Beyond core indicators of retention in HIV care: missed clinic visits are independently associated with all-cause mortality

Abstract

Background: The continuum of care is at the forefront of the domestic human immunodeficiency virus (HIV) agenda, with the Institute of Medicine (IOM) and Department of Health and Human Services (DHHS) recently releasing clinical core indicators. Core indicators for retention in care are calculated based on attended HIV care clinic visits. Beyond these retention core indicators, we evaluated the additional prognostic value of missed clinic visits for all-cause mortality.

Methods: We conducted a multisite cohort study of 3672 antiretroviral-naive patients initiating antiretroviral therapy (ART) during 2000-2010. Retention in care was measured by the IOM and DHHS core indicators (2 attended visits at defined intervals per 12-month period), and also as a count of missed primary HIV care visits (no show) during a 24-month measurement period following ART initiation. All-cause mortality was ascertained by query of the Social Security Death Index and/or National Death Index, with adjusted survival analyses starting at 24 months after ART initiation.

Results: Among participants, 64% and 59% met the IOM and DHHS retention core indicators, respectively, at 24 months. Subsequently, 332 patients died during 16 102 person-years of follow-up. Failure to achieve the IOM and DHHS indicators through 24 months following ART initiation increased mortality (hazard ratio [HR] = 2.23; 95% confidence interval [CI], 1.79-2.80 and HR = 2.36; 95% CI, 1.89-2.96, respectively). Among patients classified as retained by the IOM or DHHS clinical core indicators, >2 missed visits further increased mortality risk (HR = 3.61; 95% CI, 2.35-5.55 and HR = 3.62; 95% CI, 2.30-5.68, respectively).

Conclusions: Beyond HIV retention core indicators, missed clinic visits were independently associated with all-cause mortality. Caution is warranted in relying solely upon retention in care core indicators for policy, clinical, and programmatic purposes.

Keywords: AIDS; HIV; antiretroviral therapy; continuum of care; engagement in care.

Figure 1.

Kaplan–Meier survival curves for all-cause mortality among patients classified as retained and not retained at 24 months following antiretroviral therapy initiation according to the Institute of Medicine (IOM) (A and B) and Department of Health and Human Services (DHHS) (C and D) core indicators stratified by missed (no-show) clinic visits. A, Retained at 24 months according to IOM core indicator (n = 2358). B, Not retained at 24 months according to IOM core indicator (n = 1314). C, Retained at 24 months according to DHHS core indicator (n = 2166). D, Not retained at 24 months according to DHHS core indicator (n = 1506). Abbreviation: ART, antiretroviral therapy.