Majority of Americans with HIV Not Receiving Regular Care

Less than half of people living with HIV in the U.S. are receiving recommended regular medical care including antiretroviral treatment, according to a study described in the January 19, 2012, advance online edition of the Journal of Acquired Immune Deficiency Syndromes.

Getting tested for HIV and linked to appropriate care is a key step in managing the disease, but maintaining ongoing care and monitoring disease progression and response to treatment over time is also crucial.

H. Irene Hall from the Centers for Disease Control and Prevention (CDC) and colleagues looked at HIV positive people's retention in care, which has been less extensively studied than testing and treatment initiation.

The researchers analyzed data from more than 100,000 adults (over age 12) living with HIV at the end of 2009 in 13 areas that reported relevant HIV-related tests as part of a national HIV surveillance program.

The study authors looked at associations between ongoing care and demographic, clinical, and risk characteristics, as well as the percentage of people established in care within 12 months after an HIV diagnosis in 2008. Retention in care was defined as having at least 2 CD4 T-cell measurements or viral load tests done at least 3 months apart during the previous year.

Results

• Among 100,375 people living with HIV, 45% had received at least 2 tests at least 3 months apart.
• 59% had a single care visit and 45% had 2 care visits.
• White patients were more likely to remain in care that blacks or Hispanics/Latinos (50%, 41%, and 40%, respectively).
• Heterosexual women (50%) and men who have sex with men (48%) were most likely to remain in care, followed by heterosexual men (45%), and injection drug using women and men (43% and 37%, respectively).
• About 64% of study participants established care within 12 months after HIV diagnosis.
• Viral suppression on the most recent test was high among people in care (> 70%), but only about half had consistently undetectable viral load throughout the 2-year study period.
• People with late-stage disease or an AIDS diagnosis were more likely to remain in care, but a substantial proportion of advanced patients did not receive consistent care.

Based on these findings, the study authors concluded, "Less than half of persons living with HIV had laboratory evidence of ongoing clinical care and only two-thirds established care after diagnosis."

"Further assessments determining modifiable barriers to accessing care could assist with achieving public health targets," they suggested.

The National HIV/AIDS Strategy has set the goal of increasing the proportion of people in continuous care from 73% to 80%, but this study "suggest that overall the baseline of care for [people living with HIV] is below that for Ryan White Program clients, requiring substantial effort to reach the benchmark of 80%."

"While mental health or substance abuse problems among [people living with HIV] may indicate greater need for health services, these factors may also contribute to missed care visits, as do stigma and some social determinants of health such as lack of health insurance, lower education, poverty, unemployment, homelessness, and lack transportation," they continued. "Effective interventions for linkage and retention in care must address these barriers to accessing care."

While assessing whether HIV positive people attend clinic visits and receive appropriate tests provides valuable information, "quality care should be reflected in outcome measures such as viral suppression," the researchers wrote. This not only minimizes disease progression among infected individuals, but has taken on added importance given recent evidence that effective antiretroviral therapy can also dramatically reduce HIV transmission.

Investigator affiliations: Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA; ICF International, Atlanta, GA.

2/10/12

Reference

HI Hall, KM Gray, T Tang, J Mermin, et al. Retention in Care of Adults and Adolescents living with HIV in 13 U.S. Areas. Journal of Acquired Immune Deficiency Syndromes. January 19, 2012 (Epub ahead of print)