Annual and durable HIV retention in care and viral suppression among patients of Peter Ho Clinic, 2013-2017

Abstract

Objectives: To determine rates of annual and durable retention in medical care and viral suppression among patients enrolled in the Peter Ho Clinic, from 2013-2017.

Methods: This is a retrospective review of medical record data in an urban clinic, located in Newark, New Jersey, a high prevalence area of persons living with HIV. Viral load data were electronically downloaded, in rolling 1-year intervals, in two-month increments, from January 1, 2013 to December 31, 2019. Three teams were established, and every two months, they were provided with an updated list of patients with virologic failure. Retention and viral suppression rates were first calculated for each calendar-year. After patients were determined to be retained/suppressed annually, the proportion of patients with durable retention and viral suppression were calculated in two, three, four, five and six-year periods. Descriptive statistics were used to summarize sample characteristics by retention in care, virologic failure and viral suppression with Pearson Chi-square; p-value <0.05 was statistically significant. Multiple logistic regression models identified patient characteristics associated with retention in medical care, virologic failure and suppression.

Results: As of December 31, 2017, 1000 (57%) patients were retained in medical care of whom 870 (87%) were suppressed. Between 2013 and 2016, decreases in annual (85% to 77%) and durable retention in care were noted: two-year (72% to 70%) and three-year (63% to 59%) periods. However, increases were noted for 2017, in annual (89%) and durable retention in the two-year period (79%). In the adjusted model, when compared to current patients, retention in care was less likely among patients reengaging in medical care (adjusted Odds Ratio (aOR): 0.77, 95% CI: 0.61-0.98) but more likely among those newly diagnosed from 2014-2017 (aOR: 1.57, 95% CI: 1.08-2.29), compared to those in care since 2013. A higher proportion of patients re-engaging in medical care had virologic failure than current patients (56% vs. 47%, p < 0.0001). As age decreased, virologic failure was more likely (p<0.0001). Between 2013 and 2017, increases in annual (74% to 87%) and durable viral suppression were noted: two-year (59% to 73%) and three-year (49% to 58%) periods. Viral suppression was more likely among patients retained in medical care up to 2017 versus those who were not (aOR: 5.52, 95% CI: 4.08-7.46). Those less likely to be suppressed were 20-29 vs. 60 years or older (aOR: 0.52, 95% CI: 0.28-0.97), had public vs. private insurance (aOR: 0.29, 95% CI: 0.15-0.55) and public vs. private housing (aOR: 0.59, 95% CI: 0.40-0.87).

Conclusions: Restructuring clinical services at this urban clinic was associated with improved viral suppression. However, concurrent interventions to ensure retention in medical care were not implemented. Both retention in care and viral suppression interventions should be implemented in tandem to achieve an end to the epidemic. Retention in care and viral suppression should be measured longitudinally, instead of cross-sectional yearly evaluations, to capture dynamic changes in these indicators.

Fig 1. Flowchart of patients assessed for retention in care, virologic failure and viral suppression, Peter Ho Clinic, 2013–2017.

Fig 2. Retention in medical care and durable retention in medical care, by time-period.

Fig 3. Patients moved, lost to care or died, by year, 2013–2017.

Fig 4. Retention in medical care, virologic failure and suppression by status, Peter Ho Clinic, 2013–2017.

Note: Retention in medical care: Two medical encounters (medical visit or viral load), three months apart, in 2017, ART prescription and alive as of 12/31/2017. Virologic Failure: Most Recent Viral load > 200 copies/mL. Suppressed: Most Recent Viral load < 200 copies/mL. Status: Current patients were those in care in 2013. In the respective calendar-year, new patients were newly diagnosed and those reengaged did not previously receive care in PHC.

Fig 5. Viral suppression and durable viral suppression by time period, 2013–2017.