Geographic Variations in Retention in Care among HIV-Infected Adults in the United States

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.

Effect of Patient Navigation With or Without Financial Incentives on Viral Suppression Among Hospitalized Patients With HIV Infection and Substance Use

“…This is consistent with studies that have shown demographic and geographic variation in HIV clinical outcomes. 33,37,38 …”

Reducing rates of preventable HIV/AIDS-associated mortality among people living with HIV who inject drugs

“…For example, research has shown that physicians often defer ART initiation for some PWID because of concerns of a so-called unstable lifestyle and competing priorities that could lead to noncompliance, and potentially the emergence and transmission of drug-resistant HIV [38]. Such concerns have subsequently contributed to lower levels of access to treatment among HIV-positive PWID [42], thus contributing to higher mortality rates in this group.…”

How Do Social Capital and HIV/AIDS Outcomes Geographically Cluster and Which Sociocontextual Mechanisms Predict Differences Across Clusters?

“…Substantial geographical disparities in HIV care continuum indicators such as diagnosis, linkage, and treatment exists within the United States (US) [2, 3] . For instance, the average lifetime risk of HIV diagnosis for a US adult is 1% (i.e., 1/99), yet the risk is as high as 7.8 % (i.e., 1/13) for individuals in Washington D.C and as low as 0.14% (i.e., 1/670) for individuals in North Dakota [4] .…”