The HIV Care Cascade Measured Over Time and by Age, Sex, and Race in a Large National Integrated Care System

Abstract

HIV care cascades can evaluate programmatic success over time. However, methodologies for estimating cascade stages vary, and few have evaluated differences by demographic subgroups. We examined cascade performance over time and by age, sex, and race/ethnicity in Kaiser Permanente, providing HIV care in eight US states and Washington, DC. We created cascades for HIV+ members' age ≥13 for 2010-2012. We measured "linkage" (a visit/CD4 within 90 days of being diagnosed for new patients; ≥1 medical visit/year if established); "retention" (≥2 medical visits ≥60 days apart); filled ART (filled ≥3 months of combination ART); and viral suppression (HIV RNA <200 copies/mL last measured in year). The cascades were stratified by calendar year, sex, age, and race/ethnicity. We found men had statistically (p < 0.05) higher percent linkage, filled ART, and viral suppression for 2010 and 2011 but not for 2012. Women had significantly greater retention for all years. Annually, older age was associated (p < 0.05) with retention, filled ART, and viral suppression but not linkage. Latinos had greater (p < 0.05) retention than whites or blacks in all years, with similar retention comparing blacks and whites. Filled ART and viral suppression was increased (p < 0.05) for whites compared with all racial/ethnic groups in all years. Cascade methodology requiring success at upstream stages before measuring success at later stages (i.e., "dependent" methodology) underreported performance by up to 20% compared with evaluating each stage separately ("independent"). Thus, care results improved over time, but significant differences exist by patient demographics. Specifically, retention efforts should be targeted toward younger patients and blacks; women, blacks, and Latinos require greater ART prescribing.

Black–White and Country of Birth Disparities in Retention in HIV Care and Viral Suppression among Latinos with HIV in Florida, 2015

“…Males born in Honduras were also at increased risk compared with females born in Honduras, for retention in care only (aOR 2.22, 95% CI 1.31–3.78). Our finding of lower retention in care and viral suppression among males is consistent with the literature [36,42,43,44,45], although a few studies have found males to be more likely to be virally suppressed [44], or have found no differences by gender [35]. It is possible that males born in these countries traveled to the U.S. alone, either as migrant workers, or to work permanently in the U.S. to provide for a family member in their home country.…”

Trends in Racial and Ethnic Disparities in Antiretroviral Therapy Prescription and Viral Suppression in the United States, 2009–2013

“…While many studies have found significant black-white disparities in ART use [2, 4, 6, 21–23], some have found no racial disparities when examining specific populations, such as clinic attendees or those newly eligible for ART [3, 5, 24]. Regarding Hispanic-white disparities, many [2, 3, 6, 21, 22, 25], though not all [4, 23, 24], found no significant Hispanic-white difference in ART use. Across varying populations, most studies find black-white disparities in viral suppression [4–7, 21, 25–28].…”

“…Regarding Hispanic-white disparities, many [2, 3, 6, 21, 22, 25], though not all [4, 23, 24], found no significant Hispanic-white difference in ART use. Across varying populations, most studies find black-white disparities in viral suppression [4–7, 21, 25–28]. Only one recent analysis found no black-white differences in time to viral suppression among a large cohort of persons newly eligible for ART [3].…”

“…Only one recent analysis found no black-white differences in time to viral suppression among a large cohort of persons newly eligible for ART [3]. Among recent studies, all but one [4] found no differences between Hispanics and whites in viral suppression [3, 6, 7, 21, 25, 26]. Adjudicating between these disparate findings can be challenging due to different study populations, measurement of outcomes, and adjustment factors.…”

Cohort profile: seek, test, treat and retain United States criminal justice cohort

“…The STTR treatment cascade provides a framework for research aimed at improving the delivery of services, care and outcomes of PLWH. There is substantial dropout across each cascade step, and it has been estimated that only ~19% of PLWH in the United States (US) are aware of their HIV diagnosis, engaged in care, on ART, and have an undetectable viral load (VL) [1], although more recent numbers suggest improvements [4, 5]. The development of effective approaches to increase HIV diagnoses and engage PLWH in subsequent steps of the treatment cascade could lead to earlier and sustained ART treatment resulting in viral suppression.…”