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Impact of HIV care facility characteristics on the cascade of care in HIV-infected patients in the Netherlands

Engelhard, Esther A.N.; Smit, Colette; Van Sighem, Ard; Reiss, Peter; Nieuwkerk, Pythia T.; Kroon, Frank P.; Brinkman, Kees; Geerlings, Suzanne E.

doi: 10.1097/QAD.0000000000000938
Epidemiology and Social
Free

Objective: Successful treatment of people infected with HIV requires that patients are retained in HIV care, use combination antiretroviral therapy (cART) and ultimately reach and sustain viral suppression. Our aim was to identify health facility characteristics associated with these steps in the cascade of HIV care.

Design: Retrospective cohort study.

Methods: We included data from all adult HIV-1-infected patients who entered care in the Netherlands between 2007 and 2013 (N = 7120). Multivariate logistic regression was used to examine the associations between health facility characteristics and the outcomes ‘currently in care’, ‘initiated cART’, and ‘viral suppression’.

Results: The proportion of patients ‘currently in care’ was high in all 26 treatment centres. cART initiation was positively associated with the accreditation of the health facility [OR (odds ratio): 1.62; 95% CI (confidence interval): 1.18–2.23] and the performance of an internal audit in the preceding 3 years (OR: 1.36; 95% CI: 1.02–1.81). The odds of cART initiation were higher in middle-sized (OR: 2.00; 95% CI: 1.25–3.21) and large HIV treatment centres (OR: 1.80; 95% CI: 1.14–2.84) compared with small centres (<300 HIV-infected patients). Viral suppression was negatively associated with the presence of a social worker in the HIV treatment team (OR: 0.62; 95% CI: 0.43–0.91).

Conclusions: Our results confirm that appointing expert HIV treatment centres facilitates retention in care and that a minimum volume requirement may be desirable. Our findings suggest that quality assessment through accreditation and the measurement of performance benefits the delivery of HIV care.

aDivision of Infectious Diseases, Academic Medical Center of the University of Amsterdam

bStichting HIV Monitoring, Amsterdam

cDepartment of Global Health, Academic Medical Center of the University of Amsterdam and Amsterdam Institute for Global Health and Development

dDepartment of Medical Psychology, Academic Medical Center of the University of Amsterdam, Amsterdam

eDepartment of Infectious Diseases, Leiden University Medical Center, Leiden

fDepartment of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands.

Correspondence to Esther A.N. Engelhard, MD, Stichting HIV Monitoring, Tafelbergweg 51, 1105 BD Amsterdam, the Netherlands. Tel: +31 20 566 41 72; fax: +31 20 566 91 89; e-mail: eaengelhard@outlook.com

Received 30 July, 2015

Revised 5 October, 2015

Accepted 12 October, 2015

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Introduction

The prognosis for people infected with Human Immunodeficiency Virus (HIV) has improved greatly due to advances in combination antiretroviral therapy (cART) in the past two decades. To fully benefit from cART, it is essential that HIV-infected persons successfully engage in all steps along the continuum of care [1]. These steps, often illustrated as the cascade of HIV care, include HIV testing, linkage to care, retention in care, initiation of antiretroviral treatment (cART), and viral suppression.

Each of these steps may be affected by numerous individual and systemic factors [2]. The majority of studies addressing this issue has focused on patient characteristics. Identified patient-level barriers to engagement in the HIV care continuum include mental health issues [3,4], substance use [5,6], perceived HIV stigma [7,8], and unstable housing [9–11]. Reported systemic barriers include factors such as lack of insurance coverage [12–15] or poor infrastructure [16–19].

With regards to health facility level factors, evidence suggests that hospital volume and provider training and experience improve outcomes in HIV-infected patients [20,21]. However, professionals involved in designing best practices for HIV outpatient care are largely dependent on results from studies predating the advent of cART, often performed in an inpatient setting.

The aim of the present study was to evaluate the association between health facility characteristics and three steps of the cascade of HIV care that follow linkage to care. Patients in care in all of the 26 HIV treatment centres in the Netherlands were included in the study. The availability of these nationwide data, together with access to HIV treatment for all citizens of the Netherlands, provides a strong foundation for this type of research.

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Methods

Setting and data collection

In the Netherlands, the care for HIV-infected patients is centralized within designated HIV treatment centres (N = 26). The centres are required to meet criteria regarding staffing (such as the presence of at least two experienced infectious disease specialists and one specialised nurse), and care site volume (at least 160 HIV-infected patients in care). In addition, the centres must collaborate with the national surveillance system that monitors every HIV-infected patient in care. Data are obtained in the AIDS therapy evaluation in the Netherlands (ATHENA) cohort, maintained by the Stichting HIV Monitoring (SHM) [22]. For the collection of health facility characteristics, we developed a survey based on a review of the relevant literature. It was completed by the coordinating HIV clinicians of the HIV treatment centres between October 2012 and January 2013.

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Study population

Data of all the HIV-1-infected persons who had been linked to care in the Netherlands (i.e. registered in the SHM database and seen in one of the HIV treatment centres) between 2007 and 2013 were included in this study. Patients were aged ≥18 years at time of diagnosis. Patients who were known to have died or emigrated within this period, and patients who had opted out of registration in the SHM database at linkage to care were excluded.

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Outcomes

We studied three steps of the HIV care cascade. First, we used a cross-sectional approach to assess retention in care by calculating the proportion of patients who were ‘currently in care’. Currently in care was defined as having clinical evidence of being in care, such as a documented clinical visit or lab result after 1 January 2012. Patients not ‘currently in care’ were considered lost to follow-up. The second outcome measure, ‘cART initiation’ was the proportion of patients who had initiated cART (≥three antiretroviral drugs from ≥two classes) during the study period. The final outcome measure ‘viral suppression’ was defined as a last documented HIV RNA measurement (after 1 January 2012) of <100 copies/ml.

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Statistical analysis

First, we calculated the proportions of our study population who were currently in care. We had initiated cART and were virally suppressed and then assessed the variation in these outcomes between the HIV treatment centres.

After examining bivariate associations between treatment centre characteristics and the three outcome measures, we conducted backward logistic regression analyses with generalized estimating equation to adjust for potential hospital clustering [23]. The first multivariable regression model, assessing the outcome ‘currently in care’, was applied to all patients who were linked to care. The second model, ‘cART initiation’ was applied to the patients who were ‘currently in care’. The population in the final model, ‘viral suppression’, comprised the patients who were currently in care, had initiated cART ≥6 months prior to the last HIV RNA measurement and were still on cART.

All health facility variables with a bivariate P value <0.3, and all patient covariates (regardless of P value) were considered potential determinants. Backward selection was performed until all variables had a multivariable P value <0.05.

The following health facility characteristics were assessed:

  • Small (<300), medium (300–600), or large (>600 HIV-infected patients in care) treatment centre size (thresholds determined by calculation of tertiles and lowering the first threshold of 450 patients to the more commonly used threshold of 300 in previous studies [21,24]).
  • Disciplines in the HIV treatment team (separately): clinical pharmacologist, medical microbiologist, social worker, psychologist, and/or psychiatrist.
  • Policy/organization plan specifically for the HIV treatment centre (stating mission, vision and goals).
  • Separate HIV outpatient clinic (versus jointly with other conditions at the internal medicine outpatient clinic).
  • Internally organized audit in the 3 preceding years (evaluating performance of the HIV treatment centre).
  • Voluntary accreditation (of health facility in which the HIV treatment centre is embedded, for example by The Joint Commission International).

Patient covariates were: age, sex, region of origin, socioeconomic status (SES), mode of HIV transmission, CD4+ cell count and HIV RNA load (at entry and recent), and presence of AIDS-defining condition according to the Centers for Disease Control and Prevention classification (CDC category C) [25]. Region of origin, based on the country of birth, was grouped into the Netherlands, sub-Saharan Africa, and other. For the SES we used a classification system previously described by the Netherlands Institute for Social Research. Here, we recoded the five classes, based on area code, as high, middle, or low [26].

Our adjustment for virological and immunological status differed per model. In the ‘currently in care’ model, we corrected for CD4+ cell count and HIV RNA at linkage, assuming that patients who enter care at a late stage of HIV infection are more likely to retain in care than healthy patients. In the ‘cART initiation’ model we adjusted for recent measurements of HIV RNA and CD4+ cell counts (first measurement in 2012) for patients not yet on cART; and for measurements at the time of cART initiation for patients on cART. Finally, in the ‘viral suppression’ model, we corrected for HIV RNA and CD4+ cell counts at time of cART initiation. The analyses were performed using STATA (version 13).

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Sensitivity analyses

To assess the validity of our measures of retention in care and viral suppression, we performed two sensitivity analyses. First, we assessed whether patients had visited the outpatient clinic in each calendar year following linkage to care. Second, we assessed the number of viral blips (>200 copies/ml) the 3 years preceding the last HIV RNA measurement.

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Results

All HIV treatment centres in the Netherlands agreed to participate in our study. In total, 7120 patients were linked to care from 2007 onwards. The majority of patients were of Dutch origin and MSM (Table 1). Baseline characteristics were similar across the different treatment centre sizes. Of the 7120 patients who had ever been linked to care, 97% were currently in care, 73% had initiated cART, and 59% had an undetectable viral load (Fig. 1).

Table 1

Table 1

Fig. 1

Fig. 1

Table 2 shows the characteristics of the 26 health facilities in the Netherlands. Medical microbiologist was the most common additional discipline (N = 19), followed by social worker (N = 12), clinical pharmacologist (N = 12), and psychologist/psychiatrist (N = 11).

Table 2

Table 2

Figure 2 illustrates the variation in outcomes between the 26 HIV treatment centres, which was largest for the outcome ‘cART initiation’ (53–92%), followed by ‘viral suppression’ (81–100%), and ‘currenty in care’ (92–100%).

Fig. 2

Fig. 2

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Currently in care

Table 3 shows the adjusted associations between the health facility characteristics and the three outcomes. No significant associations were found between health facility characteristics and the outcome ‘currently in care’. The patient factors associated with being currently in care were region of origin (lower odds in non-Dutch patients), HIV RNA at linkage to care (increasing ORs with higher viral load), and CD4+ cell count (lower ORs among patients with >200 cells/μl at linkage to care).

Table 3

Table 3

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Combination antiretroviral therapy initiation

The odds of cART initiation were higher in HIV treatment centres that were embedded within health facilities with a quality accreditation (OR: 1.62; 95% CI: 1.18–2.23). cART initiation was also positively associated with the measurement of performance (i.e. internal audit) in the preceding 3 years (OR: 1.36; 95% CI: 1.02–1.81). Finally, the odds of cART initiation were higher in middle-sized (300–600 patients; OR: 2.00; 95% CI: 1.25–3.21) and large HIV treatment centres (>600 patients; OR: 1.80; 95% CI: 1.14–2.84) compared with small centres (<300 patients in care). Higher HIV RNA levels and lower CD4+ cell counts measured recently or at time of cART initiation were significantly associated with cART initiation. cART initiation was less common among patients coming from a region outside the Netherlands or sub-Saharan Africa.

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Viral suppression

Viral suppression was negatively associated with the presence of a social worker in the multidisciplinary HIV treatment team (OR: 0.62; 95% CI: 0.43–0.91). Non-MSM patients were also less likely to be virally suppressed.

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Sensitivity analyses

Of the ‘currently in care’ patients who entered care in 2007, 93% had no more than one calendar year in which they did not attend the outpatient clinic. This proportion increased over time reaching 100% of those who entered care in 2012. With regards to the virally suppressed population, less than 4% had two or more blips (>200 copies/ml) in the 3 years preceding the last HIV-RNA measurement.

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Discussion

In this study we examined health facility-related factors associated with retention in care (measured as the proportion ‘currently in care’), initiation of cART, and viral suppression among the adult HIV-1-infected population that was linked to care in the Netherlands from 2007 onwards.

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Retention in care

An important finding is that the proportion of HIV-infected patients that remains currently in care is high (97%) and that this applies to all of the HIV treatment centres in the Netherlands (92–100%). Although the great heterogeneity in methods for measuring retention in care complicates the comparison of our results with those of other studies, attrition in this step of the cascade appears to be less prominent in the Netherlands than in many other settings, where loss to follow-up rates of 25–44% have been reported [27].

A number of factors, unique to the Dutch setting, should be taken into account. Among them, the mandatory health insurance policy in the Netherlands, ensuring access to HIV care, is an important one. Furthermore, the relatively small size of the Netherlands may contribute to the high retention rates. The association between distance to care and continued HIV care has been demonstrated previously [14,18]. In addition, the remarkably low proportion of intravenous drug users, accounting for 0.3% of new infections annually [22], likely impacts the levels of engagement in care in our study population. Finally, the high rate of retention may also in part be attributed to the well structured HIV care system, in which all patients are monitored [22], and care is assigned to providers and facilities with experience.

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Combination antiretroviral therapy initiation

The odds of cART initiation were higher among patients in care at accredited health facilities and at HIV treatment centres that reported to have performed an assessment of the quality of HIV care (i.e. internal audit). The data support the practice of audit and feedback as a strategy to improve health professionals’ performance [28].

Finally, the odds of cART initiation were lower in treatment centres with <300 patients in care (N = 6). However, factors that were not adjusted for, including hepatitis coinfection, psychiatric comorbidity and pregnancy, may have led to residual confounding. Nevertheless, our data support the hypothesis that treating more patients with a specific condition increases expertise, as demonstrated in previous studies in HIV-infected patients [20].

Of the three measures ‘cART initiation’ shows the most variation between treatment centres (53–92%); and appears to correlate more with health-facility level factors than the other two measures. ‘cART initiation’, in contrast to the outcome measures ‘currently in care’ and ‘viral suppression’, is a process measure, meaning that it measures the activities of care providers. Against this background, our results correspond with the notion that process measures are more directly under provider or system control [29], whereas outcome measures are largely impacted by patient factors.

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Viral suppression

The rates of viral suppression among patients who had been using cART >6 months at the HIV treatment centres ranged from 81–100%. Interestingly, the odds were lower among patients with a social worker in their treatment team. We hypothesize that centres with a relatively complicated patient population are more likely to have a social worker in the team (N = 12).

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Patient factors

Consistent with previous research, our results suggest that immigrant patients are more at risk to attrition over the course of HIV treatment [30,31]. This also applies to non-MSM patients compared with MSM, possibly because MSM often have supportive networks within gay communities [32]. Healthcare workers and researchers need to take a closer look at why these groups of patients seem to have suboptimal engagement in care. The absence of an association between social economic status and the three outcomes confirms that ensured access to healthcare (i.e. mandatory health insurance) benefits engagement in HIV care.

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Strengths and limitations

A major strength of this study is the large study population including nationwide data of all HIV-infected patients. All HIV treatment centres in the Netherlands participated in the study, thus ruling out selection bias. Attrition bias along the HIV care continuum because of disparities in access to care is likely to be low in our population because all citizens in the Netherlands are required to have health insurance.

Our study has some limitations. Owing to the cross-sectional design in which we assume that health facility characteristics were consistent in the 5 years prior the collection of the data, we cannot infer causality between the characteristics and outcomes. Furthermore, our cross sectional approach for measuring retention in care does not account for time since linkage to care, time in between visits and missed visits. Longitudinal approaches have been developed but no gold standard has been established [33]. Our sensitivity analysis data support our assumption of continued care in patients who are currently in care. With regards to our cross-sectional viral suppression measure, our sensitivity analysis shows that the vast majority of patients with a last undetectable viral load has had sustained viral suppression in the 3 preceding years.

We did not account for criteria regarding cART eligibility in the assessment of cART initiation, but since the Dutch HIV guidelines follow the Department of Health and Human Services guidelines, recent guidelines recommend to consider cART in every HIV-infected patient regardless of CD4+ cell count [34]. Finally, our adjustment for SES has its limitations because it is based on area codes, and not on individual patient data.

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Implications

Our findings suggest that adherence to clinical guidelines is higher in health facilities that have been externally evaluated (accreditation) and that perform internal quality improvement initiatives (internal audits). Although we cannot make concrete recommendations regarding volume requirements on the basis of our results, our data and those of previous studies suggest that a minimum volume requirement is desirable [24,35,36].

In this study we have studied the performance of care after linkage to an outpatient clinic. A great challenge, however, is targeting the earlier steps in the cascade of care, namely diagnosis and linkage to care. Estimates suggest that more than 15–34% of HIV-infected persons in the Netherlands are unaware of their status [37,38]. Earlier diagnosis and linkage to care are crucial issues to be addressed by researchers and policy makers.

We conclude that ensuring access to HIV care, appointing expert health facilities and care providers, and routine monitoring of HIV-infected patients promotes retention in care. Quality assessment through accreditation and the measurement of performance benefits the delivery of HIV care.

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Acknowledgements

All authors contributed to the design of the study. E.A.N.E. collected and analysed the data, and prepared the manuscript. All authors critically revised the manuscript and approved the final version of the article.

Funding: Aids Fonds, research grant number 2011015.

Clinical centres: ‘*’ denotes site coordinating physician. Academic Medical Centre of the University of Amsterdam: HIV treating physicians: J.M. Prins*, T.W. Kuijpers, H.J. Scherpbier, J.T.M. van der Meer, F.W.M.N. Wit, M.H. Godfried, P. Reiss, T. van der Poll, F.J.B. Nellen, S.E. Geerlings, M. van Vugt, D. Pajkrt, J.C. Bos, W.J. Wiersinga, M. van der Valk, A. Goorhuis, J.W. Hovius. HIV nurse consultants: J. van Eden, A. Henderiks, A.M.H. van Hes, M. Mutschelknauss, H.E. Nobel, F.J.J. Pijnappel, A.M. Westerman. HIV clinical virologists/chemists: S. Jurriaans, N.K.T. Back, H.L. Zaaijer, B. Berkhout, M.T.E. Cornelissen, C.J. Schinkel, X.V. Thomas. Admiraal De Ruyter Ziekenhuis, Goes: HIV treating physicians: M. van den Berge, A. Stegeman. HIV nurse consultants: S. Baas, L. Hage de Looff. HIV clinical virologists/chemists: D. Versteeg. Catharina Ziekenhuis, Eindhoven: HIV treating physicians: M.J.H. Pronk*, H.S.M. Ammerlaan. HIV nurse consultants: E.M.H.M. Korsten-Vorstermans, E.S. de Munnik. HIV clinical virologists/chemists: A.R. Jansz, J. Tjhie, M.C.A. Wegdam, B. Deiman, V. Scharnhorst. Emma Kinderziekenhuis: HIV nurse consultants: A. van der Plas, A.M. Weijsenfeld. Erasmus Medisch Centrum, Rotterdam: HIV treating physicians: M.E. van der Ende*, T.E.M.S. de Vries-Sluijs, E.C.M. van Gorp, C.A.M. Schurink, J.L. Nouwen, A. Verbon, B.J.A. Rijnders, H.I. Bax, R.J. Hassing, M. van der Feltz. HIV nurse consultants: N. Bassant, J.E.A. van Beek, M. Vriesde, L.M. van Zonneveld. Data collection: A. de Oude-Lubbers, H.J. van den Berg-Cameron, F.B. Bruinsma-Broekman, J. de Groot, M. de Zeeuw- de Man. HIV clinical virologists/chemists: M. Schutten, A.D.M.E. Osterhaus, C.A.B. Boucher. Erasmus Medisch Centrum–Sophia, Rotterdam: HIV treating physicians: G.J.A. Driessen, A.M.C. van Rossum. HIV nurse consultants: L.C. van der Knaap, E. Visser. Flevoziekenhuis, Almere: HIV treating physicians: J. Branger*. HIV nurse consultant and data collection: C.J.H.M. Duijf-van de Ven. HagaZiekenhuis, Den Haag: HIV treating physicians: E.F. Schippers*, C. van Nieuwkoop, R.W. Brimicombe. HIV nurse consultants: J.M. van IJperen. Data collection: G. van der Hut. HIV clinical virologist/chemist: P.F.H. Franck. HIV Focus Centrum (DC Klinieken): HIV treating physicians: A. van Eeden*. HIV nurse consultants: W. Brokking, M. Groot, L.J.M. Elsenburg. HIV clinical virologists/chemists: M. Damen, I.S. Kwa. Isala Klinieken, Zwolle: HIV treating physicians: P.H.P. Groeneveld*, J.W. Bouwhuis. HIV nurse consultants: J.F. van den Berg, A.G.W. van Hulzen. Data collection: G.L. van der Bliek, P.C.J. Bor. HIV clinical virologists/chemists: P. Bloembergen, M.J.H.M. Wolfhagen, G.J.H.M. Ruijs. Kennemer Gasthuis, Haarlem: HIV treating physicians: S.F.L. van Lelyveld*, R. Soetekouw. HIV nurse consultants: N. Hulshoff, L.M.M. van der Prijt, M. Schoemaker. Data collection: N. Bermon. HIV clinical virologists/chemists: W.A. van der Reijden, R. Jansen, B.L. Herpers, D.Veenendaal. Leids Universitair Medisch Centrum, Leiden: HIV treating physicians: F.P. Kroon*, S.M. Arend, M.G.J. de Boer, M.P. Bauer, H. Jolink, A.M. Vollaard. HIV nurse consultants: W. Dorama, N. van Holten. HIV clinical virologists/chemists: E.C.J. Claas, A.C.M. Kroes. Maasstad Ziekenhuis, Rotterdam: HIV treating physicians: J.G. den Hollander*, K. Pogany. HIV nurse consultants: M. Kastelijns, J.V. Smit, E. Smit. Data collection: M. Bezemer, T. van Niekerk. HIV clinical virologists/chemists: O. Pontesilli. Maastricht UMC+, Maastricht: HIV treating physicians: S.H. Lowe*, A. Oude Lashof, D. Posthouwer. HIV nurse consultants: R.P. Ackens, J. Schippers, R. Vergoossen. Data collection: B. Weijenberg Maes. HIV clinical virologists/chemists: P.H.M. Savelkoul, I.H. Loo. MC Zuiderzee, Lelystad: HIV treating physicians: S. Weijer*, R. El Moussaoui. HIV nurse consultant: A.S. Bosma. Medisch Centrum Alkmaar: HIV treating physicians: W. Kortmann*, G. van Twillert*, J.W.T. Cohen Stuart, B.M.W. Diederen. HIV nurse consultant and data collection: D. Pronk, F.A. van Truijen-Oud. HIV clinical virologists/chemists: W. A. van der Reijden, R. Jansen. Medisch Centrum Haaglanden, Den Haag: HIV treating physicians: E.M.S. Leyten*, L.B.S. Gelinck. HIV nurse consultants: A. van Hartingsveld, C. Meerkerk, G.S. Wildenbeest. HIV clinical virologists/chemists: J.A.E.M. Mutsaers, C.L. Jansen. Medisch Centrum Leeuwarden, Leeuwarden: HIV treating physicians: M.G.A. van Vonderen*, D.P.F. van Houte, L.M. Kampschreur. HIV nurse consultants: K. Dijkstra, S. Faber. HIV clinical virologists/chemists: J Weel. Medisch Spectrum Twente, Enschede: HIV treating physicians: G.J. Kootstra*, C.E. Delsing. HIV nurse consultants: M. van der Burg-van de Plas, H. Heins. Data collection: E. Lucas. Onze Lieve Vrouwe Gasthuis, Amsterdam: HIV treating physicians: K. Brinkman*, P.H.J. Frissen, W.L. Blok, W.E.M. Schouten, G.E.L. van den Berk. HIV nurse consultants: C.J. Brouwer, G.F. Geerders, K. Hoeksema, M.J. Kleene, I.B. van der Meché, A.J.M. Toonen, S. Wijnands. HIV clinical virologists/chemists: M.L. van Ogtrop, R. Jansen. Radboud UMC, Nijmegen: HIV treating physicians: P.P. Koopmans, M. Keuter, A.J.A.M. van der Ven, H.J.M. ter Hofstede, A.S.M. Dofferhoff, R. van Crevel. HIV nurse consultants: M. Albers, M.E.W. Bosch, K.J.T. Grintjes-Huisman, B.J. Zomer. HIV clinical virologists/chemists: F.F. Stelma. HIV clinical pharmacology consultant: D. Burger. Rijnstate, Arnhem: HIV treating physicians: C. Richter*, J.P. van der Berg, E.H. Gisolf. HIV nurse consultants: G. ter Beest, P.H.M. van Bentum, N. Langebeek. HIV clinical virologists/chemists: R. Tiemessen, C.M.A. Swanink. Sint Lucas Andreas Ziekenhuis, Amsterdam: HIV treating physicians: J. Veenstra*, K.D. Lettinga. HIV nurse consultants: M. Spelbrink, H. Sulman. Data collection: M. Spelbrink, E. Witte. HIV clinical virologists/chemists: M. Damen, P.G.H. Peerbooms. Slotervaartziekenhuis, Amsterdam: HIV treating physicians: J.W. Mulder, S.M.E. Vrouenraets, F.N. Lauw. HIV nurse consultants: M.C. van Broekhuizen, H. Paap, D.J. Vlasblom. Data collection: E. Oudmaijer Sanders. HIV clinical virologists/chemists: P.H.M. Smits, A.W. Rosingh. Stichting Medisch Centrum Jan van Goyen, Amsterdam: HIV treating physicians: D.W.M. Verhagen. HIV nurse consultants: J. Geilings. St Elisabeth Ziekenhuis, Tilburg: HIV treating physicians: M.E.E. van Kasteren*, A.E. Brouwer. HIV nurse consultants and data collection: B.A.F.M. de Kruijf-van de Wiel, M. Kuipers, R.M.W.J. Santegoets, B. van der Ven. HIV clinical virologists/chemists: J.H. Marcelis, A.G.M. Buiting, P.J. Kabel. Universitair Medisch Centrum Groningen, Groningen: HIV treating physicians: W.F.W. Bierman*, H.G. Sprenger, E.H. Scholvinck, S. van Assen, K.R. Wilting, Y. Stienstra. HIV nurse consultants: H. de Groot-de Jonge, P.A. van der Meulen, D.A. de Weerd. HIV clinical virologists/chemists: H.G.M. Niesters, A. Riezebos-Brilman, C.C. van Leer-Buter. Universitair Medisch Centrum Utrecht, Utrecht: HIV treating physicians: A.I.M. Hoepelman*, M.M.E. Schneider, T. Mudrikova, P.M. Ellerbroek, J.J. Oosterheert, J.E. Arends, R.E. Barth, M.W.M. Wassenberg. HIV nurse consultants: D.H.M. van Elst-Laurijssen, E.E.B. van Oers-Hazelzet, J. Patist, S. Vervoort, Data collection: H.E. Nieuwenhuis, R. Frauenfelder. HIV clinical virologists/chemists: R. Schuurman, F. Verduyn-Lunel, A.M.J. Wensing. VU Medisch Centrum, Amsterdam: HIV treating physicians: E.J.G. Peters*, M.A. van Agtmael, M. Bomers, J. de Vocht. HIV nurse consultants: M. Heitmuller, L.M. Laan. HIV clinical virologists/chemists: A.M. Pettersson, C.M.J.E. Vandenbroucke-Grauls, C.W. Ang. Wilhelmina Kinderziekenhuis, UMCU, Utrecht: HIV treating physicians: S.P.M. Geelen, T.F.W. Wolfs, L.J. Bont. HIV nurse consultants: N. Nauta.

Coordinating centre: Stichting HIV Monitoring Director: P. Reiss. Data analysis: D.O. Bezemer, L. Gras, A.I. van Sighem, C. Smit. Data management and quality control: S. Zaheri, M. Hillebregt, A. de Jong. Data monitoring: D. Bergsma, P. Hoekstra, A. de Lang, M. Berkhout, S. Grivell, A. Jansen, M.J. Rademaker, M. Raethke. Data collection: Data collection: L. de Groot, M. van den Akker, Y. Bakker, M. Broekhoven, E. Claessen, El Berkaoui, E. Kruijne, C. Lodewijk, R. Meijering, L. Munjishvili, B. Peeck, C. Ree, R. Regtop, Y. Ruijs, M. Schoorl, S. Schnörr, E. Tuijn, L. Veenenberg, S. van der Vliet, T. Woudstra. Patient registration: B. Tuk.

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Conflicts of interest

A.S. has received travel grants and honoraria to his institution from Gilead Sciences, ViiV Healthcare, and Bristol-Myers Squibb. P.R. through his institution has received independent scientific grant support from Gilead Sciences, ViiV Healthcare, Merck & Co, Janssen Pharmaceutica and Bristol-Myers Squibb. In addition, he serves on a scientific advisory board for Gilead Sciences and on a data and safety monitoring board for Janssen Pharmaceutica, for which his institution has received remuneration. K.B. serves on advisory boards for MSD, Gilead, BMS, Viiv, and Janssen for which he has received remuneration. All other authors report no potential conflicts. The ATHENA database is maintained by Stichting HIV Monitoring and supported by a grant from the Dutch Ministry of Health, Welfare, and Sport through the Centre for Infectious Disease Control of the National Institute for Public Health and the Environment.

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Keywords:

ambulatory care facilities; guideline adherence; HIV; quality of healthcare; treatment outcome

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