Retention in HIV Care in Year 1: Who's In and Who's Out?
Retention in HIV Care in Year 1: Who's In and Who's Out?
Biannual attendance at medical visits is an established measure of retention in HIV care. We examined factors associated with attending at least 2 clinic visits at least 90 days apart among HIV-infected, antiretroviral therapy (ART)-naive HIV Outpatient Study participants entering care during 2000 to 2011. Of 1441 patients, 85% were retained in care during the first year of observation. Starting ART during the year was the strongest correlate of retention (adjusted odds ratio [aOR] 6.4, 95% confidence interval [CI] 4.4–9.4). After adjusting for starting ART, publicly insured patients (aOR 0.6, 95% CI 0.4–1.0), and patients with baseline CD4 counts <200 cells/mm (aOR 0.5, 95% CI 0.3–0.9) or missing CD4 counts (aOR 0.3, 95% CI 0.2–0.6) were less likely to be retained in care. Although most patients had recommended biannual care visits, some ART-naive individuals may require additional interventions to remain in care. Promptly initiating ART may facilitate engagement in care.
Improving retention in HIV care is a key goal of the US National HIV/AIDS strategy. Retention in care improves clinical outcomes such as survival and virologic control, facilitates appropriate receipt of vaccinations and other health screenings, and also decreases race-/ethnicity-related health care disparities. Various US medical sources have emphasized the importance of retention in HIV care and have proposed to measure it by a criterion of at least 2 HIV medical visits during a calendar year, spaced at least 2 to 6 months apart, depending on the specific measure employed. Retention in medical care is one of the quality performance measures used by the US HIV/AIDS Bureau within the Health Resources and Services Administration (HRSA) for any site they support that provides HIV services. An HIV-infected patient must attend at least 2 appropriately spaced medical visits within a year to meet the retention criterion. Unfortunately, it is estimated that among persons aware of their HIV status in various US populations, at least 50% may not be retained in care. In a national study based on HIV surveillance data and utilizing laboratory data as proxy measurements for retention (at least 2 CD4 counts or plasma HIV RNA viral load tests at least 3 months apart within a year), only 45% of HIV-infected patients were considered retained in HIV care. Factors associated with increased risk of not attending a minimum of 2 medical visits per year have included younger age, black or African American (hereinafter referred to as black) and Hispanic/Latino race/ethnicity, and concomitant drug or alcohol use.
Current US guidelines recommend offering HIV treatment to all patients, an important contrast to previous guidance just a few years ago that recommended assessing readiness for therapy and waiting until the CD4 count falls to 350 cells/mm. In older guidance, a few exceptions existed, such as offering treatment to persons with ongoing high-risk behavior regardless of the CD4 count. This evolution of the treatment paradigm reflects new knowledge that earlier antiretroviral therapy (ART) not only appears to improve individual outcomes but also profoundly reduces HIV transmission and new infections at the population level. Possible sociodemographic disparities associated with starting combination ART (cART) may be reduced under the current guidance that uniformly recommends cART for all who are ready. In the period of this analysis, which spanned 2000 to 2011, we hypothesized that factors such as baseline CD4 count, baseline plasma HIV RNA viral load, insurance status, and HIV risk behaviors (eg, injection drug use) may have played a more prominent role in who started cART and the frequency of clinical and virologic monitoring they subsequently received. We also hypothesized that starting ART may be associated with better retention in care, in part because of the long-standing recommendations for frequent HIV viral load monitoring in patients starting ART (4–8 weeks until viral load suppression, then 3–6 months thereafter). In this context, we sought to describe the rates of, and factors associated with, biannual clinic attendance among ART-naive HIV Outpatient Study (HOPS) participants entering HOPS care during 2000 to 2011.
Abstract and Introduction
Abstract
Biannual attendance at medical visits is an established measure of retention in HIV care. We examined factors associated with attending at least 2 clinic visits at least 90 days apart among HIV-infected, antiretroviral therapy (ART)-naive HIV Outpatient Study participants entering care during 2000 to 2011. Of 1441 patients, 85% were retained in care during the first year of observation. Starting ART during the year was the strongest correlate of retention (adjusted odds ratio [aOR] 6.4, 95% confidence interval [CI] 4.4–9.4). After adjusting for starting ART, publicly insured patients (aOR 0.6, 95% CI 0.4–1.0), and patients with baseline CD4 counts <200 cells/mm (aOR 0.5, 95% CI 0.3–0.9) or missing CD4 counts (aOR 0.3, 95% CI 0.2–0.6) were less likely to be retained in care. Although most patients had recommended biannual care visits, some ART-naive individuals may require additional interventions to remain in care. Promptly initiating ART may facilitate engagement in care.
Introduction
Improving retention in HIV care is a key goal of the US National HIV/AIDS strategy. Retention in care improves clinical outcomes such as survival and virologic control, facilitates appropriate receipt of vaccinations and other health screenings, and also decreases race-/ethnicity-related health care disparities. Various US medical sources have emphasized the importance of retention in HIV care and have proposed to measure it by a criterion of at least 2 HIV medical visits during a calendar year, spaced at least 2 to 6 months apart, depending on the specific measure employed. Retention in medical care is one of the quality performance measures used by the US HIV/AIDS Bureau within the Health Resources and Services Administration (HRSA) for any site they support that provides HIV services. An HIV-infected patient must attend at least 2 appropriately spaced medical visits within a year to meet the retention criterion. Unfortunately, it is estimated that among persons aware of their HIV status in various US populations, at least 50% may not be retained in care. In a national study based on HIV surveillance data and utilizing laboratory data as proxy measurements for retention (at least 2 CD4 counts or plasma HIV RNA viral load tests at least 3 months apart within a year), only 45% of HIV-infected patients were considered retained in HIV care. Factors associated with increased risk of not attending a minimum of 2 medical visits per year have included younger age, black or African American (hereinafter referred to as black) and Hispanic/Latino race/ethnicity, and concomitant drug or alcohol use.
Current US guidelines recommend offering HIV treatment to all patients, an important contrast to previous guidance just a few years ago that recommended assessing readiness for therapy and waiting until the CD4 count falls to 350 cells/mm. In older guidance, a few exceptions existed, such as offering treatment to persons with ongoing high-risk behavior regardless of the CD4 count. This evolution of the treatment paradigm reflects new knowledge that earlier antiretroviral therapy (ART) not only appears to improve individual outcomes but also profoundly reduces HIV transmission and new infections at the population level. Possible sociodemographic disparities associated with starting combination ART (cART) may be reduced under the current guidance that uniformly recommends cART for all who are ready. In the period of this analysis, which spanned 2000 to 2011, we hypothesized that factors such as baseline CD4 count, baseline plasma HIV RNA viral load, insurance status, and HIV risk behaviors (eg, injection drug use) may have played a more prominent role in who started cART and the frequency of clinical and virologic monitoring they subsequently received. We also hypothesized that starting ART may be associated with better retention in care, in part because of the long-standing recommendations for frequent HIV viral load monitoring in patients starting ART (4–8 weeks until viral load suppression, then 3–6 months thereafter). In this context, we sought to describe the rates of, and factors associated with, biannual clinic attendance among ART-naive HIV Outpatient Study (HOPS) participants entering HOPS care during 2000 to 2011.
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