) were more likely to have CD4 cell count >200 cells/mm3 at ARTstart. Injection drug users (IDUs) were less likely to be retained while MSM were more likely to achieve viral suppression (all p < 0.05). Despite improvements in these outcomes over the course of a decade in this cohort, significant disparities existed, disadvantaging younger patients, men, and IDUs. These gaps indicate continued progress in providing early diagnosis and ARTstart remain critical.
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Affiliation(s)
- Marcelo J Wolff
- 1 Fundacion Arriaran, University of Chile, School of Medicine, Santiago, Chile
| | - Claudia P Cortes
- 1 Fundacion Arriaran, University of Chile, School of Medicine, Santiago, Chile
| | - Fernando A Mejìa
- 2 Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Denis Padgett
- 3 Instituto Hondureño de Seguridad Social and Hospital Escuela Universitario, Tegucigalpa, Honduras
| | - Pablo Belaunzarán-Zamudio
- 4 42559 Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City, Mexico.,5 División de Investigación de Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Beatriz Grinsztejn
- 6 Instituto Nacional de Infectologia Evandro Chagas, 37903 Fundação Oswaldo Cruz , Rio de Janeiro, Brazil
| | - Mark J Giganti
- 7 Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Peter F Rebeiro
- 7 Vanderbilt University School of Medicine, Nashville, TN, USA
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Rebeiro PF, Ivey KS, Craig KS, Hulgan T, Huaman MA, Nash R, Raffanti S, Equakun KA, Person AK. New Faces of HIV Infection: Age, Race, and Timing of Entry into HIV Care in the Southeastern United States. J Int Assoc Provid AIDS Care 2017; 16:347-352. [PMID: 28560901 DOI: 10.1177/2325957417710719] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Among younger men who have sex with men (MSM), the incidence of HIV is rising nationally. Of the 281 persons who entered into care at a large HIV clinic in the southeastern United States in 2010 to 2012, 78 (27.8%) were <25 years old at the time of diagnosis. Those in the younger group were more likely than those aged ≥25 to be black (59.0% versus 37.4%), MSM (78.2% versus 55.2%), and to have a longer median time from diagnosis to entry into care (71 versus 53 days; P < .05 each). In adjusted survival analysis, persons of black race were less likely to enter care after diagnosis than those of nonblack race (hazard ratio = 0.75, P = .02). Young MSM represent an important target population for prevention and HIV testing interventions, and there is a need to shorten the time from diagnosis to linkage to care, particularly in persons aged <25 and of black race.
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Affiliation(s)
| | | | | | - Todd Hulgan
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt Comprehensive Care Clinic, Nashville, TN, USA
| | - Moises Arturo Huaman
- 3 Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Robertson Nash
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt Comprehensive Care Clinic, Nashville, TN, USA
| | - Stephen Raffanti
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt Comprehensive Care Clinic, Nashville, TN, USA
| | - Kehinde Amen Equakun
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt Comprehensive Care Clinic, Nashville, TN, USA
| | - Anna Kristine Person
- 1 Vanderbilt University Medical Center, Nashville, TN, USA.,2 Vanderbilt Comprehensive Care Clinic, Nashville, TN, USA
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Abstract
BACKGROUND Long-term HIV care and treatment engagement is required for maximal clinical and prevention benefits, but longitudinal care patterns are poorly understood. We used the last 10 years' worth of HIV surveillance data from North Carolina to describe longitudinal HIV care trajectories from diagnosis. METHODS We conducted a retrospective, population-based cohort study of all persons newly diagnosed with HIV in North Carolina between March 31, 2006 and March 31, 2015 (N = 16,207). We defined HIV care attendance in each 3-month and 6-month interval after diagnosis as the presence of viral load and/or CD4 records (care visit proxies) in the interval. We used group-based trajectory modeling to identify common care trajectories and baseline predictors thereof. RESULTS A predicted 26% of newly HIV-diagnosed persons showed consistently high care attendance over time; ∼16% exhibited steadily declining attendance; ∼26% showed consistently low attendance; ∼17% had initially weak attendance with an increase starting ∼1.5 year later; and ∼15% showed initially weak attendance with an increase starting ∼3 years later. Older age at diagnosis was protective against all suboptimal trajectories (with the "consistently high" pattern as referent), and being a man who has sex with men was protective against 3 of the 4 suboptimal patterns. CONCLUSIONS As measured by surveillance-based laboratory proxies, most newly HIV-diagnosed persons exhibited suboptimal care trajectories, but there was wide variation in the particular pathways followed. The insights provided by this analytical approach can help to inform the design of epidemic models and tailored interventions, with the ultimate goal of improving HIV care engagement and transmission prevention.
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Lesko CR, Tong W, Moore RD, Lau B. Retention, Antiretroviral Therapy Use and Viral Suppression by History of Injection Drug Use Among HIV-Infected Patients in an Urban HIV Clinical Cohort. AIDS Behav 2017; 21:1016-1024. [PMID: 27752872 DOI: 10.1007/s10461-016-1585-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Compared to HIV-infected persons who do not inject drugs (non-IDU), persons who inject drugs (PWID) experience disparities in linking to medical care, initiating antiretroviral therapy (ART) and achieving viral suppression. There has been little attention to changes in these disparities over time. We estimated the proportion of PWID and non-IDU retained in care, on ART, and virally suppressed each year from 2001-2012 in the Johns Hopkins HIV Clinical Cohort (JHHCC). We defined active clinic patients as those who had ≥1 clinical visit, CD4 cell count, or viral load between July 1 of the prior year, and June 30 of the analysis year. Within a calendar year, retention was defined as ≥2 clinical visits or HIV-related laboratory measurements >90 days; ART use was defined as ≥1 ART prescription active ≥30 days; and viral suppression was defined as ≥1 HIV viral load <400 copies/mL. While PWID were less likely to be retained in earlier years, the gaps in retention closed around 2010. After 2003-2004, PWID and non-IDU retained in care had similar probability of receiving a prescription for ART and PWID and non-IDU on ART had similar probability of viral suppression.
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Affiliation(s)
- Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St., Baltimore, MD, 21205, USA.
| | - Weiqun Tong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St., Baltimore, MD, 21205, USA
| | - Richard D Moore
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St., Baltimore, MD, 21205, USA
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St., Baltimore, MD, 21205, USA
- School of Medicine, Johns Hopkins University, Baltimore, MD, 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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Maulsby C, Valdiserri RO, Kim JJ, Mahon N, Flynn A, Eriksson E, Jain KM, Enobun B, Holtgrave DR. The Global Engagement in Care Convening: Recommended Actions to Improve Health Outcomes for People Living With HIV. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2016; 28:405-416. [PMID: 27710081 DOI: 10.1521/aeap.2016.28.5.405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The National HIV AIDS Strategy (NHAS) calls for a more coordinated response to the HIV epidemic. The Global Engagement in Care Convening created a forum for domestic and international experts to identify best practices in HIV care. This manuscript summarizes the meeting discussions and recommendations from meeting notes and an audio recording of the meeting. Recommendations include: further standardization of performance goals and performance measures; additional research; a more robust system to support competing needs of clients receiving services; electronic information exchanges for HIV-related data; an expansion of the role of other health professionals to extend the capacity of physicians and other members of the care team; and revisions to current financing systems to increase reimbursement for and access to services that promote linkage to and retention in HIV care. The recommendations provide a unique example of "reverse technical assistance" and will inform U.S. program development, research, and policy.
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Affiliation(s)
- C Maulsby
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Health, Baltimore, Maryland
| | - R O Valdiserri
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Health, Baltimore, Maryland
| | - J J Kim
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Health, Baltimore, Maryland
| | - N Mahon
- M·A·C AIDS Fund and Global Philanthropy and Corporate Citizenship, The Estée Lauder Companies, Inc
| | - A Flynn
- M·A·C AIDS Fund, New York, New York
| | | | - K M Jain
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Health, Baltimore, Maryland
| | - Blessing Enobun
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Health, Baltimore, Maryland
| | - D R Holtgrave
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Health, Baltimore, Maryland
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Identifying Best Practices for Increasing Linkage to, Retention, and Re-engagement in HIV Medical Care: Findings from a Systematic Review, 1996-2014. AIDS Behav 2016; 20:951-66. [PMID: 26404014 DOI: 10.1007/s10461-015-1204-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A systematic review was conducted to identify best practices for increasing linkage, retention and re-engagement in HIV care (LRC) for persons living with HIV (PLWH). Our search strategy consisted of automated searches of electronic databases and hand searches of journals, reference lists and listservs. We developed two sets of criteria: evidence-based to identify evidence-based interventions (EBIs) tested with a comparison group and evidence-informed to identify evidence-informed interventions (EIs) tested with a one-group design. Eligible interventions included being published between 1996 and 2014, U.S.-based studies with a comparison or one-group designs with pre-post data, international randomized controlled trials, and having objective measures of LRC-relevant outcomes. We identified 10 best practices: 5 EBIs and 5 EIs. None focused on re-engagement. Providers and prevention planners can use the review findings to identify best practices suitable for their clinics, agencies, or communities to increase engagement in care for PLWH, ultimately leading to viral suppression.
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Hall HI, Tang T, Espinoza L. Late Diagnosis of HIV Infection in Metropolitan Areas of the United States and Puerto Rico. AIDS Behav 2016; 20:967-72. [PMID: 26542730 PMCID: PMC8666845 DOI: 10.1007/s10461-015-1241-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The majority of persons infected with HIV live in large metropolitan areas and many such areas have implemented intensified HIV testing programs. A national indicator of HIV testing outcomes is late diagnosis of HIV infection (stage 3, AIDS). Based on National HIV Surveillance System data, 23.3 % of persons with HIV diagnosed in 2012 had a late diagnosis in large MSAs, 26.3 % in smaller MSAs, and 29.6 % in non-metropolitan areas. In the 105 large MSAs, the percentage diagnosed late ranged from 13.2 to 47.4 %. During 2003-2012, the percentage diagnosed late decreased in large MSAs (32.2-23.3 %), with significant decreases in 41 of 105 MSAs overall and among men who have sex with men. Sustained testing efforts may help to continue the decreasing trend in late-stage HIV diagnosis and provide opportunities for early care and treatment and potential reduction in HIV transmission.
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Affiliation(s)
- H Irene Hall
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, E-47, Atlanta, GA, 30329-4027, USA.
| | | | - Lorena Espinoza
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road NE, E-47, Atlanta, GA, 30329-4027, USA
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Assessing the HIV Care Continuum in Latin America: progress in clinical retention, cART use and viral suppression. J Int AIDS Soc 2016; 19:20636. [PMID: 27065108 PMCID: PMC4827101 DOI: 10.7448/ias.19.1.20636] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 02/22/2016] [Accepted: 03/03/2016] [Indexed: 12/20/2022] Open
Abstract
Introduction We assessed trends in HIV Care Continuum outcomes associated with delayed disease progression and reduced transmission within a large Latin American cohort over a decade: clinical retention, combination antiretroviral therapy (cART) use and viral suppression (VS). Methods Adults from Caribbean, Central and South America network for HIV epidemiology clinical cohorts in seven countries contributed data between 2003 and 2012. Retention was defined as two or more HIV care visits annually, >90 days apart. cART was defined as prescription of three or more antiretroviral agents annually. VS was defined as HIV-1 RNA <200 copies/mL at last measurement annually. cART and VS denominators were subjects with at least one visit annually. Multivariable modified Poisson regression was used to assess temporal trends and examine associations between age, sex, HIV transmission mode, cohort, calendar year and time in care. Results Among 18,799 individuals in retention analyses, 14,380 in cART analyses and 13,330 in VS analyses, differences existed between those meeting indicator definitions versus those not by most characteristics. Retention, cART and VS significantly improved from 2003 to 2012 (63 to 77%, 74 to 91% and 53 to 82%, respectively; p<0.05, each). Female sex (risk ratio (RR)=0.97 vs. males) and injection drug use as HIV transmission mode (RR=0.83 vs. male sexual contact with males (MSM)) were significantly associated with lower retention, but unrelated with cART or VS. MSM (RR=0.96) significantly decreased the probability of cART compared with heterosexual transmission. Conclusions HIV Care Continuum outcomes improved over time in Latin America, though disparities for vulnerable groups remain. Efforts must be made to increase retention, cART and VS, while engaging in additional research to sustain progress in these settings.
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40
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A picture is worth a thousand words: maps of HIV indicators to inform research, programs, and policy from NA-ACCORD and CCASAnet clinical cohorts. J Int AIDS Soc 2016; 19:20707. [PMID: 27049052 PMCID: PMC4821890 DOI: 10.7448/ias.19.1.20707] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 02/02/2016] [Accepted: 02/22/2016] [Indexed: 11/25/2022] Open
Abstract
Introduction Maps are powerful tools for visualization of differences in health indicators by geographical region, but multi-country maps of HIV indicators do not exist, perhaps due to lack of consistent data across countries. Our objective was to create maps of four HIV indicators in North, Central, and South American countries. Methods Using data from the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) and the Caribbean, Central, and South America network for HIV epidemiology (CCASAnet), we mapped median CD4 at presentation for HIV clinical care, proportion retained in HIV primary care, proportion prescribed antiretroviral therapy (ART), and the proportion with suppressed plasma HIV viral load (VL) from 2010 to 2012 for North, Central, and South America. The 15 Canadian and US clinical cohorts and 7 clinical cohorts in Argentina, Brazil, Chile, Haiti, Honduras, Mexico, and Peru represented approximately 2–7% of persons known to be living with HIV in these countries. Results Study populations were selected for each indicator: median CD4 at presentation for care was estimated among 14,811 adults; retention was estimated among 87,979 adults; ART use was estimated among 84,757 adults; and suppressed VL was estimated among 51,118 adults. Only three US states and the District of Columbia had a median CD4 at presentation >350 cells/mm3. Haiti, Mexico, and several states had >85% retention in care; lower (50–74%) retention in care was observed in the US West, South, and Mid-Atlantic, and in Argentina, Brazil, and Peru. ART use was highest (90%) in Mexico. The percentages of patients with suppressed VL in the US South and Northeast were lower than in most of Central and South America. Conclusions These maps provide visualization of gaps in the quality of HIV care and allow for comparison between and within countries as well as monitoring policy and programme goals within geographical boundaries.
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Measuring the HIV Care Continuum Using Public Health Surveillance Data in the United States. J Acquir Immune Defic Syndr 2016; 70:489-94. [PMID: 26258570 DOI: 10.1097/qai.0000000000000788] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Rebeiro PF, Althoff KN, Lau B, Gill J, Abraham AG, Horberg MA, Kitahata MM, Yehia BR, Samji H, Brooks JT, Buchacz K, Napravnik S, Silverberg MJ, Rachlis A, Gebo KA, Sterling TR, Moore RD, Gange SJ. Laboratory Measures as Proxies for Primary Care Encounters: Implications for Quantifying Clinical Retention Among HIV-Infected Adults in North America. Am J Epidemiol 2015; 182:952-60. [PMID: 26578717 DOI: 10.1093/aje/kwv181] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 06/29/2015] [Indexed: 11/13/2022] Open
Abstract
Because of limitations in the availability of data on primary care encounters, patient retention in human immunodeficiency virus (HIV) care is often estimated using laboratory measurement dates as proxies for clinical encounters, leading to possible outcome misclassification. This study included 83,041 HIV-infected adults from 14 clinical cohorts in the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) who had ≥1 HIV primary care encounters during 2000-2010, contributing 468,816 person-years of follow-up. Encounter-based retention (REB) was defined as ≥2 encounters in a calendar year, ≥90 days apart. Laboratory-based retention (RLB) was defined similarly, using the dates of CD4-positive cell counts or HIV-1 RNA measurements. Percentage of agreement and the κ statistic were used to characterize agreement between RLB and REB. Logistic regression with generalized estimating equations and stabilized inverse-probability-of-selection weights was used to elucidate temporal trends and the discriminatory power of RLB as a predictor of REB, accounting for age, sex, race/ethnicity, primary HIV risk factor, and cohort site as potential confounders. Both REB and RLB increased from 2000 to 2010 (from 67% to 78% and from 65% to 77%, respectively), though REB was higher than RLB throughout (P < 0.01). RLB agreed well with REB (80%-86% agreement; κ = 0.55-0.62, P < 0.01) and had a strong, imperfect ability to discriminate between persons retained and not retained in care by REB (C statistic: C = 0.81, P < 0.05). As a proxy for REB, RLB had a sensitivity and specificity of 84% and 77%, respectively, with misclassification error of 18%.
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Disparities in Initiation of Combination Antiretroviral Treatment and in Virologic Suppression Among Patients in the HIV Outpatient Study, 2000-2013. J Acquir Immune Defic Syndr 2015; 70:23-32. [PMID: 25886926 DOI: 10.1097/qai.0000000000000652] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The National HIV/AIDS Strategy emphasizes virologic suppression (VS) to reduce HIV incidence in the United States. We assessed temporal trends of and disparities in time to combination antiretroviral therapy (cART) initiation and HIV VS in a large demographically diverse cohort of HIV-infected patients. DESIGN We included antiretroviral-naive HIV Outpatient Study participants from 2000 to 2013 enrolled within 6 months of their HIV diagnosis who attended ≥2 HIV care-related visits. METHODS We evaluated time from HIV diagnosis to first use of cART, time from HIV diagnosis to VS, and time from first use of cART to VS. Kaplan-Meier time-to-event curves and Cox proportional hazards models were used to assess temporal trends and correlates of initiating cART and achieving HIV VS (<500 copies per milliliter). RESULTS Among 1156 HIV Outpatient Study patients [median age, 37 years; 43.2% non-Hispanic/Latino black (NHB), 14.1% Hispanic/Latino], estimated median times from HIV diagnosis to cART initiation and from HIV diagnosis to VS both shortened by >40% during the 13.5-year study period, reaching, respectively, 2.5 and 5.4 months. In multivariable analyses, NHB patients (as compared with non-Hispanic/Latino white) and those who had injected drugs (as compared with those who did not) initiated cART in a less timely fashion. After adjusting for CD4 cell count and viral load at cART initiation, NHB patients and those aged <30 years (compared with ≥40 years) had lower rates of VS. CONCLUSIONS Despite improvements in HIV treatment over time, patients who were NHB, younger, or used injection drugs had less favorable outcomes.
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Critical Review: Building on the HIV Cascade: A Complementary "HIV States and Transitions" Framework for Describing HIV Diagnosis, Care, and Treatment at the Population Level. J Acquir Immune Defic Syndr 2015; 69:341-7. [PMID: 25835604 DOI: 10.1097/qai.0000000000000611] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The HIV cascade--often referred to as "the HIV continuum"--provides a valuable framework for population-level representations of engagement with the HIV healthcare system. The importance and appeal of this framework are evidenced by a large body of scientific literature, as well as by the adoption of cascade-related indicators by medical and public health organizations worldwide. Despite its centrality in the fields of HIV treatment and prevention, however, the traditional cascade provides limited description of the processes affecting the numbers it represents. Representations that describe these processes and capture the dynamic nature of HIV-infected persons' pathways through the healthcare system are essential for monitoring and predicting intervention effects and epidemic trends. We propose here a complementary schema--termed the "HIV States and Transitions" framework--designed to maintain key strengths of the traditional cascade while addressing key limitations and more fully describing the dynamic aspects of HIV testing, care, and treatment at the population level.
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Holtzman CW, Brady KA, Yehia BR. Retention in care and medication adherence: current challenges to antiretroviral therapy success. Drugs 2015; 75:445-54. [PMID: 25792300 DOI: 10.1007/s40265-015-0373-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Health behaviors such as retention in HIV medical care and adherence to antiretroviral therapy (ART) pose major challenges to reducing new HIV infections, addressing health disparities, and improving health outcomes. Andersen's Behavioral Model of Health Service Use provides a conceptual framework for understanding how patient and environmental factors affect health behaviors and outcomes, which can inform the design of intervention strategies. Factors affecting retention and adherence among persons with HIV include patient predisposing factors (e.g., mental illness, substance abuse), patient-enabling factors (e.g., social support, reminder strategies, medication characteristics, transportation, housing, insurance), and healthcare environment factors (e.g., pharmacy services, clinic experiences, provider characteristics). Evidence-based recommendations for improving retention and adherence include (1) systematic monitoring of clinic attendance and ART adherence; (2) use of peer or paraprofessional navigators to re-engage patients in care and help them remain in care; (3) optimization of ART regimens and pharmaceutical supply chain management systems; (4) provision of reminder devices and tools; (5) general education and counseling; (6) engagement of peer, family, and community support groups; (7) case management; and (8) targeting patients with substance abuse and mental illness. Further research is needed on effective monitoring strategies and interventions that focus on improving retention and adherence, with specific attention to the healthcare environment.
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Affiliation(s)
- Carol W Holtzman
- ICAP, Columbia University Mailman School of Public Health, P.O. Box 13860, Maseru 100, Lesotho,
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47
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Assessing the use of HIV surveillance data to help gauge patient retention-in-care. J Acquir Immune Defic Syndr 2015; 69 Suppl 1:S25-30. [PMID: 25867775 DOI: 10.1097/qai.0000000000000574] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Improved retention-in-care may enhance health outcomes for people living with HIV/AIDS (PLWHA). Although laboratory surveillance data may be used to gauge retention, no previous reports have compared laboratory surveillance vs. clinic visit-based measures of retention-in-care. We compared laboratory surveillance vs. clinic visit-based approaches for identifying retention status for PLWHA. METHODS We examined 2011 patient visit data from the Ruth M. Rothstein CORE Center, Cook County's HIV clinic. We defined retained patients as those with visits every 6 months over 2 years and matched patients classified through visit data against HIV surveillance laboratories reported to the Chicago Department of Health. We determined the sensitivity, specificity, and receiver operator characteristics of varying laboratory surveillance vs. clinic visit measures of retention. RESULTS Of patients classified through clinic visit data, 91% of 1714 in-care vs. 22% of 200 out-of-care patients met our most stringent surveillance-based retention definition-having ≥2 viral load/CD4s performed 90 days apart reported by the same laboratory in 2011. Of surveillance laboratory-based definitions for retention, having ≥2 HIV viral load and/or CD4 values at least 3 months apart reported from the same facility possessed the best receiver operator parameters and the receiver operator characteristics' curve comparing several laboratory surveillance vs. clinic visit-based retention measures that had an area under the curve of 0.95. CONCLUSIONS Our findings demonstrate that surveillance laboratory data can be used to assess retention-in-care for PLWHA. These data suggest that bi-directional data sharing between public health entities and care providers could advance re-engagement efforts.
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48
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Mizuno Y, Purcell DW, Knowlton AR, Wilkinson JD, Gourevitch MN, Knight KR. Syndemic vulnerability, sexual and injection risk behaviors, and HIV continuum of care outcomes in HIV-positive injection drug users. AIDS Behav 2015; 19:684-93. [PMID: 25249392 DOI: 10.1007/s10461-014-0890-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Limited investigations have been conducted on syndemics and HIV continuum of care outcomes. Using baseline data from a multi-site, randomized controlled study of HIV-positive injection drug users (n = 1,052), we examined whether psychosocial factors co-occurred, and whether these factors were additively associated with behavioral and HIV continuum of care outcomes. Experiencing one type of psychosocial problem was significantly (p < 0.05) associated with an increased odds of experiencing another type of problem. Persons with 3 or more psychosocial problems were significantly more likely to report sexual and injection risk behaviors and were less likely to be adherent to HIV medications. Persons with 4 or more problems were less likely to be virally suppressed. Reporting any problems was associated with not currently taking HIV medications. Our findings highlight the association of syndemics not only with risk behaviors, but also with outcomes related to the continuum of care for HIV-positive persons.
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Affiliation(s)
- Yuko Mizuno
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, NE Mail Stop E37, Atlanta, GA, 30333, USA,
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Cooley LA, Pearl ML, Flynn C, Ross C, Hart-Cooper G, Elmore K, Blythe D, Morgan J, Oster AM. Low viral suppression and high HIV diagnosis rate among men who have sex with men with syphilis--Baltimore, Maryland. Sex Transm Dis 2015; 42:226-31. [PMID: 25763676 PMCID: PMC9117975 DOI: 10.1097/olq.0000000000000256] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The burden of syphilis and HIV among gay, bisexual, and other men who have sex with men (MSM) in Baltimore, Maryland, is substantial. Syphilis and HIV surveillance data were analyzed to characterize MSM with syphilis, including those with repeat infection and HIV coinfection, to strengthen prevention efforts. METHODS MSM 15 years or older from Baltimore City or County diagnosed as having early syphilis in 2010 to 2011 were included. Those previously treated for syphilis in 2007 to 2011 were considered to have repeat syphilis infection. HIV surveillance data were used to identify HIV coinfection and assess viral suppression. For MSM not diagnosed as having HIV at or before their syphilis diagnosis, annual HIV diagnosis rates were estimated, using Baltimore City data. RESULTS Of 460 MSM with early syphilis in 2010 or 2011, 92 (20%) had repeat infection; 55% of MSM with a single diagnosis and 86% with repeat infection were HIV coinfected. Among MSM diagnosed as having HIV, viral suppression was low (25%, or 46% of those with a viral load reported). Among Baltimore City MSM without a prior HIV diagnosis, estimated annual HIV diagnosis rates were high (5% for those with 1 syphilis diagnosis, 23% for those with repeat infection). CONCLUSIONS Baltimore-area MSM with syphilis, particularly those with repeat infection, represent a unique population for whom coinfection with HIV is high. Increasing frequency of syphilis and HIV testing among Baltimore area MSM with a syphilis diagnosis and prioritizing HIV-infected MSM with syphilis in efforts to achieve viral suppression may improve outcomes locally for both infections.
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Affiliation(s)
- Laura A Cooley
- From the *Division of HIV/AIDS Prevention and †Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA; ‡Maryland Department of Health and Mental Hygiene, Baltimore, MD; §Division of STD Prevention and ¶CDC Experience Applied Epidemiology Fellowship, Atlanta, GA; and **Baltimore County Department of Health and Human Services, Towson, MD
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Monitoring outcomes for newly diagnosed and prevalent HIV cases using a care continuum created with New York city surveillance data. J Acquir Immune Defic Syndr 2015; 68:217-26. [PMID: 25394192 DOI: 10.1097/qai.0000000000000424] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The HIV care continuum has been used to show the proportion of persons living with HIV/AIDS (PWHA) who are engaged in each stage of HIV care. We present 1 care continuum for persons newly diagnosed with HIV and 1 for PWHA using New York City HIV surveillance registry data. METHODS Persons newly diagnosed with HIV in 2011 or PWHA as of December 31, 2011, were included. We constructed each continuum for persons engaged at each stage of HIV care and calculated the proportion achieving each step as both dependent on or independent of preceding steps. RESULTS Of the 3408 newly diagnosed persons, 67% had timely linkage to care (≤3 months after diagnosis), 58% were established in care 3-9 months after timely linkage, and 43% achieved viral suppression (≤200 copies/mL) ≤6 months after establishment in care; losses were highest from diagnosis to linkage. Independent measures showed 84% linked, 72% established, and 61% suppressed ≤18 months after diagnosis. Of the 87,268 PWHA, 83% were in care in 2011 (≥1 visit), 70% retained in care (≥2 visits ≥3 months apart), and 52% suppressed at their last visit; losses were highest from retention to suppression. When measured independently, suppression increased to 58%. CONCLUSIONS A minority of persons newly diagnosed with HIV and a narrow majority of PWHA achieved viral suppression and all intermediate care-related steps. Outcomes measured independently of previous care-related steps were higher, particularly for newly diagnosed persons. To improve outcomes among persons with HIV and reduce transmissibility, clinical and public health efforts should focus on linkage to care among newly diagnosed persons and viral suppression among PWHA.
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