The Impact of Retention in Early HIV Medical Care on Viro-Immunological Parameters and Survival: A Statewide Study

Arnold School of Public Health, University of South Carolina, Columbia, 29208, USA.
AIDS research and human retroviruses (Impact Factor: 2.33). 07/2011; 27(7):751-8. DOI: 10.1089/AID.2010.0268
Source: PubMed


Current literature on retention in HIV care fails to account for patients who continually/simultaneously access different providers. This statewide study examined retention in early HIV medical care and its impact on viro-immunological improvement and survival outcomes. It was a retrospective study of South Carolina residents ≥13 years old who were diagnosed with HIV infection in 2004-2007 and initially entered in care. CD4 count/percent and viral load (VL) tests that must be reported to the South Carolina HIV surveillance database were used as a proxy for a clinical visit. Retention was defined as at least one visit in each of four 6-month periods over 2 years postlinkage. Retention rates were categorized as "optimal" (visits in four intervals), "suboptimal" (visits in three intervals), sporadic (visits in two or one intervals), and "dropout" (no visits). Logistic regression and Cox proportional analyses were used to examine retention. Of the 2197 persons, about 50% failed to maintain optimal retention in care postlinkage. Male gender, nonwhite race/ethnicity, younger age, delayed linkage, and HIV-only status were significant predictors of lower rate of retention. Mean decrease in baseline log(10) VL was greater among those with optimal compared to suboptimal (-1.81 vs. -1.42; p < 0.001) and sporadic retention (-1.81 vs. -0.70; p < 0.001). Mean increase in baseline CD4 count was greater in optimal retention compared to suboptimal (169.70 vs. 107.5; p < 0.001) and sporadic retention (169.70 vs. 2.43; p < 0.001). Increased risk of mortality was associated with sporadic retention (aHR 2.91; 95% CI 1.54-5.50) and "dropout" (aHR 4.00; 95% CI 1.50-10.65). Rate of poor retention in early HIV medical care was relatively higher than reported in clinic-based data. Increasing the rate of retention in early HIV care could substantially improve viro-immunological parameters and survival outcomes.

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    • "Second, the survival of the patients was not investigated and we could not obtain the prognosis of LTFU cases. However, the growing number of studies including ones without complete follow-up systems, such as nationwide databases, indicates that LTFU is associated with worse survival, which can support the clinical validity of the present findings [24–27]. The third limitation is generalizability. "
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    ABSTRACT: Poor retention in the care of patients with human immunodeficiency virus (HIV) is associated with adverse patient outcomes such as antiretroviral therapy failure and death. Therefore, appropriate case management is required for better patient retention; however, which intervention in case management is important has not been fully investigated. Meanwhile, in Japan, each local government is required to organize mental health services for patients with HIV so that a case manager at an HIV care facility can utilize them, but little is known about the association between implementation of the services and loss to follow-up. Therefore, we investigated that by a nested case-control study. The target population consisted of all patients with HIV who visited Osaka National Hospital, the largest HIV care facility in western Japan, between 2000 and 2010. Loss to follow-up was defined as not returning for follow-up care more than 1 year after the last visit. Independent variables included patient demographics, characteristics of the disease and treatment, and whether the patients have received mental health services. For each case, three controls were randomly selected and matched. Of the 1620 eligible patients, 88 loss to follow-up cases were identified and 264 controls were matched. Multivariate-adjusted conditional logistic regression revealed that loss to follow-up was less frequent among patients who had received mental health services implemented by their case managers (adjusted odds ratio [95% confidence interval] 0.35 [0.16-0.76]). Loss to follow-up also occurred more frequently in patients who did not receive antiretroviral therapy (adjusted odds ratio [95% confidence interval], 7.51 [3.34-16.9]), who were under 30 years old (2.74 [1.36-5.50]), or who were without jobs (3.38 [1.58-7.23]). Mental health service implementation by case managers has a significant impact on patient retention.
    PLoS ONE 07/2013; 8(7):e69603. DOI:10.1371/journal.pone.0069603 · 3.23 Impact Factor
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    • "Despite the potential to improve patient and public health outcomes [1-4,28,29], existing evidence-based HIV LTC interventions have yet to be widely and systematically disseminated and implemented in community-based organizations (CBOs) and health departments throughout the United States. In order to accelerate national-level scale-up, it is important to identify and understand factors associated with intentions to adopt LTC interventions and use this information to develop and test strategies to encourage intervention adoption and effective implementation among key end users, including consumers, organizations, and policy makers. "
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    ABSTRACT: Widespread dissemination and implementation of evidence-based human immunodeficiency virus (HIV) linkage-to-care (LTC) interventions is essential for improving HIV-positive patients' health outcomes and reducing transmission to uninfected others. To date, however, little work has focused on identifying factors associated with intentions to adopt LTC interventions among policy makers, including city, state, and territory health department AIDS directors who play a critical role in deciding whether an intervention is endorsed, distributed, and/or funded throughout their region. Between December 2010 and February 2011, we administered an online questionnaire with state, territory, and city health department AIDS directors throughout the United States to identify factors associated with intentions to adopt an LTC intervention. Guided by pertinent theoretical frameworks, including the Diffusion of Innovations and the "push-pull" capacity model, we assessed participants' attitudes towards the intervention, perceived organizational and contextual demand and support for the intervention, likelihood of adoption given endorsement from stakeholder groups (e.g., academic researchers, federal agencies, activist organizations), and likelihood of enabling future dissemination efforts by recommending the intervention to other health departments and community-based organizations. Forty-four participants (67% of the eligible sample) completed the online questionnaire. Approximately one-third (34.9%) reported that they intended to adopt the LTC intervention for use in their city, state, or territory in the future. Consistent with prior, related work, these participants were classified as LTC intervention "adopters" and were compared to "nonadopters" for data analysis. Overall, adopters reported more positive attitudes and greater perceived demand and support for the intervention than did nonadopters. Further, participants varied with their intention to adopt the LTC intervention in the future depending on endorsement from different key stakeholder groups. Most participants indicated that they would support the dissemination of the intervention by recommending it to other health departments and community-based organizations. Findings from this exploratory study provide initial insight into factors associated with public health policy makers' intentions to adopt an LTC intervention. Implications for future research in this area, as well as potential policy-related strategies for enhancing the adoption of LTC interventions, are discussed.
    Implementation Science 04/2012; 7(1):27. DOI:10.1186/1748-5908-7-27 · 4.12 Impact Factor
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    ABSTRACT: The US National HIV/AIDS Strategy identifies retention in care as an important quality performance measure. There is no gold standard to measure retention in care. This study is the first to compare different measures of retention, using a large geographically diverse sample. A prospective cohort of 17,425 HIV-infected adults enrolled in care at 12 US HIV clinics between 2001 and 2008. We compared three measures of retention for each patient: proportion of time not spent in a gap of more than 6 months between successive outpatient visits; proportion of 91-day quarters in which at least one visit occurred; proportion of years in which two or more visits separated by at least 90 days occurred. Associations among measures and effects of sociodemographic and clinical characteristics were examined. The three measures of retention were moderately to strongly correlated. Averaging across patients, 71% of time in care was not spent in a gap more than 6 months; 73% of all quarters had at least one visit; and 75% of all years had at least two visits separated by at least 90 days. For all measures, retention was significantly higher for women, whites, older individuals, men who had sex with men (MSM)-related HIV transmission, and initial CD4 cell counts 50 cell/μl or less. This is one of the first studies to provide a national estimate of retention in HIV care in the US, which ranged from 71 to 75% using any of the accepted retention measures. Future studies should assess how well different measures predict clinical outcomes and establish acceptable target levels for retention.
    AIDS (London, England) 02/2012; 26(9):1131-9. DOI:10.1097/QAD.0b013e3283528afa · 5.55 Impact Factor
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