Social determinants of health and care outcomes among people living with HIV in the United States

Background Fewer than 70% of people living with HIV (PLHIV) in the United States have achieved durable viral suppression. To end the HIV epidemic in the United States, clinicians, researchers, and public health practitioners must devise ways to remove barriers to effective HIV treatment. To identify PLHIV who experience challenges to accessing healthcare, we created a simple assessment of social determinants of health (SDOH) among PLHIV and examined the impact of cumulative social and economic disadvantage on key HIV care outcomes. Methods We used data from the 2015-2019 Medical Monitoring Project, a yearly cross-sectional survey of PLHIV in the United States (N=15,964). We created a ten-item index of SDOH and assessed differences in HIV care outcomes of missed medical appointments, medication adherence, and durable viral suppression by SDOH using this index using prevalence ratios with predicted marginal means. Results Eighty-three percent of PLHIV reported at least one SDOH indicator. Compared to PLHIV who experienced none of the SDOH indicators, people who experienced one, two, three, and four or more SDOH indicators, were 1.6, 2.1, 2.6 and 3.6 as likely to miss a medical appointment in the prior year; 11%, 17%, 20% and 31% less likely to report excellent adherence in the prior 30 days; and, 2%, 4%, 10% and 20% less likely to achieve durable viral suppression in the prior year, respectively. Conclusions Among PLHIV, cumulative exposure to social and economic disadvantage impacts care outcomes in a dose-dependent fashion. A simple index may identify PLHIV experiencing barriers to HIV care, adherence, and durable viral suppression in need of critical supportive services.

Evaluation of the Impact of Delayed in Diagnosis and Initiation of Antiretroviral Therapy for HIV-1 Infected Infants on Their Viral Load (Viraemia) and CD4 T Lymphocyte Cell Status Outcome in the Gambia.

Background: To enhance durable viral suppression and upgrade CD4 cell immune function of HIV-1 proviral DNA positive infants, Gambia government adopted WHO recommended sample collection from infants born to HIV infected mothers before or at 6-8 weeks soon after birth, then ensure 4 weeks’ timeframe from collection dates, through molecular testing, to ART initiation if positive. Despite, studies to determine if these infants sample were collected, tested and initiated on ART within the adopted recommended timeframe, to ensure their achievements of this benefit are lacking. Aims: We aimed to determine the effect of delayed in diagnosis and ART initiation on CD4 cell and viraemia outcome of HIV-1 proviral DNA positive infants in the Gambia. Method: 2015-2019 retrospective data collection and analysis of key dates, initial viraemia and CD4 cell outcome, and then prospective cohort study on CD4 cell and viraemia outcome of those followed within at least 6 months and at most 3 years duration on ART adherence. STATA version 13 was used for the data analysis. Delayed in diagnosis and ART initiation was dichotomized using the adopted recommended timeframe, and Pair T-test used to determine the difference between mean initial and mean prospective, CD4 cell and viraemia outcome respectively.Results: Between 2015-2019, 95 infants were found tested HIV-1 proviral DNA positive among which, 49/95 were found initiated on ART 42 weeks (IQR: 25, 83) median time from their delivery dates. Among these 49, 4 found adhered to the duration in the cohort of those not affect by the delays, difference between their mean initial and prospective CD4 cell outcome was found significantly (P = 0.02) higher than the 11 found adhered to the duration in the cohort of those affected by the delays (P = 0.37).The reverse was found in their viraemia outcome although, not statistically significant for both (P values = O.33 and 0.18 respectively). Conclusion: The overall 42 weeks median time was found in conflict with the adopted recommended timeframe thus, found affected the CD4 cell and viraemia outcome of positive infants affected by the delays. Henceforth, the urgent attention is required for those affected to improve their prognosis.

“Is a Bird in the Hand Worth 5 in the Bush?”: A Comparison of 3 Data-to-Care Referral Strategies on HIV Care Continuum Outcomes in San Francisco

Background Health departments utilize HIV surveillance data to identify people with HIV (PWH) who need re-linkage to HIV care as part of an approach known as Data to Care (D2C.) The most accurate, effective, and efficient method of identifying PWH for re-linkage is unknown. Methods We evaluated referral and care continuum outcomes among PWH identified using 3 D2C referral strategies: health care providers, surveillance, and a combination list derived by matching an electronic medical record registry to HIV surveillance. PWH who were enrolled in the re-linkage intervention received short-term case management for up to 90 days. Relative risks and 95% confidence intervals were calculated to compare proportions of PWH retained and virally suppressed before and after re-linkage. Durable viral suppression was defined as having suppressed viral loads at all viral load measurements in the 12 months after re-linkage. Results After initial investigation, 233 (24%) of 954 referrals were located and enrolled in navigation. Although the numbers of surveillance and provider referrals were similar, 72% of enrolled PWH were identified by providers, 16% by surveillance, and 12% by combination list. Overall, retention and viral suppression improved, although relative increases in retention and viral suppression were only significant among individuals identified by surveillance or providers. Seventy percent of PWH who achieved viral suppression after the intervention remained durably virally suppressed. Conclusions PWH referred by providers were more likely to be located and enrolled in navigation than PWH identified by surveillance or combination lists. Overall, D2C re-linkage efforts improved retention, viral suppression, and durable viral suppression.

Despite Early Medicaid Expansion, Decreased Durable Virologic Suppression Among Publicly Insured People with HIV in Washington, DC

Background: Despite widely available access to HIV care in Washington, DC, inequities in HIV outcomes persist. We hypothesized that laboratory monitoring and virologic outcomes would not differ significantly based on insurance type. Methods: We compared HIV monitoring with outcomes among people with HIV (PWH) with private (commercial payer) versus public (Medicare, Medicaid) insurance receiving care at community and hospital clinics. The DC Cohort follows over 8,000 PWH from 14 clinics. We included those ≥18 years old enrolled between 2011-2015 with stable insurance. Outcomes included frequency of CD4 count and HIV RNA monitoring ( > 2 lab measures/year, > 30 days apart) and durable viral suppression (VS; HIV RNA <50 copies/mL at last visit and receiving antiretroviral therapy (ART) for ≥12 months). Multivariable logistic regression models examined impact of demographic and clinical factors. Results: Among 3,908 PWH, 67.9% were publicly-insured and 58.9% attended community clinics. Compared with privately insured participants, a higher proportion of publicly insured participants had the following characteristics: female sex, Black race, heterosexual, unemployed, and attending community clinics. Despite less lab monitoring, privately-insured PWH had greater durable VS than publicly-insured PWH (ART-naïve: private 70.0% vs public 53.1%, p=0.03; ART-experienced: private 80.2% vs public 69.4%, p<0.0001). Privately-insured PWH had greater durable VS than publicly-insured PWH at hospital clinics (AOR=1.59, 95% CI: 1.20, 2.12; p=0.001). Conclusions: Paradoxical differences between HIV monitoring and durable VS exist among publicly and privately-insured PWH in Washington, DC. Programs serving PWH must improve efforts to address barriers creating inequity in HIV outcomes.

Despite Early Medicaid Expansion, Decreased Durable Virologic Suppression Among Publicly Insured People with HIV in Washington, DC: a retrospective analysis

Background: Despite widely available access to HIV care in Washington, DC, inequities in HIV outcomes persist. We hypothesized that laboratory monitoring and virologic outcomes would not differ significantly based on insurance type. Methods: We compared HIV monitoring with outcomes among people with HIV (PWH) with private (commercial payer) versus public (Medicare, Medicaid) insurance receiving care at community and hospital clinics. The DC Cohort follows over 8,000 PWH from 14 clinics. We included those ≥18 years old enrolled between 2011-2015 with stable insurance. Outcomes included frequency of CD4 count and HIV RNA monitoring ( > 2 lab measures/year, > 30 days apart) and durable viral suppression (VS; HIV RNA <50 copies/mL at last visit and receiving antiretroviral therapy (ART) for ≥12 months). Multivariable logistic regression models examined impact of demographic and clinical factors. Results: Among 3,908 PWH, 67.9% were publicly-insured and 58.9% attended community clinics. Compared with privately insured participants, a higher proportion of publicly insured participants had the following characteristics: female sex, Black race, heterosexual, unemployed, and attending community clinics. Despite less lab monitoring, privately-insured PWH had greater durable VS than publicly-insured PWH (ART-naïve: private 70.0% vs public 53.1%, p=0.03; ART-experienced: private 80.2% vs public 69.4%, p<0.0001). Privately-insured PWH had greater durable VS than publicly-insured PWH at hospital clinics (AOR=1.59, 95% CI: 1.20, 2.12; p=0.001). Conclusions: Paradoxical differences between HIV monitoring and durable VS exist among publicly and privately-insured PWH in Washington, DC. Programs serving PWH must improve efforts to address barriers creating inequity in HIV outcomes.

Despite Early Medicaid Expansion, Decreased Durable Virologic Suppression Among Publicly Insured People with HIV in Washington, DC

Background: Despite widely available access to HIV care in Washington, DC, inequities in HIV outcomes persist. We hypothesized that laboratory monitoring and virologic outcomes would not differ significantly based on insurance type. Methods: We compared HIV monitoring with outcomes among people with HIV (PWH) with private (commercial payer) versus public (Medicare, Medicaid) insurance receiving care at community and hospital clinics. The DC Cohort follows over 8,000 PWH from 14 clinics. We included those ≥18 years old enrolled between 2011-2015 with stable insurance. Outcomes included frequency of CD4 count and HIV RNA monitoring (> 2 lab measures/year, >30 days apart) and durable viral suppression (VS; HIV RNA <50 copies/mL at last visit and receiving antiretroviral therapy (ART) for ≥12 months). Multivariable logistic regression models examined impact of demographic and clinical factors. Results: Among 3,908 PWH, 67.9% were publicly-insured and 58.9% attended community clinics. Compared with privately insured participants, a higher proportion of publicly insured participants had the following characteristics: female sex, Black race, heterosexual, unemployed, and attending community clinics. Despite less lab monitoring, privately-insured PWH had greater durable VS than publicly-insured PWH (ART-naïve: private 70.0% vs public 53.1%, p=0.03; ART-experienced: private 80.2% vs public 69.4%, p<0.0001). Privately-insured PWH had greater durable VS than publicly-insured PWH at hospital clinics (AOR=1.59, 95% CI: 1.20, 2.12; p=0.001). Conclusions: Paradoxical differences between HIV monitoring and durable VS exist among publicly and privately-insured PWH in Washington, DC. Programs serving PWH must improve efforts to address barriers creating inequity in HIV outcomes.

Durable HIV Suppression Among People Who Inject Drugs From a Community-Based Cohort Study in Baltimore, Maryland, 1997–2017

People who inject drugs (PWID) face disparities in human immunodeficiency virus (HIV) treatment outcomes and may be less likely to achieve durable viral suppression. We characterized transitions into and out of viral suppression from 1997 to 2017 in a long-standing community-based cohort study of PWID, the AIDS Link to Intravenous Experience (ALIVE) Study, analyzing HIV-positive participants who had made a study visit in or after 1997. We defined the probabilities of transitioning between 4 states: 1) suppressed, 2) detectable, 3) lost to follow-up, and 4) deceased. We used multinomial logistic regression analysis to examine factors associated with transition probabilities, with a focus on transitions from suppression to other states. Among 1,061 participants, the median age was 44 years, 32% were female, 93% were African-American, 59% had recently injected drugs, and 28% were virologically suppressed at baseline. Significant improvements in durable viral suppression were observed over time; however, death rates remained relatively stable. In adjusted analysis, injection drug use and homelessness were associated with increased virological rebound in earlier time periods, while only age and race were associated with virological rebound in 2012–2017. Opioid use was associated with an increased risk of death following suppression in 2012–2017. Despite significant improvements in durable viral suppression, subgroups of PWID may need additional efforts to maintain viral suppression and prevent premature mortality.