Clinic Network Collaboration and Patient Tracing to Maximize Retention in HIV Care.

Understanding retention and loss to follow up in HIV care, in particular the number of people with unknown outcomes, is critical to maximise the benefits of antiretroviral therapy. Individual-level data are not available for these outcomes in Australia, which has an HIV epidemic predominantly focused amongst men who have sex with men.A network of the 6 main HIV clinical care sites was established in the state of Victoria, Australia. Individuals who had accessed care at these sites between February 2011 and June 2013 as assessed by HIV viral load testing but not accessed care between June 2013 and February 2014 were considered individuals with potentially unknown outcomes. For this group an intervention combining cross-referencing of clinical data between sites and phone tracing individuals with unknown outcomes was performed. 4966 people were in care in the network and before the intervention estimates of retention ranged from 85.9%-95.8% and the proportion with unknown outcomes ranged from 1.3-5.5%. After the intervention retention increased to 91.4-98.8% and unknown outcomes decreased to 0.1-2.4% (p<.01 for all sites for both outcomes). Most common reasons for disengagement from care were being too busy to attend or feeling well. For those with unknown outcomes prior to the intervention documented active psychiatric illness at last visit was associated with not re-entering care (p = 0.04).The network demonstrated low numbers of people with unknown outcomes and high levels of retention in care. Increased levels of retention in care and reductions in unknown outcomes identified after the intervention largely reflected confirmation of clinic transfers while a smaller number were successfully re-engaged in care. Factors associated with disengagement from care were identified. Systems to monitor patient retention, care transfer and minimize disengagement will maximise individual and population-level outcomes for populations with HIV

Characteristics of individuals with unknown outcomes compared for those whose outcomes remain unknown, died or declined care post-intervention^a to those who re-entered or transferred care.

<p><b>NOTES:</b> MSM, men who have sex with men; ART, antiretroviral therapy; UD, undetectable</p><p>Characteristics compared by χ2 test or Fisher’s exact test if cell frequencies ≤5 apart from age (students’ t-test) and viral load (Wilcoxon rank sum test)</p><p>^a Intervention of cross referencing data between sites and phone tracing for those still with unknown outcomes</p><p>^b MSM as compared to non-MSM categories (IDU, combined IDU/MSM, Heterosexual, Unknown)</p><p>^c Born outside of Australia and first language is not English</p><p>^d Holder of Medicare card that allows access to publicly funded healthcare</p><p>^e Receiving medication for a psychiatric condition (e.g. depression, anxiety, schizophrenia, bipolar affective disorder) or documented symptomatic psychiatric condition at last visit</p><p>Characteristics of individuals with unknown outcomes compared for those whose outcomes remain unknown, died or declined care post-intervention<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0127726#t004fn003" target="_blank">^a</a> to those who re-entered or transferred care.</p

Consort diagram of total numbers of patients entering analysis.

<p>Consort diagram of total numbers of patients entering analysis.</p

Status of individuals post-intervention who were originally considered to have unknown outcomes.

<p>Status of individuals post-intervention who were originally considered to have unknown outcomes.</p

Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study

Background: Evidence on viral load and HIV transmission risk in HIV-serodiscordant male homosexual couples is limited to one published study. We calculated transmission rates in couples reporting condomless anal intercourse (CLAI), when HIV-positive partners were virally suppressed, and daily pre-exposure prophylaxis (PrEP) was not used by HIV-negative partners. Methods: In the Opposites Attract observational cohort study, serodiscordant male homosexual couples were recruited from 13 clinics in Australia, one in Brazil, and one in Thailand. At study visits, HIV-negative partners provided information on sexual behaviour and were tested for HIV and sexually transmitted infections; HIV-positive partners had HIV viral load tests, CD4 cell count, and sexually transmitted infection tests done. Viral suppression was defined as less than 200 copies per mL. Linked within-couple HIV transmissions were identified with phylogenetic analysis. Incidence was calculated per couple-year of follow-up, focusing on periods with CLAI, no use of daily PrEP, and viral suppression. One-sided upper 95% CI limits for HIV transmission rates were calculated with exact Poisson methods. Findings: From May 8, 2012, to March 31, 2016, in Australia, and May 7, 2014, to March 31, 2016, in Brazil and Thailand, 358 couples were enrolled. 343 couples had at least one follow-up visit and were followed up for 588·4 couple-years. 258 (75%) of 343 HIV-positive partners had viral loads consistently less than 200 copies per mL and 115 (34%) of 343 HIV-negative partners used daily PrEP during follow-up. 253 (74%) of 343 couples reported within-couple CLAI during follow-up, with a total of 16 800 CLAI acts. Three new HIV infections occurred but none were phylogenetically linked. There were 232·2 couple-years of follow-up and 12 447 CLAI acts in periods when CLAI was reported, HIV-positive partners were virally suppressed, and HIV-negative partners did not use daily PrEP, resulting in an upper CI limit of 1·59 per 100 couple-years of follow-up for transmission rate. Interpretation: HIV treatment as prevention is effective in men who have sex with men. Increasing HIV testing and linking to immediate treatment is an important strategy in HIV prevention in homosexual men. Funding: National Health and Medical Research Council; amfAR, The Foundation for AIDS Research; ViiV Healthcare; and Gilead Sciences