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Disparities in the quality of HIV care when using US Department of Health and Human Services Indicators - blacks, IDUs, females
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Clinical Infectious Diseases Advance Access published January 23, 2014
"Our study, nested in the largest US collaboration of HIV-infected adults (NA-ACCORD), showed 29% of HIV-infected adults in care fail to meet the definition for retention in care, 18% were not prescribed ART, and 22% of adults did not achieve VL suppression; and these proportions were higher for young adults, females, non-Whites, and those with IDU and heterosexual risk.....Younger adults, blacks, and IDUs also had lower proportions prescribed ART in adjusted analyses. Identifying the drivers of these disparities and translation into programmatic efforts is necessary to increase the proportion prescribed ART in these groups.....49% of participants were ≥50 years of age; 83% were male; 45% were black; and 19% were IDUs......Females had a 7% higher proportion retained in care and a 6% lower proportion prescribed ART compared with males, but no significant statistical difference in the proportion with VL suppression. Hispanics had a 9% higher proportion retained in care compared with whites; blacks had a statistically significant lower proportion retained in care (3%), prescribed ART (3%), and with VL suppression (9%). IDUs and heterosexuals had an 11% and 4% lower proportion retained in care compared to MSM, respectively. Additionally, IDUs had a 6% lower proportion prescribed ART and a 7% lower proportion with VL suppression compared to MSM. There were no meaningful differences in the results after excluding VACS and KPNC."
Disparities in the quality of HIV care when using US Department of Health and Human Services Indicators
Clinical Infectious Diseases Advance Access published January 23, 2014
Keri N. Althoff1, Peter Rebeiro1, John T. Brooks2, Kate Buchacz2, Kelly Gebo1, Jeffrey
Martin3, Robert Hogg4, Jennifer E.Thorne1, Marina Klein5, M. John Gill6, Timothy R.
Sterling7, Baligh Yehia8, Michael J. Silverberg9, Heidi Crane10, Amy C. Justice11, Stephen
J. Gange1, Richard Moore1, Mari M. Kitahata10, and Michael A. Horberg12, for the North
American AIDS Cohort Collaboration on Research and Design (NA-ACCORD)
1Johns Hopkins University, Baltimore, MD 2Centers for Disease Control and Prevention, Atlanta, GA 3University of California San Francisco, San Francisco, CA 4British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC 5McGill University, Montreal, QC 6University of Calgary, Calgary, AB 7Vanderbilt University, Nashville, TN 8University of Pennsylvania, Philadelphia, PA 9Kaiser Permanente Northern California, Oakland, CA 10University of Washington, Seattle, WA 11Veterans Administration Connecticut Healthcare System and Yale University, West Haven, CT 12Kaiser Permanente Mid-Atlantic States, Rockville, MD
ABSTRACT
We estimated US Department of Health and Human Services (DHHS)-approved HIV indicators. Among patients, 71% were retained in care, 82% were prescribed treatment, and 78% had HIV RNA ≤200 copies/mL; younger adults, women, blacks, and injection drug users had poorer outcomes. Interventions are needed to reduce retention- and treatment-related disparities.
INTRODUCTION
Identifying indicators and monitoring HIV care is an established practice.1-3 In 2012, the Health Resources and Services Administration put forth clinical quality measures, which were endorsed by the National Quality Forum for monitoring HIV care services in the U.S. Three of these measures were also approved by the Department of Health and Human Services (DHHS) for monitoring DHHS-funded HIV services.3 The indicators are consistent with the Institute of Medicine's recommendations for monitoring HIV services2 and overlap with indicators from the National Committee for Quality Assurance.1
The North American AIDS Cohort Collaboration on Research and Design (NAACCORD) was identified by the Institute of Medicine as a potential data source to monitor HIV care in the U.S.2 The NA-ACCORD has previously shown that 3% of all adults living with HIV in the U.S. are captured in the clinical cohorts of the NA-ACCORD and participants are demographically similar to persons living with HIV in the U.S.4 The objectives of this study were to: 1) apply DHHS-approved indicators for retention in HIV medical care, antiretroviral therapy (ART) use and HIV viral load (VL) suppression;3 and 2) to identify differences in these indicators by age, sex, race/ethnicity and HIV risk
RESULTS
From the participating US clinical cohorts in the NA-ACCORD, 35,324 participants had ≥1 HIV care visit during January-June 2008, making them eligible to be included in the estimation of the retention in care indicator; 38,331 participants had ≥1 HIV care visit in 2009 making them eligible to be included in the estimation of the ART use and VL suppression indicators. Although these groups differed slightly in size, demographics were the same in both groups: 49% of participants were ≥50 years of age; 83% were male; 45% were black; and 19% were IDUs.
Of participants, 71% were retained in care, 82% were prescribed ART, and 78% had a suppressed VL (Table 1). All three indicators were higher in older age groups in unadjusted analyses. Differences in crude proportions existed by age, sex, race/ethnicity and HIV risk for all three indicators, with the exception of no statistically significant difference in retention in care by sex.
After adjustment for sex, race/ethnicity, HIV risk group and cohort, all three indicators were statistically more prevalent in older age groups (Table 1). Females had a 7% higher proportion retained in care and a 6% lower proportion prescribed ART compared with males, but no significant statistical difference in the proportion with VL suppression. Hispanics had a 9% higher proportion retained in care compared with whites; blacks had a statistically significant lower proportion retained in care (3%), prescribed ART (3%), and with VL suppression (9%). IDUs and heterosexuals had an 11% and 4% lower proportion retained in care compared to MSM, respectively. Additionally, IDUs had a 6% lower proportion prescribed ART and a 7% lower proportion with VL suppression compared to MSM. There were no meaningful differences in the results after excluding VACS and KPNC.
Discussion
In this era of "treatment as prevention," there is renewed emphasis on achieving VL suppression through the use of ART; adults in HIV care should be the most easily-accessible group in which 100% VL suppression could potentially be achieved. Our study, nested in the largest US collaboration of HIV-infected adults, showed 29% of HIV-infected adults in care fail to meet the definition for retention in care, 18% were not prescribed ART, and 22% of adults did not achieve VL suppression; and these proportions were higher for young adults, females, non-Whites, and those with IDU and heterosexual risk.
Our estimate of 71% retained in care is higher than the regularly used meta-analysis estimate of 59%,6 which is similar to that employed in the cascade of care.7 To date, there is currently no "gold standard" for measuring the definition of retention in care, but use of the DHHS indicator allows for consistency in this measurement.8 The indicator may need to be modified, however, to reflect changes in clinical practice with less-frequent (i.e. once per year) clinical visits for stable, suppressed patients. Consistent with previous studies,12 disparities in retention existed, with lower retention in younger adults, males, and those with IDU or heterosexual HIV risk, suggesting the need for programs specifically targeting these groups.
Overall, 18% of adults were not prescribed ART. Females were less likely than males to be prescribed ART, but were previously shown to have a higher mean CD4 count at presentation for care in the NA-ACCORD.9 In the current study, 41% of women had at least one CD4 measurement <350 cells/mm3 in 2009, of whom 80% were prescribed ART; 49% of men met this CD4 threshold for HIV treatment initiation, of whom 79% were prescribed ART. Younger adults, blacks, and IDUs also had lower proportions prescribed ART in adjusted analyses. Identifying the drivers of these disparities and translation into programmatic efforts is necessary to increase the proportion prescribed ART in these groups.
Almost a quarter of the individuals with at least one visit in 2009 were not suppressed; of these individuals, 69% were prescribed ART. In adjusted analyses, those who were younger, black, or with IDU or heterosexual HIV risk were more likely to have a detectable viral load. Assuming assortative mixing, this is consistent with findings from national surveillance data showing younger adults and blacks have the highest incidence rates of HIV infection.10 Differences in viral suppression are likely to play a role in disparities of HIV incidence; for example a higher prevalence of detectable viral load among black MSM likely contributes to the increase in odds of HIV infection if one has a Black partner.
Although these DHHS-approved measures are similar in concept to the steps depicted in the cascade of care12 and the continuum of care,13,14 proportions cannot be directly compared as the concepts and the denominators are not the same. Another important limitation to our study is the lack of distinction in active versus former IDU. Finally, enrollment criteria in the NA-ACCORD includes ≥2 HIV primary care visits in 12 months, >90 days apart among patients in clinical cohorts; thus our study population is enriched with those who successfully linked into care.
Our study provides empiric data on three DHHS-approved indicators from the large and diverse NA-ACCORD using clinical HIV cohort population data. The disparities found highlight: 1) the need for additional research to determine the drivers of these disparities; and 2) the need for programs tailored by age, race/ethnicity, and HIV risk to improve retention, ART use, and VL suppression. Prioritization of program efforts could be guided by targeting the characteristic with the largest differences in all outcomes: young adults (<40 years old). Our results suggest that continued efforts are needed to optimize these measures among patients who have successfully linked into HIV care.
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