March 29, 2017
In a 17,000-person U.S./Canadian analysis, men, blacks, and drug injectors had a higher risk of discontinuous HIV care even after statistical adjustment for access to care, the competing risk of death and other risk factors. NA-ACCORD investigators suggest these groups need "improved outreach to prevent disruption of HIV care."
Previous research links inconsistent retention in HIV care to poor outcomes, including shorter survival. Because prior work found worse HIV care retention among men, blacks and drug injectors, the National HIV/AIDS Strategy aims to diminish these disparities. But previous research in this field remains limited because the studies sometimes lacked information on antiretroviral use or were performed in the context of clinical trials, at single centers or in resource-limited settings.
To get a better understanding of factors affecting discontinuity in HIV care, NA-ACCORD investigators analyzed data from this multicohort U.S./Canadian collaboration. The analysis involved adults who had one or more primary care visits and began antiretroviral therapy (ART) between January 2000 and December 2010. To focus on people likely to have equivalent access to care, the investigators also limited the study to individuals who had one or more CD4 counts after ART began and before death or the first discontinuity in care. They defined discontinuity as failure to keep two or more HIV care visits separated by at least 90 days in a calendar year. To assess risk factors for discontinuity, the NA-ACCORD team used regression analysis that considered the competing risk of death and other variables.
The analysis involved 17,171 adults with a median age of 47.1 years, 16% of them women, 44% black and 19% with drug injection as their HIV acquisition risk. During a median follow-up of 3.97 years, 49% of cohort members experienced discontinuity in care, 9% died before experiencing discontinuity and 42% had no discontinuity in care. After 10 years of follow-up, the adjusted cumulative incidence of discontinuity was 67%, while incidence of death before discontinuity was 9%.
In an analysis adjusted for demographics, baseline CD4 count and CD4 nadir after ART initiation, two factors were independently associated with a lower hazard of discontinuity in care: older age (hazard ratio [HR] 0.61 per 10 years older, 95% confidence interval [CI] 0.59 to 0.62) and female sex (HR 0.84, 95% CI 0.79 to 0.89). Two variables were independently associated with a higher hazard of discontinuity: black versus nonblack race (HR 1.17, 95% CI 1.12 to 1.23) and drug injecting versus other HIV risks (HR 1.33, 95% CI 1.25 to 1.41).
After adjusting for drug injecting status, black race was not associated with discontinuity among women. Risk of death did not differ significantly between women and men, blacks and non-blacks or drug injectors and other HIV risk groups. Additional analysis determined that reentry to care after first discontinuity did not differ by sex, race or drug injecting status.
The researchers believe their results can be generalized to the U.S. and Canadian HIV populations because the NA-ACCORD group is demographically representative of the national U.S. and Canadian HIV populations. "Beyond clinic-level interventions aimed at improving overall clinical retention," the researchers advise, "individual-level interventions such as enhanced medical case management, peer navigation, transportation subsidies, and mental health evaluation and treatment should be offered with greater vigilance and consistency to the identified vulnerable groups[.]"
Mark Mascolini writes about HIV infection.
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