Social Determinants of Late Presentation to HIV Care

Background: In recent years, increased attention has shifted toward evaluating social determinants of health, and understanding how community, environment, and system factors affect health outcomes. HIV policies and guidelines emphasize the importance of earlier HIV diagnosis and presentation for care. This study evaluated the role of individual and community-level factors in late presentation to HIV care. Methods: HIV-infected patients newly initiating outpatient HIV medical care at an academic medical center between 2005-2010 were included. Patients\u27 self-reported addresses at their first clinic visit were geocoded using geographic information systems software to the appropriate United States census block group. Using data from the U.S. Census Bureau’s 2005-2009 American Community Survey, community-level data was recorded for each patient\u27s census block group. Poisson regression was used to evaluate associations between individual- and community-level factors with late presentation for HIV care, defined as an initial CD4 count /mm3. Results: Among 609 patients, 341 patients (56%) had an initial CD4 count /mm3. At a community level, late presentation was significantly associated with the proportion of African Americans in a census block group (RR=1.47; 95%CI=1.19-1.81); with proportion living in poverty, lack of fuel, and lack of vehicle demonstrating borderline statistical significance. At an individual level, older patients were more likely (1.12; 1.06-1.19), while white females were less likely (0.45; 0.24-0.84) to present with a CD4 count /mm3. Conclusion: Both individual and community-level characteristics were associated with late presentation for HIV medical care. Research and interventions to promote earlier HIV diagnosis and care entry should include geographical information and social determinants of health to define priority populations

Improvements in depression and changes in quality of life among HIV-infected adults

Improving QOL for HIV-infected individuals is an important objective of HIV care, given the considerable physical and emotional burden associated with living with HIV. Although worse QOL has been associated with depression, no research has quantified the potential of improvement in depression to prospectively improve QOL among HIV-infected adults. We analyzed data from 115 HIV-infected adults with depression enrolled in a randomized controlled trial to evaluate the effectiveness of improved depression care on antiretroviral drug adherence. Improvement in depression, the exposure of interest, was defined as the relative change in depression at 6 months compared to baseline and categorized as full response (≥50% improvement), partial response (25%–49% improvement) and no response (<25% improvement). Multivariable linear regression was used to investigate the relationship between improvement in depression and four continuous measures of QOL at 6 months: physical QOL, mental QOL, HIV symptoms, and fatigue intensity. In multivariable analyses, physical QOL was higher among partial responders (MD=2.51, 95% CI −1.51, 6.54) and full responders (MD=3.68, 95% CI −0.36, 7.72) compared to individuals who did not respond. Mental QOL was an average of 4.01 points higher (95% CI −1.01, 9.03) among partial responders and 14.34 points higher (95% CI 9.42, 19.25) among full responders. HIV symptoms were lower for partial responders (MD=−0.69; 95% CI −1.69, 0.30) and full responders (MD=−1.51; 95% CI −2.50, −0.53). Fatigue intensity was also lower for partial responders (MD=−0.94; 95% CI −1.94, 0.07) and full responders (MD=−3.00; 95% CI −3.98, −2.02). Among HIV-infected adults with depression, improving access to high-quality depression treatment may also improve important QOL outcomes

Implementation of PHQ-9 Depression Screening for HIV-Infected Patients in a Real-World Setting

The prevalence of depression is 20%-30% for people living with HIV, and while it is associated with poorer adherence to antiretrovirals, it is often unrecognized by medical providers. Although it has been challenging for some health care settings to develop consistent depression screening mechanisms, it is feasible to create screening protocols using the 9-item Patient Health Questionnaire (PHQ-9). Establishing a depression screening and response protocol is an iterative process that involves preparing staff, determining screening frequency, and developing procedures for response and appropriate medical record documentation. While there are multiple issues and potential challenges during implementation, it is possible to incorporate systematic depression screening into HIV primary care in a manner that achieves staff buy-in, minimizes patient burden, streamlines communication, and efficiently uses the resources available in the medical setting

Psychiatric comorbidity in depressed HIV-infected individuals: common and clinically consequential

To report on the prevalence of psychiatric comorbidity and its association with illness severity in depressed HIV patients

Providers' Attitudes Towards Treating Depression and Self-Reported Depression Treatment Practices in HIV Outpatient Care

Depression is highly prevalent among HIV-infected patients, yet little is known about the quality of HIV providers' depression treatment practices. We assessed depression treatment practices of 72 HIV providers at three academic medical centers in 2010–2011 with semi-structured interviews. Responses were compared to national depression treatment guidelines. Most providers were confident that their role included treating depression. Providers were more confident prescribing a first antidepressant than switching treatments. Only 31% reported routinely assessing all patients for depression, 13% reported following up with patients within 2 weeks of starting an antidepressant, and 36% reported systematically assessing treatment response and tolerability in adjusting treatment. Over half of providers reported not being comfortable using the full FDA-approved dosing range for antidepressants. Systematic screening for depression and best-practices depression management were uncommon. Opportunities to increase HIV clinicians' comfort and confidence in treating depression, including receiving treatment support from clinic staff, are discussed

Evidence for risk stratification when monitoring for toxicities following initiation of combination antiretroviral therapy

Laboratory monitoring is recommended during combination antiretroviral therapy (cART), but the pattern of detected abnormalities and optimal monitoring are unknown. We assessed laboratory abnormalities during initial cART in 2000–2010 across the United States

Hematologic, Hepatic, Renal, and Lipid Laboratory Monitoring After Initiation of Combination Antiretroviral Therapy in the United States, 2000–2010

We assessed laboratory monitoring following combination antiretroviral therapy (cART) initiation among 3,678 patients in a large US multi-site clinical cohort, censoring participants at last clinic visit, cART change, or three years. Median days (interquartile range) to first hematologic, hepatic, renal and lipid tests were 30 (18–53), 31 (19–56), 33 (20–59) and 350 (96–1106), respectively. At one year, approximately 80% received more than two hematologic, hepatic, and renal tests consistent with guidelines. However, only 40% received one or more lipid tests. Monitoring was more frequent in specific subgroups, likely reflecting better clinic attendance or clinician perception of higher susceptibility to toxicities

Impact of Age on Retention in Care and Viral Suppression

Retention in care is important for all HIV-infected persons and is strongly associated with initiation of antiretroviral therapy and viral suppression. However, it is unclear how retention in care and age interact to effect viral suppression. We evaluated whether the association between retention and viral suppression differed by age at entry into care

Point-of-Care HIV Testing and Linkage in an Urban Cohort in the Southern US

The Southern states experience the highest rates of HIV and AIDS in the US, and point-of-care (POC) testing outside of primary care may contribute to status awareness in medically underserved populations in this region. To evaluate POC screening and linkage to care at an urban south site, analyses were performed on a dataset of 3,651 individuals from an integrated rapid-result HIV testing and linkage program to describe this test-seeking cohort and determine trends associated with screening, results, and linkage to care. Four percent of the population had positive results. We observed significant differences by test result for age, race and gender, reported risk behaviors, test location, and motivation for screening. The overall linkage rate was 86%, and we found significant differences for clients who were linked to HIV care versus persons whose linkage could not be confirmed with respect to race and gender, location, and motivation. The linkage rate for POC testing that included a comprehensive intake visit and colocated primary care services for in-state residents was 97%. Additional research on integrated POC screening and linkage methodologies that provide intake services at time of testing is essential for increasing status awareness and improving linkage to HIV care in the US

Time above 1500 copies: a viral load measure for assessing transmission risk of HIV-positive patients in care

OBJECTIVE: We examined HIV transmission potential of patients in care by analyzing the amount of person-time spent above a viral load threshold that increases risk for transmission. DESIGN: Observational cohort and supplemental data. METHODS: The cohort included HIV patients who received care at six HIV clinics in the United States, from 1 April 2009 to 31 March 2013, and had two or more viral load tests during this interval. Person-time (in days) above a viral load of 1500 copies/ml out of the total observation time was determined by inspecting consecutive pairs of viral load results and the time intervals between those pairs. The person-time rate ratios comparing demographic and clinical subgroups were estimated with Poisson regression. RESULTS: The cohort included 14 532 patients observed for a median of 1073 days with a median of nine viral load records. Ninety percent of the patients had been prescribed antiretroviral therapy. On average, viral load exceeded 1500 copies/ml during 23% of the patients’ observation time (average of 84 days per year, per patient). Percentage of person-time above the threshold was higher among patients who had more than a fourth of their viral load pairs exceeding a 6-month interval (34% of observation time), patients not on antiretroviral therapy (58% of time), new/re-engaging patients (34% of time), patients 16–39 years of age (32% of time), and patients of black race (26% of time). CONCLUSION: HIV patients in care spent an average of nearly a quarter of their time with viral loads above 1500 copies/ml, higher among some subgroups, placing them at risk for potentially transmitting HIV to others