Aging, HIV infection, and antiretroviral therapy have been associated with increasing rates of chronic comorbidities in patients with HIV. Urban minority populations in particular are affected by both the HIV/AIDS and chronic disease epidemics. Our objectives were to estimate the prevalence of and risk factors for hypertension, dyslipidemia, and diabetes among HIV-infected adults in the Bronx and describe comorbidity-related treatment outcomes. This was a cross-sectional study of 854 HIV-positive adults receiving care at 11 clinics which provide HIV primary care services; clinics were affiliated with a large urban academic medical center. Data on blood pressure (BP), cholesterol, and glycemic control were collected through standardized chart review of outpatient medical records. We found prevalence rates of 26%, 48%, and 13% for hypertension, dyslipidemia, and diabetes, respectively. Older age, obesity, family history, and current protease inhibitor use were consistently associated with comorbidity. Diabetes treatment goals were achieved less often than BP and lipid goals, and concurrent diabetes was a significant predictor for BP and lipid control. In conclusion, major cardiovascular-related comorbidities are prevalent among HIVpositive adults in the Bronx, especially older and obese individuals. Differences exist in comorbidity-related treatment outcomes, especially for patients with concurrent diabetes. Because cardiovascular risk is modifiable, effective treatment of related comorbidities may improve morbidity and mortality in HIV-infected patients.

The HIV-infected population in the U.S. is expanding as patients survive longer and new infections are identified. In many areas, particularly rural/medically-underserved regions, there is a growing shortage of providers with sufficient HIV expertise. HIV services incorporated into community-based, primary care settings may therefore improve the distribution and delivery of HIV treatment. Our objective was to describe/compare patients and treatment outcomes in two settings: a community-located, primary care-based HIV program and a hospital-based specialty center. Community-based providers had on-site access to generalist HIV experts. The hospital center was staffed primarily by infectious disease physicians. This was a retrospective cohort study of 854 HIV-positive adults initiating care between 1/2005 and 12/2007 within an academic medical center network in the Bronx, NY. Treatment outcomes were virologic and immunologic response at 16-32 and 48 weeks, respectively, after combination antiretroviral therapy (cART) initiation. We found that hospital-based subjects presented with a higher prevalence of AIDS (59% vs. 46%, p < 0.01) and lower initial CD4 (385 vs. 437, p < 0.05) than community-based subjects. Among 178 community vs. 237 hospital subjects starting cART, 66% vs. 62% achieved virologic suppression ([95% CI difference −0.14-0.06]) and 49% vs. 59% achieved immunologic success, defined as a 100 cell/mm 3 increase in CD4 ([95% CI difference 0.00-0.19]). The multivariateadjusted likelihoods of achieving viral suppression (OR = 1.24 [95% CI 0.69-2.33]) and immunologic success (OR = 0.76 [95% CI 0.47-1.21]) were not statistically significant for community vs. hospital subjects. Because this was an observational study, propensity scores were used to address potential selection bias when subjects presented to a particular setting. In conclusion, HIV-infected patients initiate care at community-based clinics earlier and with less advanced HIV disease. Treatment outcomes are comparable to those at a hospital-based specialty center, suggesting that HIV care can be delivered effectively in community settings.

HIV infected patients continue to present late to care, with low CD4 and commonly utilize OPDs and EDs, where missed opportunities for earlier diagnosis are common. Practices that address augmentation of current HIV testing strategies are needed, especially in outpatient and first-contact acute care settings.