Stephen A. Berry

Comparing Different Measures of Retention in Outpatient HIV Care

Objectives:The US National HIV/AIDS Strategy identifies retention in care as an important quality performance measure. There is no gold standard to measure retention in care. This study is the first to compare different measures of retention, using a large geographically diverse sample. Design:A prospective cohort of 17 425 HIV-infected adults enrolled in care at 12 US HIV clinics between 2001 and 2008. Methods:We compared three measures of retention for each patient: proportion of time not spent in a gap of more than 6 months between successive outpatient visits; proportion of 91-day quarters in which at least one visit occurred; proportion of years in which two or more visits separated by at least 90 days occurred. Associations among measures and effects of sociodemographic and clinical characteristics were examined. Results:The three measures of retention were moderately to strongly correlated. Averaging across patients, 71% of time in care was not spent in a gap more than 6 months; 73% of all quarters had at least one visit; and 75% of all years had at least two visits separated by at least 90 days. For all measures, retention was significantly higher for women, whites, older individuals, men who had sex with men (MSM)-related HIV transmission, and initial CD4 cell counts 50 cell/&mgr;l or less. Conclusions:This is one of the first studies to provide a national estimate of retention in HIV care in the US, which ranged from 71 to 75% using any of the accepted retention measures. Future studies should assess how well different measures predict clinical outcomes and establish acceptable target levels for retention.

TRENDS IN REASONS FOR HOSPITALIZATION IN A MULTISITE UNITED STATES COHORT OF PERSONS LIVING WITH HIV, 2001 - 2008

Introduction:Hospitalization rates for comorbid conditions among persons living with HIV in the current highly active antiretroviral therapy era are unknown. Methods:Hospitalization data from 2001 to 2008 were obtained on 11,645 adults receiving longitudinal HIV care at 4 geographically diverse US HIV clinics within the HIV Research Network. Modified clinical classification software from the Agency for Healthcare Research and Quality assigned primary ICD-9 codes into diagnostic categories. Analysis was performed with repeated measures negative binomial regression. Results:During 2001 to 2008, the rate of AIDS-defining illness (ADI) hospitalizations declined from 6.7 to 2.7 per 100 person-years, incidence rate ratio per year, 0.89 (0.87, 0.91). Among the other diagnostic categories with average rates >2 per 100 person-years, cardiovascular hospitalizations increased over time [1.07 (1.03, 1.11)], whereas non–AIDS-defining infection [0.98 (0.96, 1.00)], psychiatric [0.96 (0.93, 1.00)], and gastrointestinal/liver [0.96 (0.92, 1.00)] were slightly decreasing or stable. Although less frequent overall, renal and pulmonary admissions also increased over time in univariate and multivariate analyses. Of all diagnostic categories, ADI admissions had the longest mean length of stay, 10.5 days. Discussion:ADI hospitalizations have continued to decline in recent years but are still relatively frequent and potentially costly given long lengths of stay. Increases or stability in the rates of chronic end-organ disease admissions imply a need for broader medical knowledge among individual clinicians and/or teams who care for persons living with HIV and a need for long-term access to medications for these conditions.

Hospitalization Rates and Reasons Among HIV Elite Controllers and Persons With Medically Controlled HIV Infection

BACKGROUND Elite controllers spontaneously suppress human immunodeficiency virus (HIV) viremia but also demonstrate chronic inflammation that may increase risk of comorbid conditions. We compared hospitalization rates and causes among elite controllers to those of immunologically intact persons with medically controlled HIV. METHODS For adults in care at 11 sites from 2005 to 2011, person-years with CD4 T-cell counts ≥350 cells/mm(2) were categorized as medical control, elite control, low viremia, or high viremia. All-cause and diagnostic category-specific hospitalization rates were compared between groups using negative binomial regression. RESULTS We identified 149 elite controllers (0.4%) among 34 354 persons in care. Unadjusted hospitalization rates among the medical control, elite control, low-viremia, and high-viremia groups were 10.5, 23.3, 12.6, and 16.9 per 100 person-years, respectively. After adjustment for demographic and clinical factors, elite control was associated with higher rates of all-cause (adjusted incidence rate ratio, 1.77 [95% confidence interval, 1.21-2.60]), cardiovascular (3.19 [1.50-6.79]) and psychiatric (3.98 [1.54-10.28]) hospitalization than was medical control. Non-AIDS-defining infections were the most common reason for admission overall (24.1% of hospitalizations) but were rare among elite controllers (2.7%), in whom cardiovascular hospitalizations were most common (31.1%). CONCLUSIONS Elite controllers are hospitalized more frequently than persons with medically controlled HIV and cardiovascular hospitalizations are an important contributor.

The Epidemiologic and Economic Impact of Improving HIV Testing, Linkage, and Retention in Care in the United States

BACKGROUND Recent guidelines advocate early antiretroviral therapy (ART) to decrease human immunodeficiency virus (HIV) morbidity and prevent transmission, but suboptimal engagement in care may compromise impact. We sought to determine the economic and epidemiologic impact of incomplete engagement in HIV care in the United States. METHODS We constructed a dynamic transmission model of HIV among US adults (aged 15-65 years) and conducted a cost-effectiveness analysis of improvements along the HIV care continuum : We evaluated enhanced HIV testing (annual for high-risk groups), increased 3-month linkage to care (to 90%), and improved retention (50% relative reduction in yearly disengagement and 50% increase in reengagement). Our primary outcomes were HIV incidence, mortality, costs and quality-adjusted life-years (QALYs). RESULTS Despite early ART initiation, a projected 1.39 million (95% uncertainty range [UR], 0.91-2.2 million) new HIV infections will occur at a (discounted) cost of

Elite Controllers are Hospitalized More Often than Persons with Medically Controlled HIV

256 billion (

Retention in care is more strongly associated with viral suppression in HIV-infected patients with lower versus higher CD4 counts.

199-298 billion) over 2 decades at existing levels of HIV care engagement. Enhanced testing with increased linkage has modest epidemiologic benefits and could reduce incident HIV infections by 21% (95% UR, 13%-26%) at a cost of

The Cost-Effectiveness of Rotavirus Vaccination in Malawi

65 700 per QALY gained (

The HIV Care Continuum: Changes over Time in Retention in Care and Viral Suppression

44 500-111 000). By contrast, comprehensive improvements that couples enhanced testing and linkage with improved retention would reduce HIV incidence by 54% (95% UR, 37%-68%) and mortality rate by 64% (46%-78%), at a cost-effectiveness ratio of

Health Insurance Coverage for Persons in HIV Care, 2006–2012

45 300 per QALY gained (

Impact of hepatitis coinfection on hospitalization rates and causes in a multicenter cohort of persons living with HIV.

27 800-72 300). CONCLUSIONS Failure to improve engagement in HIV care in the United States leads to excess infections, treatment costs, and deaths. Interventions that improve not just HIV screening but also retention in care are needed to optimize epidemiologic impact and cost-effectiveness.