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Age, Lower CD4s, Winter Predict Missed Clinic Visits by HIV+ Toronto Women
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4th International Workshop on HIV & Women, January 13-14, 2014, Washington DC
Mark Mascolini
Younger age, injection drug use, a sub-200 CD4 count, a winter appointment--these factors and others predicted why women missed HIV medical visits at a tertiary care hospital clinic in Toronto [1]. But overall--after statistical adjustment for age, race, and other relevant variables--retention in care proved similar in women and men using the clinic.
Retention in care has been linked to better virologic suppression, clinical outcomes, and survival, noted researchers from the University of Toronto. Because HIV-positive women in Canada and across the world often face steeper obstacles to steady health care than men, understanding retention rates and risk factors in women is a pressing concern.
To address that concern, the Toronto team studied HIV-positive people attending the clinic between April 2008 and August 2013. The study focused on 1206 adults--281 of them (23%) women--who kept at least one visit, had two or more scheduled visits, and had at least 6 months of follow-up. The analysis excluded rescheduled visits and visits only for blood work. The study group had an overall median follow-up of 4.6 years, during which people made a median of 16 visits.
Compared with men, women were younger (39 versus 46, P < 0.0001), included a higher proportion of blacks (64% versus 16%, P < 0.0001), and included a higher proportion who immigrated in the past 10 years (32% versus 10%, P < 0.0001). Appointment adherence was high in both women and men, though women kept a significantly lower proportion of appointments (87% versus 92%, P < 0.001). But after statistical adjustment for potential confounders, women and men had identical chances of keeping appointments (odds ratio [OR] 1.00, P = 0.99). That analysis adjusted for age, race, injection drug use, immigration within 10 years of the visit, physician, years of HIV infection, viral load, CD4 count, antiretroviral use at the previous visit, whether the previous visit was missed, whether the patient had ever missed a visit, and season of the visit.
Among women, appointment-keeping adherence was significantly higher in those 50 and older than in younger women (90% versus 86%, P < 0.05) and significantly higher in those who had not injected drugs (88% versus 81%, P < 0.05). Women with an injection drug use history missed an average 1.01 visits per year, compared with 0.49 among women who had not injected drugs (P < 0.05). Time between visits was slightly but significantly shorter in women infected for more than 3 years (3.14 versus 3.24 months in women infected under 3 years, P < 0.0001). Compared with women whose viral load lay below 50 copies, those with detectable viremia missed more visits per year (average 0.66 versus 0.40, P < 0.01) but had a significantly shorter time between visits (2.99 versus 3.22 months, P < 0.001).
To identify factors that independently predicted missing a visit, the Toronto team built a multivariate model including only women and adjusting for race, immigration status, physician, years since HIV diagnosis, viral load, and antiretroviral status at the previous visit. That analysis identified six independent predictors of one missed visit among women:
Higher risk of one missed visit:
Injection drug use: OR 2.61, P < 0.001
December-February appointment: OR 1.26, P = 0.01
Already missed one or more visits: OR 1.51, P < 0.001
Lower risk of one missed visit:
Missing previous visit: OR 0.69, P = 0.01
Every 10 years older age: OR 0.83, P < 0.01
CD4 count 200-500 versus under 200 at last visit: OR 0.69, P = 0.04
A CD4 count above 500 (versus under 200) at the last visit also lowered chances of missing one visit, but the association was not significant (OR 0.79, P = 0.22)
Reference
1. Szadkowski L, Raboud J, Walmsley S. Factors associated with missed clinic visits at a tertiary care centre. 4th International Workshop on HIV & Women, January 13-14, 2014, Washington DC. Abstract 8.
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