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Retention in Care Is More Strongly Associated With Viral Suppression in HIV-Infected Patients With Lower Versus Higher CD4 Counts

Yehia, Baligh R. MD, MPP, MSHP*,†,‡; French, Benjamin PhD§; Fleishman, John A. PhD; Metlay, Joshua P. MD, PhD; Berry, Stephen A. MD, PhD#; Korthuis, P. Todd MD, MPH**; Agwu, Allison L. MD, ScM#; Gebo, Kelly A. MD, MPH#; for the HIV Research Network

JAIDS Journal of Acquired Immune Deficiency Syndromes: 1 March 2014 - Volume 65 - Issue 3 - p 333–339
doi: 10.1097/QAI.0000000000000023
Clinical Science

Background: Retention in care is important for all HIV-infected patients, but may be more important for people with advanced HIV disease. We evaluated whether the association between retention in care and viral suppression differed by HIV disease severity.

Methods: A repeated cross-sectional analysis (2006–2011) involving 35,433 adults at 18 US HIV clinics. Multivariable logistic regression models examined associations between retention measures [Health Resources and Services Administration (HRSA) retention measure, 6-month gap, and 3-month visit constancy] and viral suppression (HIV-1 RNA ≤400 copies/mL) for HIV disease severity groups defined by CD4 counts: ≤200, 201–350, 351–500, and >500 cells per cubic millimeter.

Results: Overall, patients met the HRSA measure in 84% of person-years, did not have a 6-month gap in 76%, and had visits in all 4 quarters in 37%; patients achieved viral suppression in 72% of person-years. The association between retention in care and viral suppression differed by disease severity, and was strongest for patients with lower CD4 counts: ≤200 [adjusted odds ratio (AOR) = 2.33, 95% confidence interval (CI): 2.16 to 2.51], 201–350 (AOR = 1.96, CI: 1.81 to 2.12), 351–500 (AOR = 1.65, CI: 1.53 to 1.78), and >500 cells per cubic millimeter (AOR = 1.22, CI: 1.14 to 1.30) using the HRSA retention measure as a representative example.

Conclusions: This is one of the first studies to report the impact of HIV disease severity on retention in care and viral suppression, demonstrating that retention in care is more strongly associated with viral suppression in patients with lower CD4 counts. These results have important implications for improving the health of patients with advanced HIV disease and for test and treat approaches to HIV prevention.

*Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;

Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA;

Philadelphia Veterans Affairs Center for Health Equity Research and Promotion, Philadelphia, PA;

§Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA;

Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD;

Department of Medicine, Massachusetts General Hospital, Boston, MA;

#Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and

**Department of Medicine, Oregon Health and Sciences University, Portland, OR.

Correspondence to: Baligh R. Yehia, MD, MPP, MSHP, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 1021 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104 (e-mail: byehia@upenn.edu).

Supported by the Agency for Healthcare Research and Quality (HHSA290201100007C) and the National Institutes of Health (K23-MH097647 to B.R.Y.).

B.R.Y., B.F., J.A.F., and K.A.G. contributed to the study design, analyses and interpretation of data, and writing and revisions of the articles. J.P.M. contributed to the study design, interpretation of data, and critical revisions of the article. P.T.K. and A.L.A. contributed to the data collection, interpretation of data, and critical revisions of the article. S.A.B. contributed to the interpretation of data and critical revision of the article.

Presented at the Eighth International Conference on HIV Treatment and Prevention, June 2–4, 2013, Miami, FL.

The views expressed in this article are those of the authors. No official endorsement by the National Institutes of Health or the Agency for Healthcare Research and Quality is intended or should be inferred.

K.A.G. served as a consultant to Tibotec and Bristol-Myers Squibb, and received grants from Tibotec. All other authors have no conflicts of interest to disclose.

Received July 15, 2013

Accepted September 30, 2013

© 2014 by Lippincott Williams & Wilkins