Retention In Human Immunodeficiency Virus Care Research Articles

The impact of same-day antiretroviral therapy initiation on retention in care and clinical outcomes at four eThekwini clinics, KwaZulu-Natal, South Africa

BackgroundSame-day initiation (SDI) of antiretroviral therapy (ART) increases ART uptake, however retention in care after ART initiation remains a challenge. Public health behaviours, such as retention in HIV care and adherence to antiretroviral therapy (ART) pose major challenges to reducing new Human Immunodeficiency Virus (HIV) transmission and improving health outcomes among HIV patients.MethodsWe evaluated 6-month retention in care, and clinical outcomes of an ART cohort comprising of SDI and delayed ART initiators. We conducted a 6 months’ observational prospective cohort study of 403 patients who had been initiated on ART. A structured questionnaire was used to abstract data from patient record review which comprised the medical charts, laboratory databases, and Three Interlinked Electronic Registers.Net (TIER.Net). Treatment adherence was ascertained by patient visit constancy for the clinic scheduled visit dates. Retention in care was determined by status at 6 months after ART initiation.ResultsAmong the 403 participants enrolled in the study and followed up, 286 (70.97%) and 267 (66.25%) complied with scheduled clinics visits at 3 months and 6 months, respectively. One hundred and thirteen (28.04%) had been loss to follow-up. 17/403 (4.22%) had died and had been out of care after 6 months. 6 (1.49%) had been transferred to other health facilities and 113 (28.04%) had been loss to follow-up. Among those that had been lost to follow-up, 30 (33.63%) deferred SDI while 75 (66.37%) initiated ART under SDI. One hundred and eighty-nine (70.79%) participants who had remained in care were SDI patients while 78 (29.21%) were SDI deferred patients. In the bivariate analysis; gender (OR: 1.672; 95% CI: 1.002–2.791), number of sexual partners (OR: 2.092; 95% CI: 1.07–4.061), age (OR: 0.941; 95% CI: 0.734–2.791), ART start date (OR: 0.078; 95% CI: 0.042–0.141), partner HIV status (OR: 0.621; 95% CI: 0.387–0.995) and the number of hospitalizations after HIV diagnosis (OR: 0.173; 95% CI: 0.092–0.326). were significantly associated with viral load detection. Furthermore, SDI patients who defaulted treatment were 2.4 (95% CI: 1.165–4.928) times more likely to have increased viral load than those who had been returned in care.ConclusionViral suppression under SDI proved higher but with poor retention in care. However, the results also emphasise a vital need, to not only streamline processes to increase immediate ART uptake further, but also to ensure retention in care.

Adolescent and young adult research across the HIV prevention and care continua: an international programme analysis and targeted review

Human immunodeficiency virus (HIV) continues to rise in young people among low- and middle-income countries (LMIC). The US National Institutes of Health (NIH) supports the largest public investment in HIV research globally. Despite advancements in the last decade, adolescents and young adults (AYA) remain underrepresented in research to improve HIV prevention and care. We undertook a programme analysis of NIH grants and conducted a targeted review of linked publications on international AYA research across the HIV prevention and care continuum (HPCC) to inform new initiatives to address the needs of AYA in these settings. NIH-funded grants from 2012 to 2017, pertaining to AYA in LMIC, and evaluating areas of HIV prevention, care and/or treatment were identified. A systematic review of publications limited to funded grants was performed in two waves: 2012-2017 and 2018-2021. The review included a landscape assessment and an evaluation of NIH-defined clinical trials, respectively. Data on outcomes across the HPCC were abstracted and analysed. Among grant applications, 14% were funded and linked to 103 publications for the analytic database, 76 and 27 from the first and second waves, respectively. Fifteen (15%) wave 1 and 27 (26%) wave 2 publications included an NIH-defined clinical trial. Among these, 36 (86%) did not target a key population (men who have sex with men, drug users and sex workers) and 37 (88%) were exclusively focused on sub-Saharan Africa. Thirty (71%) publications addressed at least one HPCC milestone. Specific focus was on milestones in HIV prevention, care or both, for 12 (29%), 13 (31%) and five (12%) of publications, respectively. However, few addressed access to and retention in HIV care (4 [14%]) and none included microbicides or treatment as prevention. More focus is needed in crucial early steps of the HIV care continuum and on biomedical HIV prevention interventions. Research gaps remain in this portfolio across the AYA HPCC. To address these, NIH launched an initiative entitled Prevention and Treatment through a Comprehensive Care Continuum for HIV-affected Adolescents in Resource Constrained Settings (PATC3 H) to generate needed scientific innovation for effective public health interventions for AYA affected by HIV in LMIC.

Factors Associated with Retention in HIV Care Among HIV-Positive Adolescents in Public Antiretroviral Therapy Clinics in Ibanda District, Rural South Western Uganda.

Retention in antiretroviral therapy (ART) care is a key indicator of Human Immunodeficiency Virus (HIV) treatment success as it improves adherence, critical for better treatment outcomes and prevention of drug resistance. HIV treatment among adolescents living with HIV (ALHIV) is characterized by loss to follow-up, poor ART adherence, and eventual death. This study assessed retention in ART care and the associated factors among ALHIV in Ibanda district, rural South Western Uganda. This was a retrospective cohort study using clinical data from ALHIV enrolled from 2019 to 2020 in eight health facilities in Ibanda district. Data from the Electronic Medical Record (EMR) system was extracted to assess the associated factors and participants' status two years after enrollment. Data were analyzed using EPIdata version 3.1 in which Univariate and multivariate cox proportional hazard regression analyses were determined. A hazard ratio (HR) at a 95% confidence interval was obtained, and a P-value <0.05 was considered statistically significant. Eighty-four ALHIV comprising 86.9% (N = 73) females were enrolled. The majority 63.1% (N = 53) resided in semi/peri-urban, and 44.0% (N = 37) stayed less than 5 km from the facility. Only 35.7% (N = 30) were active on ART, while 17 (20.2%) and 36 (42.9%) were lost to follow-up and transfer-outs, respectively. Factors associated with low retention were: ALHIV that moved 5-10Km (HR = 5.371; 95% CI: 1.227-23.5050, p = 0.026), used differential service delivery model was Facility-Based Group (FBG) (HR = 12.419; 95% CI: 4.034-38.236, p < 0.001) and those enrolled on the Young Adolescent Program Support (YAPs) (HR = 4.868; 95CI:1.851-12.803; p = 0.001). Retention reduced with increasing ART duration, ALHIV on (TDF/3TC/EFV) (p < 0.001), lived more than 10Km (p = 0.043) and did not benefit from any intervention (p < 0.001). Results showed low retention in care and the urgent need to strengthen individual case management strategies for ALHIV, thus interventions focusing on peer support are desired.

Relationships Between Patient Race and Residential Race Context With Missed Human Immunodeficiency Virus Care Visits in the United States, 2010-2015.

Racial inequities exist in retention in human immunodeficiency virus (HIV) care and multilevel analyses are needed to contextualize and address these differences. Leveraging data from a multisite clinical cohort of people with HIV (PWH), we assessed the relationships between patient race and residential characteristics with missed HIV care visits. Medical record and patient-reported outcome (PRO; including mental health and substance-use measures) data were drawn from 7 participating Center for AIDS Research Network of Integrated Clinical Systems (CNICS) sites including N = 20 807 PWH from January 2010 through December 2015. Generalized estimating equations were used to account for nesting within individuals and within census tracts in multivariable models assessing the relationship between race and missed HIV care visits, controlling for individual demographic and health characteristics and census tract characteristics. Black PWH resided in more disadvantaged census tracts, on average. Black PWH residing in census tracts with higher proportion of Black residents were more likely to miss an HIV care visit. Non-Black PWH were less likely to miss a visit regardless of where they lived. These relationships were attenuated when PRO data were included. Residential racial segregation and disadvantage may create inequities between Black PWH and non-Black PWH in retention in HIV care. Multilevel approaches are needed to retain PWH in HIV care, accounting for community, healthcare setting, and individual needs and resources.

Efficient and robust approaches for analysis of sequential multiple assignment randomized trials: Illustration using the ADAPT-R trial.

Personalized intervention strategies, in particular those that modify treatment based on a participant's own response, are a core component of precision medicine approaches. Sequential multiple assignment randomized trials (SMARTs) are growing in popularity and are specifically designed to facilitate the evaluation of sequential adaptive strategies, in particular those embedded within the SMART. Advances in efficient estimation approaches that are able to incorporate machine learning while retaining valid inference can allow for more precise estimates of the effectiveness of these embedded regimes. However, to the best of our knowledge, such approaches have not yet been applied as the primary analysis in SMART trials. In this paper, we present a robust and efficient approach using targeted maximum likelihood estimation (TMLE) for estimating and contrasting expected outcomes under the dynamic regimes embedded in a SMART, together with generating simultaneous confidence intervals for the resulting estimates. We contrast this method with two alternatives (G-computation and inverse probability weighting estimators). The precision gains and robust inference achievable through the use of TMLE to evaluate the effects of embedded regimes are illustrated using both outcome-blind simulations and a real-data analysis from the Adaptive Strategies for Preventing and Treating Lapses of Retention in Human Immunodeficiency Virus (HIV) Care (ADAPT-R) trial (NCT02338739), a SMART with a primary aim of identifying strategies to improve retention in HIV care among people living with HIV in sub-SaharanAfrica.

Successful expanded clinic network collaboration and patient tracing for retention in HIV care

BackgroundThere are more than 7,800 people living with human immunodeficiency virus (HIV) in Victoria, Australia. Crucial in maximising the individual and population level benefits from antiretroviral therapy (ART) is understanding how to achieve patient retention in care and the factors that drive it. This study was an expansion of a 2015 assessment of HIV-care retention in Victoria, which sought out to determine whether the inclusion of a broader range of HIV-healthcare sites would yield more accurate estimates of retention in HIV-care. We aimed to improve our understanding of HIV-care retention in Victoria, Australia, identify people living with HIV (PLHIV) with unknown outcomes, and attempt to re-engage PLHIV in care.MethodsA network of 15 HIV-care sites was established in Victoria, Australia across diverse care settings which ranged from low-caseload rural sites to high-caseload metropolitan GP clinics and hospitals. Individuals who had an HIV viral load (VL) performed in both calendar years of 2016 and 2017 were classified as retained in care. Individuals with a VL test in 2016 but not in 2017 were considered to potentially have unknown outcomes as they may have been receiving care elsewhere, have disengaged from care or died. For this group, an intervention of cross-referencing partially de-identified data between healthcare sites, and contact tracing individuals who still had unknown outcomes was performed.ResultsFor 5223 individuals considered to be retained in care across 15 healthcare sites in the study period, 49 had unconfirmed transfers of care to an alternative provider and 79 had unknown outcomes. After the intervention, the number of unconfirmed care transfers was reduced to 17 and unknown outcomes reduced to 51. These changes were largely attributed to people being reclassified as confirmed transfers of care. Retention in care estimates that did not include the patient outcome of confirmed transfer of care ranged from 76.2 to 95.8% and did not alter with the intervention. However, retention in care estimates which considered confirmed transfers and those that re-entered care at a new site as retained in care significantly increased across five of the sites with estimates ranging from 80.9 to 98.3% pre-intervention to 83.3–100% post-intervention. Individuals whose outcomes remained unknown post-intervention were more often men who have sex with men (MSM) when compared to other categories (person who injects drugs (PWID), combined PWID/MSM, men who identify as heterosexual or unknown) (74.5% vs. 53.5%, [p = 0.06]) and receiving ART at their last HIV-care visit (84.3% vs. 67.8% [p = 0.09]).ConclusionThis study confirmed high retention in HIV-care and low numbers of people disengaged from HIV-care in Victoria. This was demonstrated across a larger number of sites with varying models of care than a prior assessment in 2015. These data align with national and state targets aiming for 95% of PLHIV retained in HIV-care.

One Pill, Once a Day: Simplified Treatment Regimens and Retention in HIV Care.

Simplified drug regimens may improve retention in care for persons with chronic diseases. In April 2013, South Africa adopted a once-daily single-pill human immunodeficiency virus (HIV) treatment regimen as the standard of care, replacing a multiple-pill regimen. Because the regimens had similar biological efficacy, the shift to single-pill therapy offered a real-world test of the impact of simplified drug-delivery mechanisms on patient behavior. Using a quasi-experimental regression discontinuity design, we assessed retention in care among patients starting HIV treatment just before and just after the guideline change. The study included 4,484 patients starting treatment at a large public sector clinic in Johannesburg, South Africa. The share of patients prescribed a single-pill regimen increased by over 40 percentage points between March and April 2013. Initiating treatment after the policy change was associated with 11.7-percentage-points' higher retention at 12 months (95% confidence interval: -2.2, 29.4). Findings were robust to different measures of retention, different bandwidths, and different statistical models. Patients starting treatment early in HIV infection-a key population in the test-and-treat era-experienced the greatest improvements in retention from single-pill regimens.

Chronic pain and medical cannabis: Narrative review and practice considerations in persons living with HIV

AbstractGlobally, 38 million persons live with human immunodeficiency virus (HIV) (PLWH), and a significant portion live with chronic pain. While not yet fully characterized, preliminary data suggest 40%‐83% of PLWH experience chronic pain, and many report undertreatment. A growing body of literature suggests undertreatment of chronic pain in PLWH leads to adverse clinical outcomes, such as poor retention in HIV care, suboptimal adherence to antiretroviral therapy, and increased use of intravenous drug use (eg, heroin). Chronic pain experienced by PLWH ranges from neuropathic to musculoskeletal with different etiologies and treatment modalities for each. Although opioids have been used to achieve analgesia in PLWH, there is growing interest in alternative pain therapies. Recently, medical cannabis (delta‐9‐tetrahydrocannabinol [THC] and cannabidiol [CBD]) products have been of high interest. Anecdotal evidence exists for medical cannabis and pain relief; however, robust clinical trial data are limited due to scheduling restrictions within the United States. The purposes of this narrative review are to summarize key literature for pain in PLWH and medical cannabis, discuss pertinent dosage forms and dosing schedules, and summarize safety and efficacy considerations for PLWH. Finally, the authors provide recommendations on cannabis rescheduling and pharmacists' and healthcare providers' roles in its prescribing and indication. Medical cannabis and pharmaceutical preparations containing both THC and CBD are a viable alternatives to opioid analgesics in the treatment of neuropathic pain in PLWH. The risks of misuse and cannabis use disorder warrant careful consideration, yet the benefits of effective analgesia associated with cannabis may outweigh these risks. Cannabis rescheduling and subsequent expansions in pain management research are warranted, particularly for CBD‐predominant and CBD‐isolate medical cannabis products.

HIV screening and retention in care in people who use drugs in Madrid, Spain: a prospective study

BackgroundThe burden of human immunodeficiency virus (HIV) infection in people who use drugs (PWUD) is significant. We aimed to screen HIV infection among PWUD and describe their retention in HIV care. Besides, we also screen for hepatitis C virus (HCV) infection among HIV-seropositive PWUD and describe their linkage to care.MethodsWe conducted a prospective study in 529 PWUD who visited the “Cañada Real Galiana” (Madrid, Spain). The study period was from June 1, 2017, to May 31, 2018. HIV diagnosis was performed with a rapid antibody screening test at the point-of-care (POC) and HCV diagnosis with immunoassay and PCR tests on dried blood spot (DBS) in a central laboratory. Positive PWUD were referred to the hospital. We used the Chi-square or Fisher’s exact tests, as appropriate, to compare rates between groups.ResultsThirty-five (6.6%) participants were positive HIV antibodies, but 34 reported previous HIV diagnoses, and 27 (76%) had prior antiretroviral therapy. Among patients with a positive HIV antibody test, we also found a higher prevalence of homeless (P < 0.001) and injection drug use (PWID) (P < 0.001), and more decades of drug use (P = 0.002). All participants received HIV test results at the POC. Of the 35 HIV positives, 28 (80%) were retained in HIV medical care at the end of the HIV screening study (2018), and only 22 (62.9%) at the end of 2020. Moreover, 12/35 (34.3%) were positive for the HCV RNA test. Of the latter, 10/12 (83.3%) were contacted to deliver the HCV results test (delivery time of 19 days), 5/12 (41.7%) had an appointment and were attended at the hospital and started HCV therapy, and only 4/12 (33.3%) cleared HCV.ConclusionsWe found almost no new HIV-infected PWUD, but their cascade of HIV care was low and remains a challenge in this population at risk. The high frequency of active hepatitis C in HIV-infected PWUD reflects the need for HCV screening and reinforcing the link to care.

Short-term mortality from HIV-infected persons diagnosed from 2012 to 2016: Impact of late diagnosis of HIV infection.

We investigated the temporal trends of short-term mortality (death within 1 year of diagnosis) and cause-specific deaths in human immunodeficiency virus (HIV)-infected persons by stage of HIV infection at diagnosis. We also assessed the impact of late diagnosis (LD) on short-term mortality.Epidemiological records of HIV-infected Singapore residents from the National HIV Registry were linked to death records from the Registry of Births and Deaths for observational analyses. Newly-diagnosed HIV cases with available cluster of differentiation 4 count at time of diagnosis in a 5-year period from 2012 to 2016 were included in the study. Hazard ratios (HRs) and 95% confidence interval (CI) of LD for all deaths excluding suicides and self-inflicted or accidental injuries, and HIV/ acquired immunodeficiency syndrome (AIDS)-related deaths occurring within 1 year post-diagnosis were calculated using Cox proportional hazards regression models with adjustment for age at HIV/AIDS diagnosis. Population attributable risk proportions (PARPs) were then calculated using the adjusted HRs.Of the 1990 newly-diagnosed HIV cases included in the study, 7.2% had died by end of 2017, giving an overall mortality rate of 2.16 per 100 person-years (PY) (95% CI 1.82–2.54). The mortality rate was 3.81 per 100 PY (95% CI 3.15–4.56) in HIV cases with LD, compared with 0.71 (95% CI 0.46–1.05) in non-LD (nLD) cases. Short-term mortality was significantly higher in LD (9.1%) than nLD cases (1.1%). Of the 143 deaths reported between 2012 and 2017, 58.0% were HIV/AIDS-related (nLD 28.0% vs LD 64.4%). HIV/AIDS-related causes represented 70.4% of all deaths which occurred during the first year of diagnosis (nLD 36.4% vs LD 74.7%). The PARP of short-term mortality due to LD was 77.8% for all deaths by natural causes, and 87.8% for HIV/AIDS-related deaths.The mortality rate of HIV-infected persons with LD was higher than nLD, especially within 1 year of diagnosis, and HIV/AIDS-related causes constituted majority of these deaths. To reduce short-term mortality, persons at high risk of late-stage HIV infection should be targeted in outreach efforts to promote health screening and remove barriers to HIV testing and treatment.

The individual, interactive, and syndemic effect of substance use, depression, education, and ethnicity on retention in HIV care.

In this study, we sought to assess the individual, syndemic, and interactive associations between individual-level factors and retention in care. The sample was derived from the Miami Adult Studies on human immunodeficiency virus (HIV)/ acquired immune deficiency syndrome (AIDS) cohort from 2009 to 2014. The variables were entered into a multiple logistic regression with retention as the outcome. Backward regression, adjusting for all main effects, was conducted to determine which two-way interactions were associated with retention. Multivariable logistic regression was used to test which number of factors were associated with retention. Non-Hispanic Black race/ethnicity was associated with improved retention (odds ratio [OR] = 2.44, 95% confidence interval [CI]: 1.06-5.75, p ≤ 0.05) when compared to Non-Hispanic White persons. Black-Hispanic and Other racial/ethnic identities were associated with increased retention (OR = 4.84, 95%CI: 1.16-25.79, p ≤ 0.05 and OR = 7.24, 95%CI: 1.54-54.05, p ≤ 0.05, respectively) when compared to Non-Hispanic White persons. The interaction between depressive symptoms and Alcohol Use Disorder Identification Test (AUDIT, a test that assesses alcohol use disorder) score was significantly and negatively associated with retention in HIV care (OR = 0.14, 95%CI: 0.01-1.11, p ≤ 0.10). The interaction between age and male gender was also negatively associated with retention (OR = 0.95, 95%CI: 0.88-1.01, p ≤ 0.10), and the interaction between male gender and depression was positively associated with retention (OR = 7.17, 95%CI: 0.84-98.49, p ≤ 0.10). In conclusion, multiple races/ethnicities, specifically Non-Hispanic Black, Black-Hispanic, and Other racial/ethnic identification, were associated with increased odds of retention. Multiple interactions, specifically depressive symptoms * alcohol use disorder and male gender * age, were negatively associated with retention. The male gender * depression interaction was positively associated with retention in HIV care.

Ending the HIV Epidemic: Contributions Resulting From Syphilis Partner Services.

There is a high level of coinfection with human immunodeficiency virus (HIV) among persons diagnosed with syphilis in the United States. Public health workers at state and local health departments help inform exposed partners to sexually transmitted disease (STD)/HIV infections to facilitate early testing and treatment (partner services). The federal initiative, Ending the HIV Epidemic (EHE), identifies 4 key strategies: diagnose, treat, prevent, and respond. This study describes the contributions of syphilis partner services to the EHE strategies in a county prioritized by the EHE plan. A retrospective record review of reported early syphilis cases (less than 1 year's duration) between 2016 and 2018 in the Indianapolis area was conducted to determine the extent of new HIV diagnoses, retention in HIV care, and other evidence-based HIV prevention interventions occurring after provision of syphilis partner services. A total of 752 partners to early syphilis were attempted to be notified of exposure. There were 1,457 case patients and partners that received STD/HIV prevention counseling; 400 partners received STD treatment, 352 partners learned their HIV status, and 22 received new HIV diagnoses, with 68% retained in medical care and 60% virally suppressed. Two thirds of partner services were completed within 21 days. New HIV positivity among partners to HIV-negative syphilis case patients was 3.5% and 14% among HIV-positive syphilis case patients. Partner services for syphilis was an effective method of addressing the EHE strategies, resulting in persons at risk tested, STD treatment provided, behavioral prevention counseling provided, and new HIV cases identified, leading to retention in medical care and viral suppression.

Increased repeat syphilis among HIV-infected patients: A nationwide population-based cohort study in Taiwan.

Among human immunodeficiency virus (HIV)–infected individuals, syphilis is an important sexually transmitted infection (STI), and repeat infections are common. Identifying risk factors for delineating the trends in repeat syphilis are essential for STI and HIV prevention.This study is to investigate the dynamic of the syphilis epidemic among HIV-infected patients and to identify the risk factors associated with repeat syphilis.A population-based cohort design was used to analyze claim data between January 2000 and December 2010 using the Taiwan National Health Insurance Research Database. The Poisson regression test was used to identify risk factors for repeat syphilis.Of 13,239 HIV-infected patients, annual syphilis screen tests have been performed in 4,907 (37.1%) of these patients. Syphilis has been diagnosed in 956 (19.5%) patients, and 524 (10.7%) had repeat syphilis. The annual trend in repeat syphilis showed a significant increase in the study period (β = 0.23, P < .001). Younger age (adjusted incidence rate ratio [aIRR] 1.43; 95% CI 1.11–1.86), male gender (aIRR 11.14, 95% CI 4.16–29.79), a history of STIs (aIRR 1.39, 95% CI 1.21–1.59) were independently associated with repeat syphilis. The retention in HIV care and adherence to antiretroviral therapy ≥85% ([aIRR] 0.77, 95% CI 0.61–0.98; P < .001) were associated with a reduced risk of repeat syphilis.The incidence of repeat syphilis increased during 11 years of follow-up. The screening of syphilis for early diagnosis and retention in HIV care with medication adherence should be encouraged to minimize the risk of repeat syphilis in the targeted population.

Characterizing the Human Immunodeficiency Virus Care Continuum Among Transgender Women and Cisgender Women and Men in Clinical Care: A Retrospective Time-series Analysis.

Prior studies suggest that transgender women (TW) with human immunodeficiency virus (HIV) are less likely to be virally suppressed than cisgender women (CW) and cisgender men (CM). However, prior data are limited by small sample sizes and cross-sectional designs. We sought to characterize the HIV care continuum comparing TW to CW and CM in the United States and Canada. We analyzed annual HIV care continuum outcomes by gender status from January 2001 through December 2015 among adults (aged ≥18 years) in 15 clinical cohorts. Outcomes were retention in care and viral suppression. The study population included TW (n = 396), CW (n = 14 094), and CM (n = 101 667). TW had lower proportions retained in care than CW and CM (P < .01). Estimates of retention in care were consistently lower in TW, with little change over time within each group. TW and CW had similar proportions virally suppressed over time (TW, 36% in 2001 and 80% in 2015; CW, 35% in 2001 and 83% in 2015) and were lower than CM (41% in 2001 and 87% in 2015). These differences did not reach statistical significance after adjusting for age, race, HIV risk group, and cohort. TW experience challenges with retention in HIV care. However, TW who are engaged in care achieve viral suppression that is comparable to that of CW and CM of similar age, race, and HIV risk group. Further research is needed to understand care engagement disparities.

REACH: a mixed-methods study to investigate the measurement, prediction and improvement of retention and engagement in outpatient HIV care

BackgroundAntiretroviral therapy (ART) benefits individuals living with human immunodeficiency virus (HIV) through reduced morbidity and mortality, and brings public health gains through a reduction in HIV transmission. People living with human immunodeficiency virus (PLWH) need to know their HIV status and engage in HIV care in order for these individual and public health benefits to be realised.ObjectiveTo explore, describe and understand HIV outpatient attendance in PLWH, in order to develop cost-effective interventions to optimise engagement in care.DesignA mixed-methods study incorporating secondary analysis of data from the UK Collaborative HIV Cohort (UK CHIC) study and primary data collection.MethodsPhase 1 – an engagement-in-care (EIC) algorithm was developed to categorise patients as in care or out of care for each month of follow-up. The algorithm was used in group-based trajectory analysis to examine patterns of attendance over time and of the association between the proportion of months in care before ART initiation and post-ART mortality and laboratory test costs. Phase 2 – a cross-sectional survey was conducted among patients attending seven London HIV clinics. Regular attenders (all appointments attended in past year), irregular attenders (one or more appointments missed in past year) and non-attenders (recent absence of ≥ 1 year) were recruited. A ‘retention risk tool’ was developed to identify those at risk of disengaging from care. Individual in-depth interviews and focus groups were conducted with PLWH. Phase 3 – key informant interviews were conducted with HIV service providers. Interventions were developed from the findings of phases 2 and 3.ResultsPlots from group-based trajectory analysis indicated that four trajectories best fitted the data. Higher EIC is associated with reduced mortality but the association between EIC before starting ART, and post-ART mortality [relative hazard (RH) per 10% increase in EIC 0.29, 95% confidence interval (CI) 0.18 to 0.47] was attenuated after adjustment for fixed covariates and post-ART cluster of differentiation 4 counts and viral loads (RH 0.74, 95% CI 0.42 to 1.30). Small differences were found in pre-ART EIC and the costs of post-ART lab tests. The final model for the retention risk tool included age at diagnosis, having children, recreational drug use, drug/alcohol dependency, insufficient money for basic needs and use of public transport to get to the clinic. Quantitative and qualitative data showed that a range of psychological, social and economic issues were associated with disengagement from care. The negative impact of stigma on attendance was highlighted. Interventions were proposed that support a holistic approach to care including peer support, address stigma by holding clinics in alternative locations and involve training staff to encourage attendance.ConclusionsThe study shows the adverse health impacts of disengaging from HIV care and demonstrates the importance of the wider health and social context in managing HIV effectively. Although phase 1 analysis was based on UK data, phases 2 and 3 were limited to London. The interventions proposed are supported by the data but their cost-effectiveness requires testing. Future research is needed to evaluate the interventions, to validate our retention risk tool across populations and settings, and to fully analyse the economic costs of disengaging from HIV care.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The UK CHIC study is funded by the Medical Research Council UK (grant numbers G0000199, G0600337, G0900274 and M004236).

Disparities in Consistent Retention in HIV Care--11 States and the District of Columbia, 2011-2013.

In 2013, 45% of new human immunodeficiency virus (HIV) infection diagnoses occurred in non-Hispanic blacks/African Americans (blacks) (1), who represent 12% of the U.S. * Antiretroviral therapy (ART) improves clinical outcomes and reduces transmission of HIV, which causes acquired immunodeficiency syndrome (AIDS) (2). Racial/ethnic disparities in HIV care limit access to ART, perpetuating disparities in survival and reduced HIV transmission. National HIV Surveillance System (NHSS) data are used to monitor progress toward reaching the National HIV/AIDS Strategy goals to improve care among persons living with HIV and to reduce HIV-related disparities.(†) CDC used NHSS data to describe retention in HIV care over 3 years and describe differences by race/ethnicity. Among persons with HIV infection diagnosed in 2010 who were alive in December 2013, 38% of blacks with HIV infection were consistently retained in care during 2011-2013, compared with 50% of Hispanics/Latinos (Hispanics) and 49% of non-Hispanic whites (whites). Differences in consistent retention in care by race/ethnicity persisted when groups were stratified by sex or transmission category. Among blacks, 35% of males were consistently retained in care compared with 44% of females. Differences in HIV care retention by race/ethnicity were established during the first year after diagnosis. Efforts to establish early HIV care among blacks are needed to mitigate racial/ethnic disparities in HIV outcomes over time.

2014 Federal Recommendations for Human Immunodeficiency Virus (HIV) Prevention With Persons With HIV: A New Road Map for High Impact Prevention

Background. In 2014, Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration, National Institutes of Health (NIH), and 5 nongovernmental organizations issued Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States. This evidence-based guideline for clinical providers, nonclinical providers, and health departments updates 2003 federal guidance for clinicians to incorporate HIV prevention into HIV medical care. Methods. The new guideline compiles the latest federal recommendations on biomedical, behavioral, and structural interventions to reduce HIV transmission from persons with HIV. Recommendations address linkage to and retention in HIV care; antiretroviral treatment (ART) and adherence; behavioral risk-reduction strategies; partner services; sexually transmitted disease (STD) services; and reproductive and pregnancy services. Results. Important new recommendations for clinicians include: inform all persons with HIV about the benefits of early ART to improve health and to reduce transmission; help with appointment scheduling, insurance enrollment, and other proactive linkage assistance; offer ART to all patients regardless of CD4 count; support care retention and long-term ART adherence (through patient monitoring, simplified regimens, and advice on managing ART dosing, side effects, and costs); offer evidence-based risk-reduction interventions; routinely screen genital and extra-genital sites for STDs that facilitate HIV transmission; offer reproductive health counseling, family planning, special conception methods, and pregnancy services that reduce sexual and perinatal HIV transmission; and screen partners for HIV, STD, and viral hepatitis. The guideline stresses use of multidisciplinary teams and collaboration of clinical, nonclinical, and public health sectors to improve quality of prevention and care services. Conclusion. Providers who implement these recommendations can advance goals of the National HIV/AIDS Strategy: prevent new HIV infections and reduce HIV-related illness and health disparities. Guideline sponsors are promoting guideline awareness among health professionals and persons with HIV, training, decision-support tools, and expanded access to services. Ongoing evaluations will assess the impact of recommended interventions on delivery of HIV services. Disclosures. All authors: No reported disclosures.

The effects of a pharmacist-delivered patient education programme on retention in human immunodeficiency virus care: a pilot study

Objectives To determine the potential impact of a brief human immunodeficiency virus (HIV) educational intervention delivered by a pharmacist during a provider visit on patient knowledge and retention in HIV care. Methods This study was performed in an HIV clinic at a large medical centre in Philadelphia. Patients had been attending the clinic for at least 1 year and were receiving antiretroviral therapy (ART). Participants were randomized to standard care (SC) or SC plus a 10-min educational presentation (EP). Participants were followed over their next two scheduled visits. All participants received a baseline and end of study knowledge assessment. EP patients also received a knowledge assessment immediately following the presentation. A participant answering all assessment questions correctly was considered to have perfect knowledge. Participant retention in care was measured by attendance at provider visits, completion of laboratory work and adherence to ART. Key findings Forty-five patients were enrolled; 24 received the EP. At baseline, two-thirds of participants (31/45) had nonperfect knowledge and most had nonperfect retention (31/45). Among those with nonperfect baseline knowledge, most had nonperfect retention (23/31, P = 0.042). Following education, perfect knowledge improved in the intervention group (5/24 at baseline versus 16/24 post-EP, P = 0.002) and maintained through study completion. EP patients were more likely to have perfect retention compared with SC patients at study visit two (17/24 versus 5/21, P = 0.002) and study completion (16/24 versus 5/21, P = 0.026). Conclusion Brief education delivered by a pharmacist may improve patient knowledge and retention in HIV care.

Beyond core indicators of retention in HIV care: missed clinic visits are independently associated with all-cause mortality.

The continuum of care is at the forefront of the domestic human immunodeficiency virus (HIV) agenda, with the Institute of Medicine (IOM) and Department of Health and Human Services (DHHS) recently releasing clinical core indicators. Core indicators for retention in care are calculated based on attended HIV care clinic visits. Beyond these retention core indicators, we evaluated the additional prognostic value of missed clinic visits for all-cause mortality. We conducted a multisite cohort study of 3672 antiretroviral-naive patients initiating antiretroviral therapy (ART) during 2000-2010. Retention in care was measured by the IOM and DHHS core indicators (2 attended visits at defined intervals per 12-month period), and also as a count of missed primary HIV care visits (no show) during a 24-month measurement period following ART initiation. All-cause mortality was ascertained by query of the Social Security Death Index and/or National Death Index, with adjusted survival analyses starting at 24 months after ART initiation. Among participants, 64% and 59% met the IOM and DHHS retention core indicators, respectively, at 24 months. Subsequently, 332 patients died during 16 102 person-years of follow-up. Failure to achieve the IOM and DHHS indicators through 24 months following ART initiation increased mortality (hazard ratio [HR] = 2.23; 95% confidence interval [CI], 1.79-2.80 and HR = 2.36; 95% CI, 1.89-2.96, respectively). Among patients classified as retained by the IOM or DHHS clinical core indicators, >2 missed visits further increased mortality risk (HR = 3.61; 95% CI, 2.35-5.55 and HR = 3.62; 95% CI, 2.30-5.68, respectively). Beyond HIV retention core indicators, missed clinic visits were independently associated with all-cause mortality. Caution is warranted in relying solely upon retention in care core indicators for policy, clinical, and programmatic purposes.

Voucher Incentives Improve Linkage to and Retention in Care Among HIV-Infected Drug Users in Chennai, India

Drug users (DUs), a population that accounts for some of the fastest-growing human immunodeficiency virus (HIV) epidemics globally, lag behind other populations with regard to HIV-related outcomes. We evaluated the role of voucher incentives on linkage and retention in care among DUs in India. In this randomized clinical trial, 120 DUs who were aged ≥18 years, HIV-infected, antiretroviral therapy (ART) naive, and ART eligible and who reported drug use in the prior month were randomized to incentive (INC) or control (CTL) conditions for 12 months. Participants randomized to the INC arm received incentives (redeemable for food/household goods) ranging in value from USD4 to USD8 for achieving prespecified targets (eg, ART initiation, visits to ART center). Subjects in the CTL group could win vouchers in prize-bowl drawings, but HIV care behaviors were not incentivized. The primary endpoint was time to ART initiation. Sixty participants each were randomized to the INC and CTL arms between December 2009 and September 2010. Participants in the INC arm were more likely to visit the government ART center (49 vs 33; P = .002); 27 participants in the INC and 16 participants in the CTL arm initiated ART (P = .04; hazard ratio for ART = 2.33 [95% confidence interval, 1.15-4.73]). Participants in the INC arm also had significantly more visits to the ART center (median number of visits, 8 vs 3.5; P = .005). However, no difference in viral suppression was observed. Modest voucher incentives improved linkage to and retention in HIV care, but did not significantly impact viral suppression among DUs in India, a disenfranchised and difficult-to-treat population. NCT01031745.