In the Journals

Continuous HIV care critical to viral suppression, long-term outcomes

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January 5, 2016

Most patients with HIV treated at an urban clinic received continuous care and had high viral suppression for 12 months; however, less than half of those patients remained in care and maintained viral suppression for 36 months, according to recent findings.

Retention in care may be the most important step along the care continuum as missed clinic visits are a powerful predictor of mortality and the majority of HIV transmissions result from patients who are diagnosed but not retained,” Carlos del Rio, MD, professor of medicine at Emory University School of Medicine and chair of the HIV Medicine Association (HIVMA); Wendy S. Armstrong, MD, FIDSA, FACP, medical director of the Ponce de Leon Center in Atlanta and vice chair of HIVMA; and colleagues wrote. “The current analysis demonstrates the significant impact that time has on attrition for continuous retention and viral suppression.”

Carlos del-Rio

Carlos del Rio

Wendy S. Armstrong, MD, FIDSA, FACP

Wendy Armstrong

The researchers retrospectively evaluated 655 patients with HIV treated at the Infectious Disease Program of the Grady Health System, Atlanta, in 2010. Most were uninsured (78%), male (77%), black (83%), and more than half (54%) were men who have sex with men. The investigators obtained data on CD4 + T-lymphocyte and HIV RNA values for patients who were neither retained nor virally suppressed from the Georgia Department of Public Health Surveillance’s Enhanced HIV/AIDS Surveillance database. The primary outcomes were continuous care retention (defined as attending two provider visits at least 90 days apart within 1 year) and viral suppression (VS) at 12, 24 and 36 months.

Continuous care retention and VS were significantly lower at 24 and 36 months than at 12 months (P < .0001). At 12 months post-enrollment, 84% of patients were receiving care, and 64% were virally suppressed. By 24 months, the continuous retention rate was 60%, and VS was 48%. At 36 months, the continuous retention rate fell to 49%, and the VS rate was 39%.

A multivariate analysis adjusted for factors including age, race, gender and HIV transmission risk showed retention in care was the only predictor of viral suppression at 36 months (adjusted prevalence ratio = 3.12; 95% CI, 2.4-4.07).

Further analysis, however, indicated the interaction between race and time significantly influenced retention and VS for 36 months (adjusted OR = 0.75; 95% CI, 0.59-0.95). While the 12-month retention rates were similar for blacks (84%) and non-blacks (85%), fewer blacks were retained in care vs. non-blacks at 36 months (46% vs. 63%).

“Traditionally, retention and VS have been evaluated in cross-sectional analyses, but in order to understand continuous retention and maintenance of viral suppression, these outcomes should be evaluated longitudinally,” the researchers wrote. “Continuous retention in care and persistence of VS are critically important measures to evaluate long term success in HIV care delivery and may uncover disparities not readily apparent in cross-sectional analyses.” – by Jen Byrne

Disclosure: The researchers report no relevant financial disclosures.