Missed Opportunities: Adapting the HIV Care Continuum to Reduce HIV-Related Deaths.

Abstract

With advances in HIV care, persons with HIV/AIDS (PWHA) can lead healthy lives, but avoidable HIV-related deaths continue to occur in New York City (NYC). We selected PWHA from our surveillance registry who died between 2007 and 2013, resided in NYC, and survived ≥15 months after diagnosis to generate an HIV Mortality Reduction Continuum of Care (HMRCC) describing predeath care patterns among PWHA. We used HIV laboratory test reports to measure care outcomes during an "intervenable period" during which deaths may have been avoided. The continuum was stratified by the underlying cause of death (HIV-related vs. other), and the HIV-related HMRCC was stratified by demographic characteristics. Eleven thousand one hundred eighty-seven analysis-eligible PWHA died during 2007-2013. Ninety-eight percent linked to care; 80% were retained in care during the intervenable period; 66% were prescribed antiretroviral therapy; 47% had viral load ≤1500 copies/mL; and 40% achieved viral suppression (VS). Half (47%) of the deaths were HIV-related. Retention was higher among HIV-related cause of death (83% vs. 78%) but VS was lower (34% vs. 46%). The HIV-related HMRCC revealed disparities in VS. Despite comparable retention rates, whites had the highest VS (42%, vs. 32% blacks and 33% Latinos/Hispanics). In addition, retention and VS increased with increasing age. People with a history of injection drug use had relatively high rates of retention (88%) and VS (37%). The HMRCC is a novel framework for evaluating predeath care patterns among PWHA and identifying opportunities to reduce preventable deaths. In NYC, reducing mortality will require increasing VS among those already in care, particularly for blacks and Latinos/Hispanics.