Continued physician care correlates with survival in patients with HIV

Despite adequate access to care, retention remains a major concern for patients with HIV.

Issue: June 2007

Patients with HIV should visit their doctor at least every three months to improve survival and adherence, according to the results of a recent study of patients at veterans’ hospitals.

Many patients with HIV do not remain in care even when access to clinicians and medications is not an issue, according to researchers.

“If you miss a lot of visits, you may not know that your virus is now resistant,” Thomas P. Giordano, MD, MPH, associate professor of medicine at Baylor College of Medicine, told Infectious Disease News. “Many patients may not realize how important it is to undergo regular evaluation.”

Giordano and colleagues studied outcomes and retention in patients with HIV who were treated at U.S. Department of Veterans Affairs hospitals and clinics. The study results appeared in Clinical Infectious Disease.

Thomas P. Giordano

“Most people who are dying from HIV aren’t dying from untreatable HIV; they’re dying from untreated HIV,” Giordano said. “They are not treated because they are not in care or are poorly retained in care.”

Most clinicians would not be surprised that at least 35% of patients had difficulty with retention in care, according to Giordano. Study findings could be applied to other chronic conditions for the correlation between retention, outcomes and survival rates.

“We suspected that HIV would be an efficient model to see the effect of poor retention in care because in mortality and treatment, you can see the effect in a short time,” Giordano said.

With other diseases, such as diabetes or hypertension, it could take 10 years to see the effects.

Cohort selected

In a retrospective cohort, men (n=2,619) newly-identified with HIV infection during 1997-1998 at any U.S. Department of Veterans Affairs hospital or clinic were included in the study. With clinics in every state, the U.S. Department of Veteran Affairs is the largest single provider of care to people living with HIV and AIDS in the United States.

All participants were veterans and had started antiretroviral therapy after Jan. 1, 1997, had seen a clinician at least once after their first antiretroviral prescription and had survived for at least one year. Women were excluded due to small sample size.

Participants were divided into four groups corresponding to the number of quarters in the year they had at least one primary care visit. Survival was measured through 2002. Participants were followed for an average of more than four years each. At baseline, median CD4 counts were 228 cells/L and median viral loads were 4.58 copies/mL.

More visits, better outcomes

Of participants, 36% had visits in fewer than four quarters of the year, and 16% died during follow-up. Compared with participants with visits in all four quarters during the first year, participants with visits in three of four quarters had a 1.42 adjusted hazard ratio of death (95% CI, 1.11-1.83), which rose to 1.95 for those who had visits in only one quarter of the year (95% CI, 1.37-2.78).

The majority of participants (64%) had visits in all four quarters, 18% had visits in three quarters, 11% had visits in two quarters and 6% had visits in one quarter. Participants who had visits in all four quarters also had greater mean adherence to antiretroviral therapy (79%) than participants who had a visit in only one quarter (59%; P<.001).

Poor retention in care was associated with less CD4 count improvement and greater viral loads.

Participants with better retention in care were older, had more advanced disease and received highly active antiretroviral therapy more often than other participants. They also reported less alcohol and hard drug use and had less hepatitis C virus co-infection.

Further studies

A prospective study is underway for gaining insight into poor retention to care from a patient’s perspective.

“Even in a system with few financial barriers to care, a substantial portion of people living with HIV have poor retention in care. Poor retention predicts poor survival with HIV infection,” Giordano said.

Competing needs, such as the need to work interfering with the ability to see a physician, are a common reason for poor retention in care. Issues of HIV stigma are also considered.

“We have patients who are afraid to come in. They think it’s a death sentence, or that if their families found out, they won’t have support,” Giordano said. “There are probably veterans who fear they’ll lose their benefits if it comes up that they have HIV because it might identify them as someone who has had sex with men.”

Clinicians can retain patients through counseling patients, offering extended office hours, giving reminder calls and linking patients to case management. – by Kirsten H. Ellis

For more information:

Giordano TP, Gifford AL, White AC, et al. Retention in care: A challenge to survival with HIV infection. Clin Infect Dis. 2007;44:1493-1499.