Evaluation of New Hypertension Guidelines on the Prevalence and Control of Hypertension in a Clinical HIV Cohort: A Community-Based Study.

The prevalence and control of hypertension (HTN) among people with HIV (PWH) have not been widely studied since the release of newer 2017 ACC/AHA guidelines ("new guidelines"). To address this research gap, we evaluated and compared the prevalence and control of HTN using both 2003 JNC 7 ("old guidelines") and new guidelines. We identified 3,206 PWH with HTN from the DC Cohort study in Washington, DC, between January 2018 and June 2019. We defined HTN using International Classification of Diseases (ICD)-9/-10 diagnosis codes for HTN or ≥2 blood pressure (BP) measurements obtained at least 1 month apart (>139/89 mm Hg per old or >129/79 mm Hg per new guidelines). We defined HTN control based on recent BP (≤129/≤79 mm Hg per new guidelines). We identified socio-demographics, cardiovascular risk factors, and co-morbidities associated with HTN control using multivariable logistic regression [adjusted odds ratio (aOR); 95% confidence interval (CI)]. The prevalence of HTN was 50.9% per old versus 62.2% per new guidelines. Of the 3,206 PWH with HTN, 887 (27.7%) had a recent BP ≤129/≤79 mm Hg, 1,196 (37.3%) had a BP 130-139/80-89 mm Hg, and 1,123 (35.0%) had a BP ≥140/≥90 mm Hg. After adjusting for socio-demographics, cardiovascular risk factors, and co-morbidities, factors associated with HTN control included age 60-69 (vs. <40) years (aOR: 1.42; 95% CI: 1.03-1.98), Hispanic (vs. non-Hispanic Black) race/ethnicity (aOR 1.49; 95% CI: 1.04-2.15), receipt of HIV care at a hospital-based (vs. community-based) clinic (aOR 1.21; 95% CI: 1.00-1.47), being unemployed (aOR 1.42; 95% CI: 1.11-1.83), and diabetes (aOR 1.35; 95% CI: 1.13-1.63). In a large urban cohort of PWH, nearly two-thirds had HTN and less than one-third of those met new guideline criteria. Our data suggest that more aggressive HTN control is warranted among PWH, with additional attention to younger patients and non-Hispanic Black patients.

HIV care continuum outcomes among recently diagnosed people with HIV (PWH) in Washington, DC.

The Ending the HIV Epidemic initiative aims to decrease new HIV infections and promote test-and-treat strategies. Our aims were to establish a baseline of HIV outcomes among newly diagnosed PWH in Washington, DC (DC), a 'hotspot' for the HIV epidemic. We also examined sociodemographic and clinical factors associated with retention in care (RIC), antiretroviral therapy (ART) initiation and viral suppression (VS) among newly diagnosed PWH in the DC Cohort from 2011-2016. Among 455 newly diagnosed participants, 92% were RIC at 12 months, ART was initiated in 65% at 3 months and 91% at 12 months, VS in at least 17% at 3 months and 82% at 12 months and 55% of those with VS at 12 months had sustained VS for an additional 12 months. AIDS diagnosis was associated with RIC (aOR 2.99; 1.13-2.28), ART initiation by 3 months (aOR 2.58; 1.61-4.12) and VS by 12 months (aOR4.87; 1.69-14.03). This analysis contributes to our understanding of the HIV treatment dynamics of persons with recently diagnosed HIV infection in a city with a severe HIV epidemic.

Factors Influencing Successful Recruitment of Racial and Ethnic Minority Patients for an Observational HIV Cohort Study in Washington, DC.

The process of recruiting racial and ethnic minority persons living with HIV (PLWH) is important for research studies to ensure inclusivity of underrepresented groups. To understand factors associated with recruitment of minority PLWH, this study examined the recruitment process of PLWH for an observational study of their routine medical care at 14 clinics in Washington, DC. Research assistant (RA) recruiters were interviewed to assess their consenting processes and strategies. Data were collected on clinic services, patient demographics, and recruitment logs of patient approaches for obtaining informed consent resulting in agreement or refusal. A median of 96% of eligible patients was approached to obtain consent, yielding a median consent rate of 78% across all sites. A total of 8438 patients consented and 1326 refused study participation. Clinical sites with more comprehensive services had higher consent rates. black/African American and Hispanic/Latinx PLWH consented or refused study participation in similar proportions, while significantly more white patients enrolled than refused. More men, compared with women, enrolled than refused study participation. The most frequent reasons for refusing study participation were the lack of interest in research (33.2%) and no specific reason provided (28%). RAs identified that effective recruitment strategies used culturally sensitive approaches, built rapport with patients, and obtained provider support for the study. Recruitment strategies that are gender sensitive to address the disparity of underrepresentation of women, address perceived barriers, and examine clinic-specific services are needed to maximize research participation for minority PLWH to improve prevention and health outcomes.

Diabetes mellitus control in a large cohort of people with HIV in care-Washington, D.C.

With more effective antiretroviral therapy (ART), people with HIV (PWH) are living longer and have more chronic diseases, including diabetes mellitus (DM). The prevalence of DM has been estimated in PWH previously, however there is less research regarding DM control. Our objectives were to determine the prevalence of DM and DM control and determine factors associated with DM control in a large urban cohort of PWH in care. We examined DC Cohort participants aged ≥18 years old to determine DM prevalence and to assess DM control (HbA1c measurement <7.0%). Demographic, clinical, and HIV-related factors associated with DM control were identified using multivariate logistic regression. The cohort of 5876 participants was predominantly male (71.3%), Non-Hispanic Black (78.1%) and had a median age of 52.0 years. DM prevalence was 17.4% (1023/5876). Among participants with recent HbA1c data available (39.9%) the proportion with DM control was 60.0% (245/408). In multivariate analysis, higher BMI (aOR: 0.47; 95% CI 0.28, 0.79) and use of non-insulin DM medication (aOR 0.43, 95% CI 0.25, 0.73) or insulin (aOR 0.010, 95% CI 0.04,0.24) compared to no medication use. Our findings suggest that individuals on medication for their DM likely need enhanced support to reach their treatment goals.

Individual-Level and Clinic-Level Factors Associated With Achieving Glycemic Control in a Large Cohort of People With HIV in Care-Washington, DC.

BACKGROUND: Optimal management of noncommunicable diseases, including diabetes mellitus (DM), is crucially important as people with HIV (PWH) live longer with antiretroviral therapy. Our objective was to assess patient-level and clinic-level factors associated with achieving hemoglobin A1c (HbA1c) ≤7.0% among PWH and DM. SETTING: The DC Cohort, an observational clinical cohort of PWH, followed from 2011 to 2019 at 12 sites in Washington, DC. METHODS: Among PWH with diagnosed DM and elevated HbA1c (>7.0%), we examined the association between achieving HbA1c ≤7.0% and demographic and clinical factors, including time-updated medication data, and clinic-level factors related to services and structure. A multilevel marginal extended Cox regression model was generated to identify factors associated with time to HbA1c ≤7.0%. RESULTS: Over half (52.3%) of 419 participants achieved HbA1c ≤7.0%. Individual-level factors associated with HbA1c ≤7.0% included a diagnosis of DM after enrollment and a longer time since HIV diagnosis [hazard ratio (HR) = 2.65 and 1.13, P < 0.05 for both]. Attending a clinic with an endocrinologist was associated with the outcome [adjusted HR (aHR) = 1.41 95% confidence interval (CI): (1.01 to 1.97)]. In addition, comparing clinics that treat everyone, refer everyone or have a mix of treating and referring, showed an association between attending a clinic that treats everyone [aHR = 1.52 95% CI: (1.21 to 1.90)] or a clinic that refers everyone [aHR = 2.24 95% CI: (1.63 to 3.07)] compared with clinics with a mix in achieving glycemic control. CONCLUSION: Multiple factors are associated with achieving glycemic control in an urban cohort of PWH. Determining if specific services or structures improve DM outcomes may improve health outcomes for PWH and DM.

Defining Care Patterns and Outcomes Among Persons Living with HIV in Washington, DC: Linkage of Clinical Cohort and Surveillance Data.

BACKGROUND: Triangulation of data from multiple sources such as clinical cohort and surveillance data can help improve our ability to describe care patterns, service utilization, comorbidities, and ultimately measure and monitor clinical outcomes among persons living with HIV infection. OBJECTIVES: The objective of this study was to determine whether linkage of clinical cohort data and routinely collected HIV surveillance data would enhance the completeness and accuracy of each database and improve the understanding of care patterns and clinical outcomes. METHODS: We linked data from the District of Columbia (DC) Cohort, a large HIV observational clinical cohort, with Washington, DC, Department of Health (DOH) surveillance data between January 2011 and June 2015. We determined percent concordance between select variables in the pre- and postlinked databases using kappa test statistics. We compared retention in care (RIC), viral suppression (VS), sexually transmitted diseases (STDs), and non-HIV comorbid conditions (eg, hypertension) and compared HIV clinic visit patterns determined using the prelinked database (DC Cohort) versus the postlinked database (DC Cohort + DOH) using chi-square testing. Additionally, we compared sociodemographic characteristics, RIC, and VS among participants receiving HIV care at ≥3 sites versus <3 sites using chi-square testing. RESULTS: Of the 6054 DC Cohort participants, 5521 (91.19%) were included in the postlinked database and enrolled at a single DC Cohort site. The majority of the participants was male, black, and had men who have sex with men (MSM) as their HIV risk factor. In the postlinked database, 619 STD diagnoses previously unknown to the DC Cohort were identified. Additionally, the proportion of participants with RIC was higher compared with the prelinked database (59.83%, 2678/4476 vs 64.95%, 2907/4476; P<.001) and the proportion with VS was lower (87.85%, 2277/2592 vs 85.15%, 2391/2808; P<.001). Almost a quarter of participants (23.06%, 1279/5521) were identified as receiving HIV care at ≥2 sites (postlinked database). The participants using ≥3 care sites were more likely to achieve RIC (80.7%, 234/290 vs 62.61%, 2197/3509) but less likely to achieve VS (72.3%, 154/213 vs 89.51%, 1869/2088). The participants using ≥3 care sites were more likely to have unstable housing (15.1%, 64/424 vs 8.96%, 380/4242), public insurance (86.1%, 365/424 vs 57.57%, 2442/4242), comorbid conditions (eg, hypertension) (37.7%, 160/424 vs 22.98%, 975/4242), and have acquired immunodeficiency syndrome (77.8%, 330/424 vs 61.20%, 2596/4242) (all P<.001). CONCLUSIONS: Linking surveillance and clinical data resulted in the improved completeness of each database and a larger volume of available data to evaluate HIV outcomes, allowing for refinement of HIV care continuum estimates. The postlinked database also highlighted important differences between participants who sought HIV care at multiple clinical sites. Our findings suggest that combined datasets can enhance evaluation of HIV-related outcomes across an entire metropolitan area. Future research will evaluate how to best utilize this information to improve outcomes in addition to monitoring them.

Disparities in achieving and sustaining viral suppression among a large cohort of HIV-infected persons in care - Washington, DC.

One goal of the HIV care continuum is achieving viral suppression (VS), yet disparities in suppression exist among subpopulations of HIV-infected persons. We sought to identify disparities in both the ability to achieve and sustain VS among an urban cohort of HIV-infected persons in care. Data from HIV-infected persons enrolled at the 13 DC Cohort study clinical sites between January 2011 and June 2014 were analyzed. Univariate and multivariate logistic regression were conducted to identify factors associated with achieving VS (viral load < 200 copies/ml) at least once, and Kaplan-Meier (KM) curves and Cox proportional hazards models were used to identify factors associated with sustaining VS and time to virologic failure (VL ≥ 200 copies/ml after achievement of VS). Among the 4311 participants, 95.4% were either virally suppressed at study enrollment or able to achieve VS during the follow-up period. In multivariate analyses, achieving VS was significantly associated with age (aOR: 1.04; 95%CI: 1.03-1.06 per five-year increase) and having a higher CD4 (aOR: 1.05, 95% CI 1.04-1.06 per 100 cells/mm(3)). Patients infected through perinatal transmission were less likely to achieve VS compared to MSM patients (aOR: 0.63, 95% CI 0.51-0.79). Once achieved, most participants (74.4%) sustained VS during follow-up. Blacks and perinatally infected persons were less likely to have sustained VS in KM survival analysis (log rank chi-square p ≤ .001 for both) compared to other races and risk groups. Earlier time to failure was observed among females, Blacks, publically insured, perinatally infected, those with longer standing HIV infection, and those with diagnoses of mental health issues or depression. Among this HIV-infected cohort, most people achieved and maintained VS; however, disparities exist with regard to patient age, race, HIV transmission risk, and co-morbid conditions. Identifying populations with disparate outcomes allows for appropriate targeting of resources to improve outcomes along the care continuum.

Development of a large urban longitudinal HIV clinical cohort using a web-based platform to merge electronically and manually abstracted data from disparate medical record systems: technical challenges and innovative solutions.

OBJECTIVE: Electronic medical records (EMRs) are being increasingly utilized to conduct clinical and epidemiologic research in numerous fields. To monitor and improve care of HIV-infected patients in Washington, DC, one of the most severely affected urban areas in the United States, we developed a city-wide database across 13 clinical sites using electronic data abstraction and manual data entry from EMRs. MATERIALS AND METHODS: To develop this unique longitudinal cohort, a web-based electronic data capture system (Discovere®) was used. An Agile software development methodology was implemented across multiple EMR platforms. Clinical informatics staff worked with information technology specialists from each site to abstract data electronically from each respective site's EMR through an extract, transform, and load process. RESULTS: Since enrollment began in 2011, more than 7000 patients have been enrolled, with longitudinal clinical data available on all patients. Data sets are produced for scientific analyses on a quarterly basis, and benchmarking reports are generated semi-annually enabling each site to compare their participants' clinical status, treatments, and outcomes to the aggregated summaries from all other sites. DISCUSSION: Numerous technical challenges were identified and innovative solutions developed to ensure the successful implementation of the DC Cohort. Central to the success of this project was the broad collaboration established between government, academia, clinics, community, information technology staff, and the patients themselves. CONCLUSIONS: Our experiences may have practical implications for researchers who seek to merge data from diverse clinical databases, and are applicable to the study of health-related issues beyond HIV.