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Hospital Admission May Not Signal Poor Healthcare Engagement in DC HIV Group
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52nd ICAAC, September 9-12, 2012, San Francisco
Mark Mascolini
Contrary to the perception of at least some clinicians, hospital use by HIV-positive people did not indicate poor outpatient healthcare engagement in a largely poor, black group seen at two hospitals in Washington, DC [1]. Most of the 233 people in this 2009-2011 study had indicators of outpatient care, even though two thirds felt like an "outcast" because of their HIV infection and more than 85% avoided divulging their HIV status to others.
People without regular healthcare or a primary care clinician may get admitted to the hospital more than people with good outpatient care because they have no place to seek routine care. To determine nonmedical barriers to outpatient healthcare engagement, researchers at the VA Medical Center and George Washington University in Washington, DC conducted this study of medically stable HIV-positive adults admitted to one of the two hospitals from 2009 to 2012.
Each study participant was interviewed to assess psychosocial and economic barriers to healthcare engagement. The researchers defined HIV-associated hospital admissions as those due to opportunistic infections, infections attributable to immunodeficiency, HIV-related malignancies, and toxicities or complications of antiretroviral therapy.
The 233 study participants averaged 48.3 years in age (+/- 12.9), 189 (81%) were black, and 188 (81%) were men. When admitted to the hospital, 12 (5%) were living in a shelter and 66 (28%) had ever lived in a shelter. About one quarter (26%) were uninsured, and among people who had insurance, 44% used Medicaid. More than half of the study group (54.5%) had used cocaine, 19% had used heroin, and 12% had used methamphetamine. Sixty-four people (27.5%) had been incarcerated.
Several factors indicated that most study participants had outpatient care: 159 of 233 participants (68%) could identify a healthcare provider by name, 185 (79%) said they had visited a provider within 6 months, and 170 (73%) were on antiretroviral therapy. Eighty-three people (36%) were on prophylaxis for opportunistic infections. Self-reported antiretroviral adherence (taking antiretrovirals all or most of the time) exceeded 90%, and most treated participants (61%) had taken a stable regimen for more than 1 year. The study group had HIV infection for an average 11.4 years (+/- 8.2).
The researchers classified 90 admissions (39%) as HIV-associated admissions, and opportunistic infections explained almost three quarters of these admissions (73%). The most common opportunistic infections were cryptococcal meningitis (18%), Pneumocystis pneumonia (14%), and Mycobacterium avium complex or tuberculosis (12%). Malignancies made up the second most frequent cause of HIV-related admissions (10%). Drug reactions or toxicity accounted for only 3 HIV-related admissions (3%).
People with an HIV-associated admission were an average 5.2 years younger than those with a non-HIV admission (P = 0.001); they had a lower CD4 count (147 versus 296, P = 0.003) and were more likely to have an inpatient infectious disease consultation (77% versus 46%, P = 0.001) and to be discharged on prophylaxis (58% versus 30%, P = 0.01). People with an HIV-related admission were less likely to be insured (19% versus 31%, P = 0.05).
Nearly 90% of study participants had a contact at their time of admission, and 87% of those contacts were aware of the patient's HIV infection. But a large majority of these inpatients (86%) avoided divulging their HIV status, while two thirds (67%) said they felt judged because of their HIV infection or felt like an outcast. These indicators of HIV stigma were each significantly more likely in people with an HIV-associated admission (P < 0.01).
"Despite significant disease burden, aging with disease and perceived stigma," the researchers concluded, "we found the need for hospitalization did not necessarily indicate poor healthcare engagement."
Reference
1. Liappis AP, Yoon B, McIntosh SD, et al. Barriers to healthcare engagement in hospitalized HIV-infected patients. 52nd Interscience Conference on Antimicrobials and Chemotherapy (ICAAC). September 9-12, 2012. San Francisco. Abstract H-213.
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