Association Between Substance Abuse and Mental Illness Symptoms Screener (SAMISS) Scores and HIV Care Continuum Outcomes in People Newly Diagnosed with HIV in the US South.

Mental illness (MI) and substance use (SU) are highly prevalent among people with HIV (PWH) and impact care outcomes. The Substance Abuse and Mental Illness Symptoms Screener (SAMISS) is a validated screener for MI and SU, but it is unknown how screening results at entry to care correlate with subsequent HIV outcomes. This is a retrospective chart review of individuals newly diagnosed with HIV between 2016 and 2019 in a Southern US, safety-net clinic. Baseline demographics, HIV risk factors, socioeconomic variables, and SAMISS screening scores were collected. Outcomes included retention in care, achieving virologic suppression (VS), and continuous VS. Data analyses included stepwise Cox and logistic multivariate regression modeling. Among the 544 newly diagnosed PWH, mean age was 35, 76% were male, 46% non-Hispanic Black, 40% Hispanic/other. Overall, 35% screened positive for SU and 41% for MI. A positive SU (odds ratio (OR) 0.66, p = 0.04) or MI (OR 0.65, p = 0.03) SAMISS screening was associated with lower retention in care in univariate analysis, but was not statistically significant after adjusting for other variables. Positive SAMISS screening for SU and MI were both associated with reduced continuous VS in univariate and multivariate analyses (SU: adjusted OR (aOR) 0.67, p = 0.05; MI: aOR 0.66, p = 0.03). SAMISS is a useful tool for prospectively identifying individuals at risk for low retention in care and for not achieving sustained VS. Future interventions guided by SAMISS may improve HIV care continuum outcomes.

Syndemic of Substance Abuse, Depression, and Type 2 Diabetes and Their Association with Retention in Care Among People Living with HIV.

Substance abuse (SA), depression, and type 2 diabetes (DM2) often co-occur among people living with HIV (PLHIV). Guided by a syndemic framework, this cross-sectional retrospective study examined the cumulative and interaction effects of SA, depression, and DM2 on retention in HIV care (RIC) among 621 PLHIV receiving medical care in central Pennsylvania. We performed logistic regression analysis to test the associations between SA, depression, and DM2 and RIC. To test the "syndemic" model, we assessed additive and multiplicative interactions. In an unadjusted model, a dose-response pattern between the syndemic index (total number of health conditions) and RIC was detected (OR for 1 syndemic factor vs. none: 1.01, 95% CI: 0.69-1.47; 2 syndemic factors: 1.59, 0.89-2.84; 3 syndemic factors: 1.62, 0.44-5.94), but no group reached statistical significance. Interactions on both additive and multiplicative scales were not significant, demonstrating no syndemic effect of SA, depression, and DM2 on RIC among our study sample. Our findings highlight that comorbid conditions may, in some populations, facilitate RIC rather than act as barriers, which may be due to higher levels of engagement with medical care.

Interventions to improve early retention of patients in antiretroviral therapy programmes in sub-Saharan Africa: A systematic review.

BACKGROUND: Several interventions to improve long term retention (12 months and above) on treatment have been rigorously evaluated in Sub-Saharan Africa (SSA). However, research on interventions to improve retention of patients in the early stages of treatment (6 months) during this era of Universal Test and Treat has only recently emerged. The aim of this study is to systematically map evidence of interventions used to improve early retention of patients in antiretroviral therapy (ART) programmes in SSA. METHODS: We searched PubMed, EMBASE and Cochrane electronic databases to identify studies describing interventions aimed at improving early retention in ART treatment. We applied the methodological frameworks by Arksey and O'Malley (2005) and Levac et al. (2010). We also followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Interventions were categorized according to key broad areas in the existing literature. RESULTS: A total of 2,241 articles were identified of which 19 met the inclusion criteria and were eligible for this review, with the majority either being randomized control trials 32% (n = 6) or cohort studies 32% (n = 6). The studies reviewed were conducted in 11 SSA countries. The most common interventions described under key broad areas included: Health system interventions such as Universal Test-and-Treat, integration of ART initiation, HIV Testing and Counselling and Antenatal Care services and reduction of ART drug costs; Patient centered approaches such as fast track ART initiation, Differentiated Drug Delivery models and point of care HIV birth testing; Behavioral interventions and support through lay counselors, mentor mothers, nurse counselors and application of quality improvement interventions and financial incentives. Majority of the studies targeted the HIV positive adults and pregnant women. CONCLUSION: With the introduction of Universal Test-and-Treat and same-day initiation of ART, findings suggest that adoption of policies that expand ART uptake with the goal of reducing HIV transmission at the population level, promoting patient centered approaches such as fast track ART initiation, Differentiated Service Delivery models and providing adequate support through Mentor Mothers, lay and nurse counselors may improve early retention in HIV care in SSA. However, these interventions have only been tested in few countries in the region which points to how hard evidence based HIV programming is. Further research investigating the impact of individual and a combination of interventions to improve early retention in HIV care, including for various groups at high risk of attrition, is warranted across SSA countries to fast track the achievement of 95-95-95 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets by 2030.

Person-centred care and short oral treatment for rifampicin-resistant tuberculosis improve retention in care in Kandahar, Afghanistan.

OBJECTIVES: To describe the effect of adaptations to a person-centred care with short oral regimens on retention in care for rifampicin-resistant TB (RR-TB) in Kandahar province, Afghanistan. METHODS: The study included people with RR-TB registered in the programme between 01 October 2016 and 18 April 2021. From 19 November 2019, the programme implemented a trial investigating the safety and effectiveness of short oral RR-TB regimens. During the trial, person-centred care was adapted. We included the data from people living with RR-TB treated in the period before and after the care model was adapted and applied Kaplan-Meier statistics to compare rates of retention in care. RESULTS: Of 236 patients registered in the RR-TB programme, 146 (61.9%) were registered before and 90 (38.1%) after the model of care was adapted. Before adaptations enhancing person-centred care, pre-treatment attrition was 23.3% (n = 34/146), whilst under the adapted care model it was 5.6% (n = 5/90). Attrition on treatment was 22.3% (n = 25/112) before adaptations, whilst during the study period none of the participants were lost-to-follow-up on treatment and 3.3% died (n = 3/90). CONCLUSIONS: As person-centred care delivery and treatment regimens were adapted to better fit-specific contextual challenges and the needs of the target population, retention in care improved amongst people with RR-TB in Kandahar, Afghanistan.

Post-immigration factors affecting retention in HIV care and viral suppression in Latin American and Caribbean immigrant populations in the United States: a systematic review.

OBJECTIVES: To reduce disparities in HIV care outcomes among Latin American and Caribbean (LAC) immigrants living with HIV in the U.S., it is necessary to identify factors influencing HIV care in this population. A systematic review that provides a comprehensive understanding of factors influencing retention in HIV care and viral suppression among LAC immigrants living with HIV in the U.S. is lacking. This systematic review used the Immigrant Health Services Utilization theoretical framework to provide an understanding of these factors. DESIGN: We searched for peer-reviewed publications in MEDLINE, EMBASE, CINAHL, PsycINFO, and ASSIA, from January 1996 to June 2020. RESULTS: A total of 17 qualitative (n = 10) and quantitative (n = 7) studies were included in the review. The most commonly reported general and immigrant-specific factors appearing in studies were undocumented immigration status, HIV stigma, homophobia, cultural norms, values and beliefs, family and social support, language barriers, structure, complexity and quality of the U.S. healthcare delivery system, and patient-provider relationship. CONCLUSION: These findings highlight the importance of considering immigrant-specific factors along with general factors to improve the provision of HIV care services and HIV care outcomes among LAC immigrant populations.

Retention of pediatric patients in care: a study of the Kibera Community Health Center HIV/AIDS Program.

BACKGROUND: In 2011, 3.4 million children were living with HIV worldwide1. OBJECTIVES: Describe the characteristics of pediatric patients enrolled into the HIV program at the Kibera community health center between January 2012 and March 2013. Determine the proportion of enrolled paediatric patients lost to follow up. Determine the correlates associated with retention and loss to follow up. METHODS: The study was a retrospective cohort study of program data of all pediatric patients enrolled into the HIV program in the facility between January 2012 and March 2013. The data was analyzed using SPSS. RESULTS: Of the 100 pediatric patients enrolled during the study period, 79 and 21 were HIV negative and positive respectively. Only 4 (5%) of the HIV exposed Infants and 11 (52%) of the HIV positive children were started on ART within the study period. The retention rate of the children at 3 months was 87% while the retention at both 12 and 15 months was 79%. There was an association between the mother or guardian disclosing their status and the retention of the child (p-value 0.026). CONCLUSION: The disclosure of the HIV status by parent/guardian to the child was associated with better retention of the children in the program.

Pharmacotherapy for Attention-Deficit/Hyperactivity Disorder and Retention in Outpatient Substance Use Disorder Treatment: A Retrospective Cohort Study.

OBJECTIVE: To assess the relationship between short- and longer-term retention in outpatient substance use disorder (SUD) treatment and pharmacotherapy for comorbid attention-deficit/hyperactivity disorder (ADHD). METHODS: In this retrospective cohort study conducted in a single addiction psychiatry clinic, electronic health record data from July 14, 2014, through January 15, 2020, were queried for clinical ADHD diagnosis (DSM-5 criteria), ADHD pharmacotherapy, treatment duration, demographic variables, comorbid psychiatric and SUD diagnoses, and buprenorphine therapy. Individuals with ADHD (n = 203) were grouped by ADHD pharmacotherapy status (171 receiving medication compared to 32 receiving none). Kaplan-Meier and Cox proportional hazards regression analyses were performed and assessed for significance. RESULTS: ADHD was clinically diagnosed in 9.4% of outpatients and was associated with younger age, comorbid cocaine use, and private insurance (P < .001). Individuals receiving no ADHD pharmacotherapy were younger than those receiving medication (P = .003). Compared to no ADHD medication, ADHD pharmacotherapy was associated with greater long-term retention, with apparent group half-lives of 9 months and 36 months, respectively (P < .001). Individuals receiving no ADHD medication had a 4.9-fold increased likelihood of attrition within 90 days (P = .041). Regression analysis showed only ADHD pharmacotherapy to be significantly associated with treatment retention (hazard ratio = 0.59; 95% CI, 0.40-0.86; P = .008). CONCLUSIONS: ADHD pharmacotherapy is robustly associated with improved short- and longer-term retention in outpatient SUD treatment. The retrospective, nonrandomized naturalistic study design limits causal inference. Further studies addressing unmeasured covariates and associated risks of treatment in adults with ADHD and SUD are necessary.

Patient feedback surveys among pregnant women in Eswatini to improve antenatal care retention.

BACKGROUND: Uptake and retention in antenatal care (ANC) is critical for preventing adverse pregnancy outcomes for both mothers and infants. METHODS: We implemented a rapid quality improvement project to improve ANC retention at seven health facilities in Eswatini (October-December 2017). All pregnant women attending ANC visits were eligible to participate in anonymous tablet-based audio assisted computer self-interview (ACASI) surveys. The 24-question survey asked about women's interactions with health facility staff (HFS) (nurses, mentor mothers, receptionists and lab workers) with a three-level symbolic response options (agree/happy, neutral, disagree/sad). Women were asked to self-report HIV status. Survey results were shared with HFS at monthly quality improvement sessions. Chi-square tests were used to assess differences in responses between months one and three, and between HIV-positive and negative women. Routine medical record data were used to compare retention among pregnant women newly enrolled in ANC two periods, January-February 2017 ('pre-period') and January-February 2018 ('post-period') at two of the participating health facilities. Proportions of women retained at 3 and 6 months were compared using Cochran-Mantel-Haenszel and Wilcoxon tests. RESULTS: A total of 1,483 surveys were completed by pregnant women attending ANC, of whom 508 (34.3%) self-reported to be HIV-positive. The only significant change in responses from month one to three was whether nurses listened with agreement increasing from 88.3% to 94.8% (p<0.01). Overall, WLHIV had significantly higher proportions of reported satisfaction with HFS interactions compared to HIV-negative women. A total of 680 pregnant women were included in the retention analysis; 454 (66.8%) HIV-negative and 226 (33.2%) WLHIV. In the pre- and post-periods, 59.4% and 64.6%, respectively, attended at least four ANC visits (p = 0.16). The proportion of women retained at six months increased from 60.9% in the pre-period to 72.7% in the post-period (p = 0.03). For HIV-negative women, pre- and post-period six-month retention significantly increased from 56.6% to 71.6% (p = 0.02); however, the increase in WLHIV retained at six months from 70.7% (pre-period) to 75.0% (post-period) was not statistically significant (p = 0.64). CONCLUSION: The type of rapid quality improvement intervention we implemented may be useful in improving patient-provider relationships although whether it can improve retention remains unclear.

Office-Based Addiction Treatment Retention and Mortality Among People Experiencing Homelessness.

Importance: People experiencing homelessness have been disproportionately affected by the opioid overdose crisis. To mitigate morbidity and mortality, several office-based addiction treatment (OBAT) programs designed for this population have been established across the US, but studies have not yet evaluated their outcomes. Objective: To evaluate treatment retention and mortality in an OBAT program designed specifically for individuals experiencing homelessness with opioid use disorder (OUD). Design, Setting, and Participants: A retrospective cohort study was conducted in the Boston Health Care for the Homeless Program (BHCHP). Participants included all adult patients (N = 1467) who had 1 or more OBAT program encounter at BHCHP from January 1 through December 31, 2018. Data analysis was conducted from January 13 to December 14, 2020. Exposures: Sociodemographic, clinical, and addiction treatment-related characteristics were abstracted from the BHCHP electronic health record. Main Outcomes and Measures: The primary outcome was all-cause mortality, identified by linkage to the Massachusetts Department of Public Health vital records. Multivariable Cox proportional hazards regression analyses were performed to evaluate baseline and time-varying variables associated with all-cause mortality. Secondary addiction treatment-related outcomes were abstracted from the electronic health record and included (1) BHCHP OBAT program retention, (2) buprenorphine continuation and adherence verified by toxicology testing, and (3) opioid abstinence verified by toxicology testing. Results: Of 1467 patients in the cohort, 1046 were men (71.3%) and 731 (49.8%) were non-Hispanic White; mean (SD) age was 42.2 (10.6) years. Continuous retention in the OBAT program was 45.2% at 1 month, 21.7% at 6 months, and 11.3% at 12 months. Continuous buprenorphine adherence was 41.5% at 1 month, 17.6% at 6 months, and 10.2% at 12 months, and continuous opioid abstinence was 28.3% at 1 month, 6.1% at 6 months, and 2.9% at 12 months. The all-cause mortality rate was 29.0 deaths per 1000 person-years, with 51.8% dying from drug overdose. Past-month OBAT program attendance was associated with lower mortality risk (adjusted hazard ratio, 0.34; 95% CI, 0.21-0.55). Conclusions and Relevance: Mortality rates were high in this cohort of addiction treatment-seeking homeless and unstably housed individuals with OUD. Although continuous OBAT program retention was low, past-month attendance in care was associated with reduced mortality risk. Future work should examine interventions to promote increased OBAT attendance to mitigate morbidity and mortality in this vulnerable population.

Projected Estimates of Opioid Mortality After Community-Level Interventions.

Importance: The United States is experiencing a crisis of opioid overdose. In response, the US Department of Health and Human Services has defined a goal to reduce overdose mortality by 40% by 2022. Objective: To identify specific combinations of 3 interventions (initiating more people to medications for opioid use disorder [MOUD], increasing 6-month retention with MOUD, and increasing naloxone distribution) associated with at least a 40% reduction in opioid overdose in simulated populations. Design, Setting, and Participants: This decision analytical model used a dynamic population-level state-transition model to project outcomes over a 2-year horizon. Each intervention scenario was compared with the counterfactual of no intervention in simulated urban and rural communities in Massachusetts. Simulation modeling was used to determine the associations of community-level interventions with opioid overdose rates. The 3 examined interventions were initiation of more people to MOUD, increasing individuals' retention with MOUD, and increasing distribution of naloxone. Data were analyzed from July to November 2020. Main Outcomes and Measures: Reduction in overdose mortality, medication treatment capacity needs, and naloxone needs. Results: No single intervention was associated with a 40% reduction in overdose mortality in the simulated communities. Reaching this goal required use of MOUD and naloxone. Achieving a 40% reduction required that 10% to 15% of the estimated OUD population not already receiving MOUD initiate MOUD every month, with 45% to 60%% retention for at least 6 months, and increased naloxone distribution. In all feasible settings and scenarios, attaining a 40% reduction in overdose mortality required that in every month, at least 10% of the population with OUD who were not currently receiving treatment initiate an MOUD. Conclusions and Relevance: In this modeling study, only communities with increased capacity for treating with MOUD and increased MOUD retention experienced a 40% decrease in overdose mortality. These findings could provide a framework for developing community-level interventions to reduce opioid overdose death.

Predictors of disparities in retention in care among African Americans living with HIV.

Limited health literacy may contribute to racial disparities in retention in HIV care. The purpose of this study was to evaluate the effects of health literacy and patient and social-level factors on retention in care among African Americans living with HIV. This study included 699 participants recruited from outpatient HIV clinics and retention in care was defined as visit adherence. Multivariable logistic regression models were used to assess predictors of visit adherence among persons with 100% visit adherence compared to less than 100% visit adherence. Controlling for demographic factors, the odds of 100% visit adherence was greater among non-African Americans compared to African Americans. In models that included health literacy, race was no longer significant and health literacy was a significant predictor of 100% visit adherence. Among participants with less than 100% visit adherence, health literacy was not a significant predictor of visit adherence; however, age, marital status, and patient attitudes towards the health care provider were significant predictors. Findings suggest that health literacy may mediate the relationship between race and visit adherence. Future studies should further examine these relationships and develop interventions that target modifiable factors, with a goal of improving health equity and minimizing disparities.

Antiretroviral prescription, retention in care and viral suppression by place of birth among adults with diagnosed HIV in the United States-2015-2017, medical monitoring project.

HIV clinical outcomes have not been fully assessed by place of birth at the national level. We analyzed the Medical Monitoring Project data, an annual cross-sectional survey designed to produce nationally representative estimates on adults with diagnosed HIV in the United States, collected during 2015-2017 (n = 7617). We compared sociodemographic, behavioral, and clinical outcomes by place of birth using Rao-Scott chi-square tests (P < .05). Overall, 13.6% of adults with diagnosed HIV were non-US-born. During the past 12 months, a higher percentage of non-US-born than US-born adults, respectively, were prescribed ART (89.4% vs. 84.1%), retained in care (87.1% vs. 80.0%), virally suppressed at the last test (77.2% vs. 70.9%), and had sustained viral suppression (70.9% vs. 63.3%). A lower percentage of non-US-born adults reported binge drinking (13.0% vs. 16.1%), using non-injection drugs (15.3% vs. 31.7%), and suffering from depression (15.9% vs. 23.3%) or anxiety (10.0% vs. 20.2%). A significantly higher percentage of non-US-born adults had Ryan White HIV/AIDS Program (RWHAP) coverage (54.4% vs. 43.1%) and attended a RWHAP-funded health care facility (73.9% vs. 66.6%). Factors contributing to better HIV clinical outcomes among non-US-born persons may include access to RWHAP coverage, lower levels of substance use, and better mental health.

Reporting on patients living with HIV "disengaging from care". Who is actually "lost to follow-up"?

Retention in care remains an important concern for health care providers. However, accurately identifying who is or is not retained in care can be problematic. Not all patients believed to be engaged in care are actually in care, and not all patients believed to be disengaged are truly disengaged. Identifying the status of individuals within populations is important for clinical, administrative and surveillance concerns. As part of the Linkage and Retention in Care Project at St Michael's Hospital in Toronto, Canada, we investigated the status of patients diagnosed with HIV. Detailed investigation determined who was actually Lost-to-Follow-Up (i.e., disengaged from care >12 months) and who had disengaged for known reasons. This approach determined more precisely who was currently followed in care and who was not, and to target efforts to contact and reengage patients more effectively. This study illustrates the importance of accurately monitoring populations enhancing disease management.

Buprenorphine Medication for Opioid Use Disorder: A Study of Factors Associated With Postpartum Treatment Retention.

BACKGROUND AND OBJECTIVES: The factors associated with medication for opioid use disorder (MOUD) treatment retention among pregnant women with opioid use disorder (OUD) are largely unknown. This study sought to characterize factors associated with postpartum treatment retention. METHODS: A retrospective chart review from 2014 to 2017 was conducted among women with OUD in pregnancy treated with buprenorphine. Women were assigned to the treatment retention group if they attended an appointment within 10 to 14 weeks postpartum. Others were assigned to the dropout group. The groups were compared using bivariate analysis for sociodemographic variables, obstetrical and neonatal outcomes, clinical and subjective opioid withdrawal symptoms, buprenorphine dosage, urine drug toxicology (UDT) results, and other factors. RESULTS: A total of 64 pregnancies received treatment until delivery, and 47 (73.1%) were retained in treatment by 12 weeks postpartum. The treatment dropout group had lower buprenorphine doses at delivery, a higher percentage of benzodiazepine positive UDT, and number of UDT positive for benzodiazepine in the third trimester. Breastfeeding rates were higher in the treatment retention group. DISCUSSION AND CONCLUSIONS: Future research of variables related to postpartum treatment retention is needed to provide guidelines regarding MOUD during the perinatal period and to optimize maternal and fetal well-being. SCIENTIFIC SIGNIFICANCE: This study supports previous recommendations that aggressive treatment of withdrawal symptoms in pregnant women with OUD is needed to maximize treatment retention. This is the first study to find that breastfeeding was associated with postpartum treatment retention; while, increased use of benzodiazepines during pregnancy was associated with postpartum treatment dropout. (Am J Addict 2021;30:43-48).

Identifying patterns of retention in care and viral suppression using latent class analysis among women living with HIV in Florida 2015-2017.

The study objective was to classify women with newly diagnosed HIV into patterns of retention in care (≥2 HIV care visits ≥3 months apart) and viral suppression over time and identify factors associated with class membership. Florida HIV/AIDS surveillance data were used to conduct Latent Class Analysis to classify women into patterns, and multinomial regression was used to compare the prevalence of class membership by demographic and clinical factors. Four classes were selected based on model fit parameters: (Class 1) consistently retained and suppressed (>90% probability of being retained and suppressed), (Class 2) not consistently retained or suppressed (≤10% probability of being retained and suppressed), (Class 3) increasingly retained and suppressed, and (Class 4) decreasingly retained and suppressed. The proportion of women in each class was 48.6%, 24.9%, 14.3%, and 12.2%, respectively. Women aged 25-34 compared to 35-49 years old, injection drug use mode of exposure, US born, and not linked to care three months post-diagnosis had a lower prevalence of belonging to the consistently retained and suppressed class. Findings may be useful in tailoring and targeting interventions to increase the prevalence of women who are consistently retained in care and virally suppressed.

The individual, interactive, and syndemic effect of substance use, depression, education, and ethnicity on retention in HIV care.

In this study, we sought to assess the individual, syndemic, and interactive associations between individual-level factors and retention in care. The sample was derived from the Miami Adult Studies on human immunodeficiency virus (HIV)/ acquired immune deficiency syndrome (AIDS) cohort from 2009 to 2014. The variables were entered into a multiple logistic regression with retention as the outcome. Backward regression, adjusting for all main effects, was conducted to determine which two-way interactions were associated with retention. Multivariable logistic regression was used to test which number of factors were associated with retention. Non-Hispanic Black race/ethnicity was associated with improved retention (odds ratio [OR] = 2.44, 95% confidence interval [CI]: 1.06-5.75, p ≤ 0.05) when compared to Non-Hispanic White persons. Black-Hispanic and Other racial/ethnic identities were associated with increased retention (OR = 4.84, 95%CI: 1.16-25.79, p ≤ 0.05 and OR = 7.24, 95%CI: 1.54-54.05, p ≤ 0.05, respectively) when compared to Non-Hispanic White persons. The interaction between depressive symptoms and Alcohol Use Disorder Identification Test (AUDIT, a test that assesses alcohol use disorder) score was significantly and negatively associated with retention in HIV care (OR = 0.14, 95%CI: 0.01-1.11, p ≤ 0.10). The interaction between age and male gender was also negatively associated with retention (OR = 0.95, 95%CI: 0.88-1.01, p ≤ 0.10), and the interaction between male gender and depression was positively associated with retention (OR = 7.17, 95%CI: 0.84-98.49, p ≤ 0.10). In conclusion, multiple races/ethnicities, specifically Non-Hispanic Black, Black-Hispanic, and Other racial/ethnic identification, were associated with increased odds of retention. Multiple interactions, specifically depressive symptoms * alcohol use disorder and male gender * age, were negatively associated with retention. The male gender * depression interaction was positively associated with retention in HIV care.

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

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.

Cumulative Effects of Stigma Experiences on Retention in HIV Care Among Men and Women in the Rural Southeastern United States.

The stigmatization of HIV infection impedes every step along the HIV continuum of care, particularly care engagement and retention. The differential effects of various sources of stigma on retention in HIV care have been the subject of limited research. We examined the accumulation of HIV stigma experiences over 1 year in relationship to treatment retention among 251 men and women marginally engaged in HIV care in the southeastern United States. Results showed that cumulative stigma experiences predicted poorer retention in care, with greater stigma experiences related to less consistency in attending scheduled medical appointments. HIV stigma originating from family members and acts of overt discrimination were the most frequently experienced sources of stigma and were most closely associated with disengagement from HIV care. In addition, analyses by gender indicated that retention in care for men was impacted by stigma to a greater extent than among women. These findings reaffirm the importance of HIV stigma as a barrier to HIV care and provide new directions for interventions to mitigate the negative effects of stigma on patients who are not fully engaged in HIV care. Clinical trials registration NCT104180280.

Transition from pediatric to adult care for adolescents living with HIV in South Africa: A natural experiment and survival analysis.

OBJECTIVE: To determine rates of retention and viral suppression among adolescents living with perinatally-acquired HIV who remained in pediatric care compared to those who transitioned to adult care. METHODS: We evaluated a natural experiment involving adolescents living with perinatally-acquired HIV who were attending a government-supported antiretroviral clinic in KwaZulu-Natal, South Africa. Prior to 2011, all adolescents transitioned to adult care at 12 years of age. Due to a policy change, all adolescents were retained in pediatric care after 2011. We analyzed adolescents two years before and two years after this policy change. Outcomes were retention in care and HIV viral suppression one year after transition to adult care or the 13th birthday if remaining in pediatric care. RESULTS: In the natural experiment, 180 adolescents who turned 12 years old between 2011 and 2014 were evaluated; 35 (20%) transitioned to adult care under the old policy and 145 (80%) remained in pediatric care under the new policy. Adolescents who transitioned to the adult clinic had lower rates of retention in care (49%; 17/35) compared to adolescents remaining in the pediatric clinic (92%; 134/145; p<0.001). Retention in care was lower (ARR 0.59; 95%CI 0.43-0.82; p = 0.001) and viral suppression was similar (ARR = 1.06, 95%CI 0.89-1.26; p = 0.53) for adolescents who transitioned to adult care compared to adolescents remaining in pediatric care. CONCLUSION: Adolescents living with perinatally-acquired HIV appear to have higher retention in care when cared for in pediatric clinics compared to adult clinics. Longer-term follow-up is needed to fully assess viral suppression.

A cluster feasibility trial to explore the uptake and use of e-cigarettes versus usual care offered to smokers attending homeless centres in Great Britain.

Smoking rates in the UK are at an all-time low but this masks considerable inequalities; prevalence amongst adults who are homeless remains four times higher than the national average. The objective of this trial was to assess the feasibility of supplying free e-cigarette starter kits to smokers accessing homeless centres and to estimate parameters to inform a possible future larger trial. In this feasibility cluster trial, four homeless centres in Great Britain were non-randomly allocated to either a Usual Care (UC) or E-Cigarette (EC) arm. Smokers attending the centres were recruited by staff. UC arm participants (N = 32) received advice to quit and signposting to the local Stop Smoking Service. EC arm participants (N = 48) received an EC starter kit and 4-weeks supply of e-liquid. Outcome measures were recruitment and retention rates, use of ECs, smoking cessation/reduction and completion of measures required for economic evaluation. Eighty (mean age 43 years; 65% male) of the 153 eligible participants who were invited to participate, were successfully recruited (52%) within a five-month period, and 47 (59%) of these were retained at 24 weeks. The EC intervention was well received with minimal negative effects and very few unintended consequences (e.g. lost, theft, adding illicit substances). In both study arm, depression and anxiety scores declined over the duration of the study. Substance dependence scores remained constant. Assuming those with missing follow up data were smoking, CO validated sustained abstinence at 24 weeks was 3/48 (6.25%) and 0/32 (0%) respectively for the EC and UC arms. Almost all participants present at follow-up visits completed data collection for healthcare service and health-related quality of life measures. Providing an e-cigarette starter kit to smokers experiencing homelessness was associated with reasonable recruitment and retention rates and promising evidence of effectiveness and cost-effectiveness.