The Impact of “Churn” on Plasma HIV Burden Within a Population Under Care

Abstract

Background Cross-sectional reporting of viral suppression rates within a population underestimates the community viral load (VL) burden. Longitudinal approaches, while addressing cumulative effects, may still underestimate viral burden if “churn” (movement in and out of care) is not incorporated. We examined the impact of churn on the cumulative community HIV viral burden. Methods All HIV+ patients followed in 2016–2017 at the Southern Alberta Clinic (Calgary, Canada) were categorized as follows: (1) in continuous care, (2) newly diagnosed, (3) diagnosed elsewhere transferring care, (4) returning to care, (5) lost-to-follow-up, (6) moved care elsewhere, or (7) died. Patient days were classified by VL as suppressed (≤200copies/ml), unsuppressed (>200 copies/ml), and transmittable (>1500 copies/ml). Results Of 1934 patients, 78.4% had suppressed VL; 21.4% had ≥1 unsuppressed VL, and 18.7% ≥1 transmittable VL. Of 1 276 507 total patient days in care, 92.1% were spent suppressed, 7.9% unsuppressed (101 459 days), and 6.4% (81 847 days) transmittable. 88.7% of category 1 patients had suppressed VL, 11.3% ≥1 unsuppressed VL, and 8.9% ever a transmittable VL. Of category 2 patients, 90% became suppressed on treatment (mean – 62 days). 38.5% of category 3 patients presented with a transmittable VL. Category 4 and 5 patients combined had high rates of unsuppressed (54.5%) and transmittable (51.2%) VL and, while representing only 6.2% of all patients, they accounted for 37.1% of unsuppressed and 41.5% of all transmittable days. Conclusion Focus on VL of patients continuously in care misses those with unsuppressed and transmittable VL in a community. Patients moving in and out of care pose an underappreciated risk for HIV transmissions.

Patterns and Predictors of Incident Return to HIV Care Among Traced, Disengaged Patients in Zambia: Analysis of a Prospective Cohort

“…The finding that previous care gaps predict incident re-engagement adds additional urgency to the need to conceptualize care engagement as a dynamic process 4 , 5 , 10 , 14 and the need for effective interventions to support continuity of care. Although complex factors are likely associated with both having a previous care gap and a patient's subsequent re-engagement, our findings suggest that investment in supporting patient return after one care gap may pay future re-engagement dividends.…”

“… 4 , 6 These interruptions put patients at risk of poor health outcomes 7 – 9 and the onward transmission of HIV. 10 – 12 They threaten achievement of the global 95-95-95 targets. 13 However, return to care is a positive patient behavior that has the potential to improve treatment outcomes.…”

The expansion of a patient tracer programme to identify and return patients loss to follow up at a large HIV clinic in Trinidad

“…Patients who miss their clinic appointments often have unsuppressed and transmissible viral loads and are generally not included in the ascertainment of the HIV Treatment Cascade of the HIV clinic [ 24 ]. Of the 1869 patients returned to care, 1278 (68.6%) were virally unsuppressed, 1727 (92.4%) were re-initiated/started on ART, and after 12 months, 1341 (77.6%) of these were retained in care and 1154 (86.1%) of these were virally suppressed.…”

“…Of the 1869 patients returned to care, 1278 (68.6%) were virally unsuppressed, 1727 (92.4%) were re-initiated/started on ART, and after 12 months, 1341 (77.6%) of these were retained in care and 1154 (86.1%) of these were virally suppressed. In the study by Krentz et al [ 24 ], it was found that patients who missed their clinic visits and returned to care had high rates of unsuppressed viral loads (54.5%) especially if the patients were out of care for more than a year [ 24 ]. Our study showed that patients who were retained in care after 12 months were more likely to be virally suppressed (OR, 2.48; 95% CI 1.90–3.24) compared to those with suboptimal retention in care and multiple studies have demonstrated this [ 7 , 25 , 26 ].…”

“…One of the limitations of the study is the difficulty in tracking patients’ VL over time, given the cross-sectional approach used. This approach may underestimate the VL burden given the changing nature of VL suppression over time [ 24 ]. Another limitation is that some patients may have returned to care after the study concluded or may have transferred to other clinics closer to their homes to reduce transportation costs [ 31 ], these factors make it challenging to effectively track patient retention in care in care at any given point in time.…”