Abstract
ObjectiveTo understand geographic variations in clinical retention, a central component of the HIV care continuum and key to improving individual- and population-level HIV outcomes.DesignWe evaluated retention by US region in a retrospective observational study.MethodsAdults receiving care from 2000–2010 in 12 clinical cohorts of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) contributed data. Individuals were assigned to Centers for Disease Control and Prevention (CDC)-defined regions by residential data (10 cohorts) and clinic location as proxy (2 cohorts). Retention was ≥2 primary HIV outpatient visits within a calendar year, >90 days apart. Trends and regional differences were analyzed using modified Poisson regression with clustering, adjusting for time in care, age, sex, race/ethnicity, and HIV risk, and stratified by baseline CD4+ count.ResultsAmong 78,993 adults with 444,212 person-years of follow-up, median time in care was 7 years (Interquartile Range: 4–9). Retention increased from 2000 to 2010: from 73% (5,000/6,875) to 85% (7,189/8,462) in the Northeast, 75% (1,778/2,356) to 87% (1,630/1,880) in the Midwest, 68% (8,451/12,417) to 80% (9,892/12,304) in the South, and 68% (5,147/7,520) to 72% (6,401/8,895) in the West. In adjusted analyses, retention improved over time in all regions (p<0.01, trend), although the average percent retained lagged in the West and South vs. the Northeast (p<0.01).ConclusionsIn our population, retention improved, though regional differences persisted even after adjusting for demographic and HIV risk factors. These data demonstrate regional differences in the US which may affect patient care, despite national care recommendations.
Highlights
Geographic Variations in Retention in HIV Care in the United States restrictions, data are available upon request
Retention in care is associated with improved access to antiretroviral therapy (ART), greater likelihood of virologic suppression, and less rapid HIV disease progression.[22,23,24,25,26,27]
Some of the studies in which these patterns of retention were discerned may have cohort-specific traits which could affect clinic attendance such as state Medicaid funding levels or local social stigmas that could limit their external generalizability to persons living with HIV/AIDS (PLWHA) in the U.S recent major policy initiatives, including the National HIV/AIDS Strategy (NHAS), have identified improving clinical retention, and targeting impediments to these improvements, as goals central to improving outcomes across the HIV Care Continuum in the U.S.[40,41,42,43]
Summary
Retention in care is associated with improved access to antiretroviral therapy (ART), greater likelihood of virologic suppression, and less rapid HIV disease progression.[22,23,24,25,26,27] the same demographic, clinical, and socioeconomic factors (i.e., younger age, Black race, higher CD4 count, and unstable housing status) have been repeatedly associated with suboptimal retention in various contexts These analyses have rarely focused on geographic heterogeneity as a potential source of clinical retention differences and have incorporated these data by adjusting for clinic site in multi-site analyses or examining relatively small numbers of jurisdictions.[28,29,30,31,32,33,34,35,36,37,38,39] Further, some of the studies in which these patterns of retention were discerned may have cohort-specific traits which could affect clinic attendance such as state Medicaid funding levels or local social stigmas (e.g., a history of intolerance toward sexual minorities) that could limit their external generalizability to persons living with HIV/AIDS (PLWHA) in the U.S recent major policy initiatives, including the National HIV/AIDS Strategy (NHAS), have identified improving clinical retention, and targeting impediments to these improvements, as goals central to improving outcomes across the HIV Care Continuum in the U.S.[40,41,42,43]
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