Variation in subsequent viral load testing and outcomes by visit type patterns in the first year of the COVID-19 pandemic at a large academic medical center in North Carolina

Abstract

While telehealth was widely used to provide human immunodeficiency virus (HIV) care during the coronavirus disease 2019 (COVID-19) pandemic, research evaluating viral suppression by visit type is conflicting. This study assessed variation in viral load (VL) testing and outcomes by visit type for routine HIV care visits among people living with HIV (PWH) at a large academic health center in central North Carolina (NC). Electronic health records (EHRs) data from the Duke University Infectious Disease (ID) Clinic in NC were extracted in aggregated form. Pearson's Chi-square (χ²) tests were used to examine variation in VL testing and virologic suppression (VS) in 2022 by visit type patterns in the first year of the pandemic. Tipping point (TP) sensitivity analyses were conducted. EHR data from 1,835 PWH were included. Between March 16, 2020 and March 15, 2021, 53% of PWH received in-person HIV care only, 32% received a combination of telehealth and in-person care, and 15% received telehealth care only. About 20% of PWH did not have any VL test recorded in 2022. Among PWH with a VL test, 90% were virologically suppressed at all tests in 2022. Visit type was significantly associated with VL testing (P<0.001). The proportion of people who had no VL test in 2022 was larger among telehealth only users (31%) as compared to in-person only or PWH who received a combination (19% and 18%, respectively). VS in 2022 did not differ by visit type pattern in the first year of the pandemic (P=0.36) among PWH with a VL test in 2022. TP analyses identified that the proportion of unsuppressed VL tests among PWH without any VL test in 2022 would need to be multiplied by 2.1 to result in a statistically significant difference in VS by visit type (P=0.045). Our findings indicate that VL outcomes among telehealth users who had VL testing results documented in EHR at least one year later did not differ from in-person HIV care users. However, VL testing uptake was lower among telehealth only users suggesting the need for strategies such as remote VL testing to ensure regular VL testing among PWH who use telehealth HIV care.

Keywords: Human immunodeficiency virus care outcomes (HIV care outcomes); North Carolina (NC); coronavirus disease 2019 (COVID-19); electronic health records (EHRs); telehealth.

Figure 1

Systematic variation in viral load testing and virologic suppression in 2022 with patterns of HIV care visit types during the first year of the COVID-19 pandemic*. (A) Variation in viral load testing by visit type. (B) Variation in virologic suppression by visit type. ^a, P values are calculated by Pearson’s Chi-square test. *, March 16, 2020 through March 15, 2021. COVID-19, coronavirus disease 2019; HIV, human immunodeficiency virus.

Figure 2

TP sensitivity analysis #1: Pearson’s Chi-square test results and proportion of people with at least one unsuppressed VL test by TP multiplier and visit type. Tipping point scenarios incrementally increased the proportion of people with HIV with at least one unsuppressed VL test among those who had no VL test in 2022. Tipping point multipliers ranged from 1 to 4. Pearson’s Chi-square tests were used to assess the variation in virologic suppression by visit type patterns for each tipping point scenario. *, statistical significance at α =0.05; **, statistical significance at α =0.01. HIV, human immunodeficiency virus; TP, tipping point; PWH, people living with HIV; VL, viral load.

Figure 3

TP sensitivity analysis #2: Pearson’s Chi-square test results and treatment effect of people with at least one unsuppressed VL test by TP percentage point increase and visit type. Tipping point scenarios incrementally increased the proportion of people with HIV with at least one unsuppressed VL test among telehealth and mixed visit type users who had no VL test in 2022. Percentage point increases ranged from 0 to 20. Pearson’s Chi-square tests were used to assess the variation in virologic suppression comparing telehealth only vs. in-person only and mixed visit types vs. in-person only for each tipping point scenario. (A) Telehealth only versus in-person only. (B) Mixed visit types vs. in-person only. *, statistical significance at α =0.05; **, indicate statistical significance at α =0.01; ***, indicate statistical significance at α =0.001. HIV, human immunodeficiency virus; PWH, people living with HIV; TP, tipping point; VL, viral load.