The Continuum of HIV Care in a Veterans' Affairs Clinic

Abstract

The cascade of HIV care in the United States has become a focus for interventions aimed at improving the success of HIV treatment. The Atlanta VA Medical Center (AVAMC) Infectious Disease Clinic (IDC) is an urban clinic that provides care for over 1,400 people living with HIV (PLHIV) annually. Using data from the HIV Atlanta VA Cohort Study (HAVACS), we modeled the continuum of care in the AVAMC IDC and explored similarities and differences with national models. We conducted a cross-sectional analysis of 1,474 individuals receiving care in the AVAMC IDC. We estimated total PLHIV and defined several categories within the spectrum of HIV care. We then developed the continuum of care using two methodologies. The first required each stage to be a dependent subset of the immediate upstream stage. The second allowed each stage to be independent of upstream stages. Dependent stage categorization estimated that 95.3% of individuals were diagnosed with HIV, 89.8% of individuals were linked to care, 73.0% of individuals were retained in care, 65.9% of individuals were eligible for antiretroviral treatment (ART), 62.8% were prescribed ART, and 52.4% had a suppressed viral load (VL). Independent stage categorization estimated that 83.9% of individuals were prescribed ART and 61.5% had a suppressed VL. Our analyses showed that the AVAMC IDC estimates were significantly better than national estimates at every stage. This may reflect the benefits of a universal healthcare system. We propose the use of independent stages for the continuum as this more accurately represents healthcare utilization.

Engagement in Outpatient Care for Persons Living with HIV in the United States

“…4,8 It has also been demonstrated that clinics with highly integrated healthcare systems (such as the VA system) can attain even greater engagement at each of the stages of care, when compared to these national estimates. 14 In contrast, our study revealed that engagement in care was lower in comparison to previous studies. We found that only 72% of those receiving HIV-related medical care were prescribed ARV, a finding that is similar to estimates modeled by Gardner et al 6 Although this finding is likely attributed to our broader scope of outpatient facilities, it may also be a reflection of low ARV treatment utilization in nonspecialty clinics.…”

Addressing the Challenges of the HIV Continuum of Care in High-Prevalence Cities in the United States

“…21 Similarly, the VA has reported high rates of virologic suppression with the reduction of institutional barriers to care and treatment. 22 An analysis of the Ryan White Program in 2011 also suggested high rates of virologic suppression among patients retained in care 23 but this study also reminds us that retention in care is challenging, particularly for individuals aged 13 – 34 years.…”

Conceptualizing Care Continua: Lessons from HIV, Hepatitis C Virus, Tuberculosis and Implications for the Development of Improved Care and Prevention Continua

“…In most continuum models, the presumption is that those represented in the numerator of one step of necessity were in the numerator of the prior step. Yet, Magnal et al identified individuals in an HIV continuum analysis who did in fact meet definitions for having been prescribed ART or even being virologically suppressed but did not meet definitions for having been retained in care (24). In their comparison, categorization of continuum stages as dependent subsets of prior stages led to underestimates of those prescribed ART or achieving viral suppression.…”