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

East Flatbush Brooklyn

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

Retention Score

Low High 0 1 2 3 4

Quarters with primary care visits

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

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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