Saturday, November 28, 2015

Retention in Care within 1 Year of Initial HIV Care Visit in a Multisite US Cohort: 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/mm3 (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.

...The strongest correlate of retention during the first year of care was the initiation of ART and this association was present even among patients with baseline CD4 counts >350 cells/mm3. Overall, 93% of patients who started ART in our study were retained in care, and the adjusted odds of retention were 6 times as great for patients prescribed ART as for those patients who were not prescribed ART. The retained patients had a median of 7 visits during the year, and among the subset that also started ART, 75% did so before achieving the second visit and meeting retention outcome, giving credence to the notion that starting ART facilitated retention, possibly due to the need for more frequent follow-up provider contact and laboratory monitoring. The emerging paradigm of “test and treat” to reduce HIV transmission and improve individual clinical outcomes for both HIV and non-HIV complications is gaining hold.,,, The findings from our analysis suggest that universal early initiation of ART may well improve retention during the first year in care.

Our study provides a variation from other US-based analyses that examined establishing care or visit adherence in the first few months to years in HIV care. In the HIV Research Network, 22% of patients never established HIV care (defined as having an out-patient visit >6 months after initial enrollment), an estimate somewhat higher than ours. In that study, rates of establishment in care differed by race/ethnicity and insurance status, but this analysis was not restricted to ARV-naive patients and did not explicitly consider initiation of cART use. Torian and Wiewel examined HIV laboratory surveillance data as a proxy for clinic visits and found that 77% of HIV-infected patients in New York city made an initial HIV care visit within 6 months of their diagnosis, 94%of these made at least 1 subsequent visit, but only 45% met their definition of adequate retention (≥1 visit every 6 months) during their first 4 years of care. Ineligibility for ART at the time was also associated with lower visit frequency in these analyses. The clinical consequences of early nonretention in HIV care were highlighted by Mugavero and colleagues who found that at 2 university clinics patients who had at least 1 “no show” visit during the 2 years after initiation of care experienced a longer time to virologic suppression. Finally, our findings corroborate those from a recent US-based multisite study, which found that 84% of HIV-infected patients were engaged in continuous care in 2010 (defined as ≥2 visits at least 3 months apart) and that engagement in continuous care was the single factor most strongly associated with ART use and virologic suppression.

Although patients with lower CD4 counts were more likely to initiate ART, which was associated with greater likelihood of retention, paradoxically we also observed that when we controlled for ART initiation such patients were less likely to be retained in care during the first year (Table 2, multivariable model A). We expected such patients would be more likely to be retained since they have been prioritized for treatment initiation and can require more frequent visits to address opportunistic illnesses and comorbidities. However, we have observed in prior HOPS work that persons diagnosed with HIV infection at a CD4 count <200 cells/mm3 were more likely to have been heterosexual or IDU, to be of age ≥35 years at diagnosis, and to be of nonwhite race/ethnicity. These sociodemographic characteristics may correlate with underlying risk factors for nonretention such as incarceration, homelessness, mental illness, active drug use, not disclosing HIV status, or patient refusal of ART offer and lack of readiness to start lifelong therapy.,,,, Our data caution that prescribing ART will not necessarily improve retention for everyone, particularly for persons with lower CD4 counts who may face myriad other socioeconomic and behavioral challenges that may need to be addressed to achieve successful retention... 

Full article at:

By:  Ellen M. Tedaldi, MD,1 James T. Richardson, MS,2 Rachel Debes, MS,2 Benjamin Young, MD, PhD,3,4 Joan S. Chmiel, PhD,5 Marcus D. Durham, MS,6 John T. Brooks, MD,6 Kate Buchacz, PhD,6 and the HOPS Investigators
1Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
2Cerner Corporation, Vienna, VA, USA
3Department of Medicine, University of Colorado, APEX Family Medicine, Denver, CO, USA
4Adjunct Korbel School of International Studies, International Association of Providers of AIDS Care, Washington, DC, USA
5Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
6Centers for Disease Control and Prevention, Atlanta, GA, USA
Corresponding Author: Ellen M. Tedaldi, Temple General Internal Medicine, 1316 W Ontario Street, Philadelphia, PA 19140, USA. ude.elpmet@idladete

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