The HIV care continuum

Changes over time in retention in care and viral suppression

Baligh R. Yehia, Alisa J. Stephens-Shields, John A. Fleishman, Stephen A. Berry, Allison L. Agwu, Joshua P. Metlay, Richard D. Moore, W. Christopher Mathews, Ank Nijhawan, Richard Rutstein, Aditya H. Gaur, Kelly A. Gebo, Howard Edelstein, Roberto Corales, Jeffrey Jacobson, Sara Allen, Stephen Boswell, Robert S. Beil, Carolyn Chu, Lawrence Hanau & 14 others P. Todd Korthuis, Muhammad Akbar, Laura Armas-Kolostroubis, Victoria Sharp, Stephen Arpadi, Charurut Somboonwit, Jonathan Cohn, Fred Hellinger, Irene Fraser, Robert Mills, Faye Malitz, Jeanne Keruly, Cindy Voss, Nikki Balding

Research output: Contribution to journalArticle

32 Citations (Scopus)

Abstract

Background: The HIV care continuum (diagnosis, linkage to care, retention in care, receipt of antiretroviral therapy (ART), viral suppression) has been used to identify opportunities for improving the delivery of HIV care. Continuum steps are typically calculated in a conditional manner, with the number of persons completing the prior step serving as the base population for the next step. This approach may underestimate the prevalence of viral suppression by excluding patients who are suppressed but do not meet standard definitions of retention in care. Understanding how retention in care and viral suppression interact and change over time may improve our ability to intervene on these steps in the continuum. Methods: We followed 17,140 patients at 11 U.S. HIV clinics between 2010-2012. For each calendar year, patients were classified into one of five categories: (1) retained/suppressed, (2) retained/not-suppressed, (3) not-retained/suppressed, (4) not-retained/not-suppressed, and (5) lost to follow-up (for calendar years 2011 and 2012 only). Retained individuals were those completing ≥2 HIV medical visits separated by ≥90 days in the year. Persons not retained completed ≥1 HIV medical visit during the year, but did not meet the retention definition. Persons lost to follow-up had no HIV medical visits in the year. HIV viral suppression was defined as HIV-1 RNA ≤200 copies/mL at the last measure in the year. Multinomial logistic regression was used to determine the probability of patients' transitioning between retention/suppression categories from 2010 to 2011 and 2010 to 2012, adjusting for age, sex, race/ethnicity, HIV risk factor, insurance status, CD4 count, and use of ART. Results: Overall, 65.8% of patients were retained/suppressed, 17.4% retained/not-suppressed, 10.0% not-retained/suppressed, and 6.8% not-retained/not-suppressed in 2010. 59.5% of patients maintained the same status in 2011 (kappa=0.458) and 53.3% maintained the same status in 2012 (kappa=0.437). Conclusions: Not counting patients not-retained/suppressed as virally suppressed, as is commonly done in the HIV care continuum, underestimated the proportion suppressed by 13%. Applying the care continuum in a longitudinal manner will enhance its utility.

Original languageEnglish (US)
Article numbere0129376
JournalPLoS One
Volume10
Issue number6
DOIs
StatePublished - Jun 18 2015

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Continuity of Patient Care
Insurance
Logistics
HIV
RNA
Lost to Follow-Up
HIV-1
therapeutics
HIV-2
Insurance Coverage
insurance
CD4 Lymphocyte Count
Human immunodeficiency virus 1
nationalities and ethnic groups
linkage (genetics)
risk factors
Logistic Models
gender
Therapeutics
Population

ASJC Scopus subject areas

  • Medicine(all)
  • Biochemistry, Genetics and Molecular Biology(all)
  • Agricultural and Biological Sciences(all)

Cite this

Yehia, B. R., Stephens-Shields, A. J., Fleishman, J. A., Berry, S. A., Agwu, A. L., Metlay, J. P., ... Balding, N. (2015). The HIV care continuum: Changes over time in retention in care and viral suppression. PLoS One, 10(6), [e0129376]. https://doi.org/10.1371/journal.pone.0129376

The HIV care continuum : Changes over time in retention in care and viral suppression. / Yehia, Baligh R.; Stephens-Shields, Alisa J.; Fleishman, John A.; Berry, Stephen A.; Agwu, Allison L.; Metlay, Joshua P.; Moore, Richard D.; Mathews, W. Christopher; Nijhawan, Ank; Rutstein, Richard; Gaur, Aditya H.; Gebo, Kelly A.; Edelstein, Howard; Corales, Roberto; Jacobson, Jeffrey; Allen, Sara; Boswell, Stephen; Beil, Robert S.; Chu, Carolyn; Hanau, Lawrence; Korthuis, P. Todd; Akbar, Muhammad; Armas-Kolostroubis, Laura; Sharp, Victoria; Arpadi, Stephen; Somboonwit, Charurut; Cohn, Jonathan; Hellinger, Fred; Fraser, Irene; Mills, Robert; Malitz, Faye; Keruly, Jeanne; Voss, Cindy; Balding, Nikki.

In: PLoS One, Vol. 10, No. 6, e0129376, 18.06.2015.

Research output: Contribution to journalArticle

Yehia, BR, Stephens-Shields, AJ, Fleishman, JA, Berry, SA, Agwu, AL, Metlay, JP, Moore, RD, Mathews, WC, Nijhawan, A, Rutstein, R, Gaur, AH, Gebo, KA, Edelstein, H, Corales, R, Jacobson, J, Allen, S, Boswell, S, Beil, RS, Chu, C, Hanau, L, Korthuis, PT, Akbar, M, Armas-Kolostroubis, L, Sharp, V, Arpadi, S, Somboonwit, C, Cohn, J, Hellinger, F, Fraser, I, Mills, R, Malitz, F, Keruly, J, Voss, C & Balding, N 2015, 'The HIV care continuum: Changes over time in retention in care and viral suppression', PLoS One, vol. 10, no. 6, e0129376. https://doi.org/10.1371/journal.pone.0129376
Yehia BR, Stephens-Shields AJ, Fleishman JA, Berry SA, Agwu AL, Metlay JP et al. The HIV care continuum: Changes over time in retention in care and viral suppression. PLoS One. 2015 Jun 18;10(6). e0129376. https://doi.org/10.1371/journal.pone.0129376
Yehia, Baligh R. ; Stephens-Shields, Alisa J. ; Fleishman, John A. ; Berry, Stephen A. ; Agwu, Allison L. ; Metlay, Joshua P. ; Moore, Richard D. ; Mathews, W. Christopher ; Nijhawan, Ank ; Rutstein, Richard ; Gaur, Aditya H. ; Gebo, Kelly A. ; Edelstein, Howard ; Corales, Roberto ; Jacobson, Jeffrey ; Allen, Sara ; Boswell, Stephen ; Beil, Robert S. ; Chu, Carolyn ; Hanau, Lawrence ; Korthuis, P. Todd ; Akbar, Muhammad ; Armas-Kolostroubis, Laura ; Sharp, Victoria ; Arpadi, Stephen ; Somboonwit, Charurut ; Cohn, Jonathan ; Hellinger, Fred ; Fraser, Irene ; Mills, Robert ; Malitz, Faye ; Keruly, Jeanne ; Voss, Cindy ; Balding, Nikki. / The HIV care continuum : Changes over time in retention in care and viral suppression. In: PLoS One. 2015 ; Vol. 10, No. 6.
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abstract = "Background: The HIV care continuum (diagnosis, linkage to care, retention in care, receipt of antiretroviral therapy (ART), viral suppression) has been used to identify opportunities for improving the delivery of HIV care. Continuum steps are typically calculated in a conditional manner, with the number of persons completing the prior step serving as the base population for the next step. This approach may underestimate the prevalence of viral suppression by excluding patients who are suppressed but do not meet standard definitions of retention in care. Understanding how retention in care and viral suppression interact and change over time may improve our ability to intervene on these steps in the continuum. Methods: We followed 17,140 patients at 11 U.S. HIV clinics between 2010-2012. For each calendar year, patients were classified into one of five categories: (1) retained/suppressed, (2) retained/not-suppressed, (3) not-retained/suppressed, (4) not-retained/not-suppressed, and (5) lost to follow-up (for calendar years 2011 and 2012 only). Retained individuals were those completing ≥2 HIV medical visits separated by ≥90 days in the year. Persons not retained completed ≥1 HIV medical visit during the year, but did not meet the retention definition. Persons lost to follow-up had no HIV medical visits in the year. HIV viral suppression was defined as HIV-1 RNA ≤200 copies/mL at the last measure in the year. Multinomial logistic regression was used to determine the probability of patients' transitioning between retention/suppression categories from 2010 to 2011 and 2010 to 2012, adjusting for age, sex, race/ethnicity, HIV risk factor, insurance status, CD4 count, and use of ART. Results: Overall, 65.8{\%} of patients were retained/suppressed, 17.4{\%} retained/not-suppressed, 10.0{\%} not-retained/suppressed, and 6.8{\%} not-retained/not-suppressed in 2010. 59.5{\%} of patients maintained the same status in 2011 (kappa=0.458) and 53.3{\%} maintained the same status in 2012 (kappa=0.437). Conclusions: Not counting patients not-retained/suppressed as virally suppressed, as is commonly done in the HIV care continuum, underestimated the proportion suppressed by 13{\%}. Applying the care continuum in a longitudinal manner will enhance its utility.",
author = "Yehia, {Baligh R.} and Stephens-Shields, {Alisa J.} and Fleishman, {John A.} and Berry, {Stephen A.} and Agwu, {Allison L.} and Metlay, {Joshua P.} and Moore, {Richard D.} and Mathews, {W. Christopher} and Ank Nijhawan and Richard Rutstein and Gaur, {Aditya H.} and Gebo, {Kelly A.} and Howard Edelstein and Roberto Corales and Jeffrey Jacobson and Sara Allen and Stephen Boswell and Beil, {Robert S.} and Carolyn Chu and Lawrence Hanau and Korthuis, {P. Todd} and Muhammad Akbar and Laura Armas-Kolostroubis and Victoria Sharp and Stephen Arpadi and Charurut Somboonwit and Jonathan Cohn and Fred Hellinger and Irene Fraser and Robert Mills and Faye Malitz and Jeanne Keruly and Cindy Voss and Nikki Balding",
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T1 - The HIV care continuum

T2 - Changes over time in retention in care and viral suppression

AU - Yehia, Baligh R.

AU - Stephens-Shields, Alisa J.

AU - Fleishman, John A.

AU - Berry, Stephen A.

AU - Agwu, Allison L.

AU - Metlay, Joshua P.

AU - Moore, Richard D.

AU - Mathews, W. Christopher

AU - Nijhawan, Ank

AU - Rutstein, Richard

AU - Gaur, Aditya H.

AU - Gebo, Kelly A.

AU - Edelstein, Howard

AU - Corales, Roberto

AU - Jacobson, Jeffrey

AU - Allen, Sara

AU - Boswell, Stephen

AU - Beil, Robert S.

AU - Chu, Carolyn

AU - Hanau, Lawrence

AU - Korthuis, P. Todd

AU - Akbar, Muhammad

AU - Armas-Kolostroubis, Laura

AU - Sharp, Victoria

AU - Arpadi, Stephen

AU - Somboonwit, Charurut

AU - Cohn, Jonathan

AU - Hellinger, Fred

AU - Fraser, Irene

AU - Mills, Robert

AU - Malitz, Faye

AU - Keruly, Jeanne

AU - Voss, Cindy

AU - Balding, Nikki

PY - 2015/6/18

Y1 - 2015/6/18

N2 - Background: The HIV care continuum (diagnosis, linkage to care, retention in care, receipt of antiretroviral therapy (ART), viral suppression) has been used to identify opportunities for improving the delivery of HIV care. Continuum steps are typically calculated in a conditional manner, with the number of persons completing the prior step serving as the base population for the next step. This approach may underestimate the prevalence of viral suppression by excluding patients who are suppressed but do not meet standard definitions of retention in care. Understanding how retention in care and viral suppression interact and change over time may improve our ability to intervene on these steps in the continuum. Methods: We followed 17,140 patients at 11 U.S. HIV clinics between 2010-2012. For each calendar year, patients were classified into one of five categories: (1) retained/suppressed, (2) retained/not-suppressed, (3) not-retained/suppressed, (4) not-retained/not-suppressed, and (5) lost to follow-up (for calendar years 2011 and 2012 only). Retained individuals were those completing ≥2 HIV medical visits separated by ≥90 days in the year. Persons not retained completed ≥1 HIV medical visit during the year, but did not meet the retention definition. Persons lost to follow-up had no HIV medical visits in the year. HIV viral suppression was defined as HIV-1 RNA ≤200 copies/mL at the last measure in the year. Multinomial logistic regression was used to determine the probability of patients' transitioning between retention/suppression categories from 2010 to 2011 and 2010 to 2012, adjusting for age, sex, race/ethnicity, HIV risk factor, insurance status, CD4 count, and use of ART. Results: Overall, 65.8% of patients were retained/suppressed, 17.4% retained/not-suppressed, 10.0% not-retained/suppressed, and 6.8% not-retained/not-suppressed in 2010. 59.5% of patients maintained the same status in 2011 (kappa=0.458) and 53.3% maintained the same status in 2012 (kappa=0.437). Conclusions: Not counting patients not-retained/suppressed as virally suppressed, as is commonly done in the HIV care continuum, underestimated the proportion suppressed by 13%. Applying the care continuum in a longitudinal manner will enhance its utility.

AB - Background: The HIV care continuum (diagnosis, linkage to care, retention in care, receipt of antiretroviral therapy (ART), viral suppression) has been used to identify opportunities for improving the delivery of HIV care. Continuum steps are typically calculated in a conditional manner, with the number of persons completing the prior step serving as the base population for the next step. This approach may underestimate the prevalence of viral suppression by excluding patients who are suppressed but do not meet standard definitions of retention in care. Understanding how retention in care and viral suppression interact and change over time may improve our ability to intervene on these steps in the continuum. Methods: We followed 17,140 patients at 11 U.S. HIV clinics between 2010-2012. For each calendar year, patients were classified into one of five categories: (1) retained/suppressed, (2) retained/not-suppressed, (3) not-retained/suppressed, (4) not-retained/not-suppressed, and (5) lost to follow-up (for calendar years 2011 and 2012 only). Retained individuals were those completing ≥2 HIV medical visits separated by ≥90 days in the year. Persons not retained completed ≥1 HIV medical visit during the year, but did not meet the retention definition. Persons lost to follow-up had no HIV medical visits in the year. HIV viral suppression was defined as HIV-1 RNA ≤200 copies/mL at the last measure in the year. Multinomial logistic regression was used to determine the probability of patients' transitioning between retention/suppression categories from 2010 to 2011 and 2010 to 2012, adjusting for age, sex, race/ethnicity, HIV risk factor, insurance status, CD4 count, and use of ART. Results: Overall, 65.8% of patients were retained/suppressed, 17.4% retained/not-suppressed, 10.0% not-retained/suppressed, and 6.8% not-retained/not-suppressed in 2010. 59.5% of patients maintained the same status in 2011 (kappa=0.458) and 53.3% maintained the same status in 2012 (kappa=0.437). Conclusions: Not counting patients not-retained/suppressed as virally suppressed, as is commonly done in the HIV care continuum, underestimated the proportion suppressed by 13%. Applying the care continuum in a longitudinal manner will enhance its utility.

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