The Contribution of Missed Clinic Visits to Disparities in HIV Viral Load Outcomes

Zinski, Anne; Westfall, Andrew O.; Gardner, Lytt I.; Giordano, Thomas P.; Wilson, Tracey E.; Drainoni, Mari-Lynn; Keruly, Jeanne C.; Rodríguez, Allan; Malitz, Faye; Batey, D. Scott; Mugavero, Michael J.

doi:10.2105/ajph.2015.302695

Cited by 49 publications

(42 citation statements)

References 52 publications

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“…In the Veterans Affairs healthcare system, black veterans were still less likely to undergo HCV treatment compared with non-black veterans in the DAA era [34]. Similar racial disparities have been observed in the treatment of HIV infection and may in part be explained by a higher rate of missed visits among black patients in HIV care [35]. Other factors, including general mistrust of the medical system, providers, and treatments, have also been associated with lower adherence to antiretrovirals among black patients and may also be important contributors to decreased HIV engagement in care [36].…”

Section: Discussionmentioning

confidence: 99%

Barriers to Hepatitis C Virus (HCV) Treatment Initiation in Patients With Human Immunodeficiency Virus/HCV Coinfection: Lessons From the Interferon Era

Wansom

Falade‐Nwulia

Sutcliffe

et al. 2017

Open Forum Infectious Diseases

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Background.Hepatitis C is a major cause of mortality among human immunodeficiency virus (HIV)-infected patients, yet hepatitis C virus (HCV) treatment uptake has historically been low. Although the removal of interferon removes a major barrier to HCV treatment uptake, oral therapies alone may not fully eliminate barriers in this population.Methods.Within the Johns Hopkins Hospital HIV cohort, a nested case-control study was conducted to identify cases, defined as patients initiating HCV treatment between January 1996 and 2013, and controls, which were selected using incidence density sampling (3:1 ratio). Controls were matched to cases on date of enrollment. Conditional logistic regression was used to evaluate factors associated with HCV treatment initiation.Results.Among 208 treated cases and 624 untreated controls, the presence of advanced fibrosis (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.26–3.95), recent active drug use (OR, 0.36; 95% CI, 0.19–0.69), and non-black race (OR, 2.01; 95% CI, 1.26–3.20) were independently associated with initiation of HCV therapy. An increasing proportion of missed visits was also independently associated with lower odds of HCV treatment (25%–49% missed visits [OR, 0.49; 95% CI, 0.27–0.91] and ≥50% missed visits [OR, 0.24; 95% CI, 0.12–0.48]).Conclusions.Interferon-free treatments may not be sufficient to fully overcome barriers to HCV care in HIV-infected patients. Interventions to increase engagement in care for HIV and substance use are needed to expand HCV treatment uptake.

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Section: Discussionmentioning

confidence: 99%

Barriers to Hepatitis C Virus (HCV) Treatment Initiation in Patients With Human Immunodeficiency Virus/HCV Coinfection: Lessons From the Interferon Era

Wansom

Falade‐Nwulia

Sutcliffe

et al. 2017

Open Forum Infectious Diseases

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“…34,35 The present study contributes that this relationship may be explained by disparities in visit adherence, supporting a previous study that suggested that racial differences in engagement in care contribute to downstream clinical consequences, and this effect is mediated by visit adherence. 36 Future studies should explore the possibility that non-HIV related and intersectional stigmas (i.e., racism) contribute to these findings. 37,38 …”

Section: Discussionmentioning

confidence: 99%

Association Between Internalized HIV-Related Stigma and HIV Care Visit Adherence

Rice

Crockett

Mugavero

et al. 2017

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Background Internalized HIV-related stigma acts as a barrier to antiretroviral therapy (ART) adherence, but its effects on other HIV care continuum outcomes is unclear. Methods Among 196 HIV clinic patients in Birmingham, Alabama, we assessed internalized HIV-related stigma and depressive symptom severity using validated multi-item scales, and assessed ART adherence using a validated single-item measure. HIV visit adherence (attended out of total scheduled visits) was calculated using data from clinic records. Using covariate-adjusted regression analysis, we investigated the association between internalized stigma and visit adherence. Using path analytic methods with bootstrapping, we tested the mediating role of depressive symptoms in the association between internalized stigma and visit adherence, and the mediating role of visit adherence in the association between internalized stigma and ART adherence. Results Higher internalized stigma was associated with lower visit adherence (B=−0.04, p=0.04). Black (versus white) race and depressive symptoms were significant predictors within this model. Mediation analysis yielded no effect by depression in the association between internalized stigma and visit adherence (B = −0.18, SE = .11, 95% CI [−0.44, −0.02]) in the whole sample. Supplemental mediated moderation analyses revealed gender-specific effects. Additionally, the indirect effect of internalized stigma on sub-optimal ART adherence was mediated by lower visit adherence (B = −0.18, SE = .11, 95% CI [−0.44, −0.02]). Conclusion Results highlight the importance of internalized HIV stigma to multiple and sequential HIV care continuum outcomes. Also, findings suggest multiple intervention targets, including addressing internalized stigma directly, reducing depressive symptoms, and promoting consistent engagement in care.

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“…Moreover, national racial disparities in HIV health outcomes [24, 35] may actually belie the presence of other factors. For example, in a multi-site trial, Zinski and colleagues found that the lower proportion of viral suppression found among African Americans in comparison to other racial groups loses statistical significance when accounting for the number of missed visits [36]. …”

Section: Reviewmentioning

confidence: 99%

The HIV treatment cascade and care continuum: updates, goals, and recommendations for the future

2016

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The HIV care continuum is a framework that models the dynamic stages of HIV care. The continuum consists of five main steps, which, at the population level, are depicted cross-sectionally as the HIV treatment cascade. These steps include diagnosis, linkage to care (LTC), retention in care (RiC), adherence to antiretroviral therapy (ART), and viral suppression. Although the HIV treatment cascade is represented as a linear, unidirectional framework, persons living with HIV (PLWH) often experience the care continuum in a less streamlined fashion, skip steps altogether, or even exit the continuum for a period of time and regress to an earlier stage. The proportion of PLWH decreases at each successive step of the cascade, beginning with an estimated 86% who are diagnosed and dropping dramatically to approximately 30% of PLWH who are virally suppressed in the United States (US). In this current issues review, we describe each step in the cascade, discuss targeted interventions that address weak points in the continuum, review domestic and international policies that help shape and direct HIV care strategies, and conclude with recommendations and future directions for HIV providers and policymakers. While we primarily examine issues related to domestic HIV care in the US, we also discuss international applications of the continuum in order to provide broader context.

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The Contribution of Missed Clinic Visits to Disparities in HIV Viral Load Outcomes

Cited by 49 publications

References 52 publications

Barriers to Hepatitis C Virus (HCV) Treatment Initiation in Patients With Human Immunodeficiency Virus/HCV Coinfection: Lessons From the Interferon Era

Barriers to Hepatitis C Virus (HCV) Treatment Initiation in Patients With Human Immunodeficiency Virus/HCV Coinfection: Lessons From the Interferon Era

Association Between Internalized HIV-Related Stigma and HIV Care Visit Adherence

The HIV treatment cascade and care continuum: updates, goals, and recommendations for the future

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