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Retention in Care Among Adults Infected with HIV
Katherine A. Marx, MS, MPH, Rebecca M. Schwartz, PhD, Edmond S. Malka, MPH, CPH, Jayashree Ravishankar, MD, MPH
SUNY Downstate Medical Center, Brooklyn, NY
Presenter Disclosures
Katherine A. Marx
(1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:
No relationships to disclose
HIV Care Retention and Survival
• Retention in medical care associated with decreased mortality
• Antiretroviral use associated with longer life
Giordano TP, et al. Clin Infect Dis 2007;44(11):1493-1499.Walensky RP, et al. J Infec Dis 2006;194(1):11-19.
Retention Deficits
• ½ of adults medically eligible for HIV care in United States not receiving treatment
• Missed appointments associated with treatment failure
• Clinic retention rates 38% - 77%
Teshale E, et al., 12th Conference on Retroviruses and Opportunistic Infections.2005 Feb 22-25;Boston. Meyerson BE,et al. Am J Pub Health 2007;97(4):744-749.Rastegar DA,et al, AIDS Care 2003;15(2):231-237Berg MB,et al., AIDS Care 2005;17(7):902-907.Sherer R, et al. AIDS Care 2002;14(Suppl 1):S31-S44.Lo W. et al., AIDS Care 2002;14(Suppl 1): S45-S57.Gardner LI, et al. AIDS 2005:19(4):423-431.Horstmann E, et al., International Conference on AIDS.2006 Aug 13-18; Toronto
Predicting Retention: Individual Characteristics
AIDS Diagnosis (CD4<200 or symptomatic)
Substance use (active or past)
Giordano TP, et al. AIDS Care 2005;17(6):773-783. Giordano TP, et al. Clin Infect Dis 2007;44(11):1493-1499.Naar-King S, et al. AIDS Patient Care STDS 2007;21(Suppl 1):S40-S48.Rumptz MH, et al. AIDS Patient Care STD 2007;21(Suppl 1):S30-S39.Ashman JJ,et al. AIDS Care 2002;14(Suppl 1):S109-118.Cunningham WE,et al. Med Care 2006;44(11):1038-1047.
Predicting Retention: Individual Characteristics
Age
Employment
HousingGiordano TP, et al. AIDS Care 2005;17(6):773-783. Giordano TP, et al. Clin Infect Dis 2007;44(11):1493-1499.Naar-King S, et al. AIDS Patient Care STDS 2007;21(Suppl 1):S40-S48.Rumptz MH, et al. AIDS Patient Care STD 2007;21(Suppl 1):S30-S39.Ashman JJ,et al. AIDS Care 2002;14(Suppl 1):S109-118.Cunningham WE,et al. Med Care 2006;44(11):1038-1047.
Insurance
Language
Mental illness
Race
Sex
Time
Goals
• Compare retention definitions• Examine associations between individual
characteristics and retention in care
Methods• Retrospective cohort: chart review
– Approved by Institutional Review Board• Sample (N=212)
– Active adult clients on 12/31/05– Exclusion for death (N=3), incomplete data (N=3)– All eligible 18-29 included, random selection for
30-49 and 50 and over age groups• Study period: 1/1/06 - 12/31/06 • Analysis:
– De-identified database– SPSS version 16.0– Logistic Regression – binary vs. ordinal
Retention Status
Retention :
attended 1 or more primary care visits in each 6 month
period of a 12 month year
No retention
Demographic and health characteristics
Variable N %
Female 126 59
BlackHispanicWhite
176297
8314 3
Substance use
78 37
Alcohol use 87 41
Marijuana use 38 18
Mental illness 89 42
AIDS diagnosis
78 37
Homelessness 10 5
English 185 87
Retention Status - Binary Model
• 3 variables• 2 significant predictors
↑ AIDS diagnosis• (OR = 2.18, 95% CI 1.17 - 4.10)
↓ History of substance use• (OR = .52, 95% CI .29 - .94)
– Primary language English• (OR = .57, 95% CI .23 - 1.46)
Retention Score - Ordinal Model
• 3 significant predictors↑ AIDS diagnosis
• (OR 1.81, 95% CI 1.09-3.01)
↓ Substance use• (OR .58, 95% CI .35-.96)
↓ Primary language English• (OR .40, 95% CI .19-.84)
Model Comparison
• Retention variables highly correlated(R=0.82, p<.001)
• Model findings consistent• Ordinal model sensitive to association
between language and retention
0
0.1
0.2
0.3
0.4
0.5
Retention score
Pre
dic
ted
pro
bab
ilit
y
no
yes
Predicted probabilities for English as a primary language by retention score
0 2 3 41
Language and Retention
• Linguistic resources at the study site– Provider language concurrence– Professional telephone interpretation– Ad hoc interpretation by staff
Retention Interventions
• Substance use history– Treatment and harm reduction– Mental health and ancillary services
• AIDS diagnosis– Peer programming– Health literacy
Limitations
• Individual determinants of retention • One clinic• Existing dataset• Exclusion of walk-in visits
Conclusions
• Ordinal measure identified additional predictor• Binary measure simple to interpret• Language status predicts retention in care
Thank you!SUNY Downstate Medical Center School of Public HealthSTAR Health CenterNicholas A Rango HIV Clinical Scholars ProgramRebecca SchwartzEdmond MalkaJayashree RavishankarKaren BenkerTracey WilsonDavid OdegaardAlexa KazimMikhail ZlotinSusan HolmanJack DeHovitzCassandra RaphaelGenevieve JeanbartMarie MartialMagna Robinson
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