Routine HIV clinic visit adherence in the African Cohort Study

Background Retention in clinical care is important for people living with HIV (PLWH). Evidence suggests that missed clinic visits are associated with interruptions in antiretroviral therapy (ART), lower CD4 counts, virologic failure, and overlooked coinfections. We identified factors associated with missed routine clinic visits in the African Cohort Study (AFRICOS). Methods In 2013, AFRICOS began enrolling people with and without HIV in Uganda, Kenya, Tanzania, and Nigeria. At enrollment and every 6 months thereafter, sociodemographic questionnaires are administered and clinical outcomes assessed. Missed clinic visits were measured as the self-reported number of clinic visits missed in the past 6 months and dichotomized into none or one or more visits missed. Logistic regression with generalized estimating equations was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between risk factors and missed visits. Results Between January 2013 and March 2020, 2937 PLWH were enrolled, of whom 2807 (95.6%) had initiated ART and 2771 had complete data available for analyses. Compared to PLWH 50+, missed clinic visits were more common among those 18–29 years (aOR 2.33, 95% CI 1.65–3.29), 30–39 years (aOR 1.59, 95% CI 1.19–2.13), and 40–49 years (aOR 1.42, 95% CI 1.07–1.89). As compared to PLWH on ART for < 2 years, those on ART for 4+ years were less likely to have missed clinic visits (aOR 0.72, 95% CI 0.55–0.95). Missed clinic visits were associated with alcohol use (aOR 1.34, 95% CI 1.05–1.70), a history of incarceration (aOR 1.42, 95% CI 1.07–1.88), depression (aOR 1.47, 95% CI 1.13–1.91), and viral non-suppression (aOR 2.50, 95% CI 2.00–3.12). As compared to PLWH who did not miss any ART in the past month, missed clinic visits were more common among those who missed 1–2 days (aOR 2.09, 95% CI 1.65–2.64) and 3+ days of ART (aOR 7.06, 95% CI 5.43–9.19). Conclusions Inconsistent clinic attendance is associated with worsened HIV-related outcomes. Strategies to improve visit adherence are especially needed for young PLWH and those with depression.

Association of Dementia Severity and Assistances Needs on Missed Home Health Visits

Individuals with Alzheimer’s Disease and Related Dementias (ADRD) experience barriers to accessing health care services, including services provided during home health care. Additionally, it is not clear if people with ADRD who are admitted to home health care receive all the services needed to maximize their outcomes. Barriers to receiving the optimal care can include the presence or absence of a care giver, behavioral and psychological symptoms of ADRD, or therapists lacking the skills needed to effectively engage patients in therapy sessions. These barriers may vary dependent on the patient’s ADRD severity. The purpose of this study was to examine the relationship between dementia severity and early discharge from home health care. This was a retrospective study of 142,376 Medicare beneficiaries with ADRD who received home health care between October 2016 and September 2017. Early discharge was defined as discharge from home health with more than two missed visits. Early discharge rates were calculated, and multilevel logistic regression was used to estimate the relative risk (RR) of early discharge, by dementia severity level, adjusted for patient and clinical characteristics. 10.4% of beneficiaries had an early discharge. Dementia severity was not associated with risk of early discharge. However, level of medication assistance needed was found to be associated with risk of early discharge (RR=0.849; 95% CI 0.759 - 0.948). Medication management may impact a patient’s ability to adequately attend and engage in home health therapy services. Further studies are needed to better delineate the interaction between medication management and early discharge.

PrEP uptake, persistence, adherence, and effect of retrospective drug level feedback on PrEP adherence among young women in southern Africa: Results from HPTN 082, a randomized controlled trial

Background Pre-exposure prophylaxis (PrEP) is highly effective and an important prevention tool for African adolescent girls and young women (AGYW), but adherence and persistence are challenging. PrEP adherence support strategies for African AGYW were studied in an implementation study. Methods and findings HIV Prevention Trials Network (HPTN) 082 was conducted in Cape Town, Johannesburg (South Africa) and Harare (Zimbabwe) from October 2016 to October 2018 to evaluate PrEP uptake, persistence, and the effect of drug level feedback on adherence. Sexually active HIV–negative women ages 16–25 were offered PrEP and followed for 12 months; women who accepted were randomized to standard adherence support (counseling, 2-way SMS, and adherence clubs) or enhanced adherence support with adherence feedback from intracellular tenofovir-diphosphate (TFV-DP) levels in dried blood spots (DBS). PrEP uptake, persistence through 12 months (no PrEP hold or missed visits), and adherence were assessed. The primary outcome was high adherence (TFV-DP ≥700 fmol/punch) at 6 months, compared by study arm. Of 451 women enrolled, median age was 21 years, and 39% had curable sexually transmitted infections (STIs). Most (95%) started PrEP, of whom 55% had uninterrupted PrEP refills through 12 months. Of those with DBS, 84% had detectable TFV-DP levels at month 3, 57% at month 6, and 31% at month 12. At 6 months, 36/179 (21%) of AGYW in the enhanced arm had high adherence and 40/184 (22%) in the standard adherence support arm (adjusted odds ratio [OR] of 0.92; 95% confidence interval [CI] 0.55, 1.34; p = 0.76). Four women acquired HIV (incidence 1.0/100 person-years), with low or undetectable TFV-DP levels at or prior to seroconversion, and none of whom had tenofovir or emtricitabine resistance mutations. The study had limited power to detect a modest effect of incentives on adherence, and there was limited awareness of PrEP at the time the study was conducted. Conclusions In this study, PrEP initiation was high, over half of study participants persisted with PrEP through month 12, and the majority of young African women had detectable TFV-DP levels through month 6 with one-fifth having high adherence. Drug level feedback in the first 3 months of PrEP use did not increase the proportion with high adherence at month 6. HIV incidence was 1% in this cohort with 39% prevalence of curable STIs and moderate PrEP adherence. Strategies to support PrEP use and less adherence-dependent formulations are needed for this population. Trial registration ClinicalTrials.gov NCT02732730.

Impact of COVID-19 pandemic on HIV viremia: a single-center cohort study in northern Italy

Background Brescia Province, northern Italy, was one of the worst epicenters of the COVID-19 pandemic. The division of infectious diseases of ASST (Azienda Socio Sanitaria Territoriale) Spedali Civili Hospital of Brescia had to face a great number of inpatients with severe COVID-19 infection and to ensure the continuum of care for almost 4000 outpatients with HIV infection actively followed by us. In a recent manuscript we described the impact of the pandemic on continuum of care in our HIV cohort expressed as number of missed visits, number of new HIV diagnosis, drop in ART (antiretroviral therapy) dispensation and number of hospitalized HIV patients due to SARS-CoV-2 infection. In this short communication, we completed the previous article with data of HIV plasmatic viremia of the same cohort before and during pandemic. Methods We considered all HIV-patients in stable ART for at least 6 months and with at least 1 available HIV viremia in the time window March 01–November 30, 2019, and another group of HIV patients with the same two requisites but in different time windows of the COVID-19 period (March 01–May 31, 2020, and June 01–November 30, 2020). For patients with positive viremia (PV) during COVID-19 period, we reported also the values of viral load (VL) just before and after PV. Results: the percentage of patients with PV during COVID-19 period was lower than the previous year (2.8% vs 7%). Only 1% of our outpatients surely suffered from pandemic in term of loss of previous viral suppression. Conclusions Our efforts to limit the impact of pandemic on our HIV outpatients were effective to ensure HIV continuum of care.

Development and Validation of a Multivariable Prediction Model for Missed HIV Healthcare Provider Visits in a Large United States Clinical Cohort

Background Identifying individuals at high risk of missing HIV care provider visits could support proactive intervention. Previous prediction models for missed visits have not incorporated data beyond the individual-level. Methods We developed prediction models for missed visits among people living with HIV (PLWH) with ≥1 follow-up visit in the Center for AIDS Research Network of Integrated Clinical Systems from 2010-2016. Individual-level (medical record data and patient-reported outcomes), community-level (American Community Survey), HIV care site-level (standardized clinic leadership survey), and structural-level (HIV criminalization laws, Medicaid expansion, and state AIDS Drug Assistance Program budget) predictors were included. Models were developed using random forests with 10-fold cross-validation; candidate models with highest area under the curve (AUC) were identified. Results Data from 382,432 visits among 20,807 PLWH followed for a median of 3.8 years were included; median age was 44 years, 81% were male, 37% were Black, 15% reported injection drug use, and 57% reported male-to-male sexual contact. The highest AUC was 0.76 and strongest predictors were at the individual-level (prior visit adherence, age, CD4+ count) and community-level (proportion living in poverty, unemployed, and of Black race). A simplified model, including readily accessible variables available in a web-based calculator, had a slightly lower AUC of 0.700. Conclusions Prediction models validated using multi-level data had a similar AUC to previous models developed using only individual-level data. Strongest predictors were individual-level variables, particularly prior visit adherence, though community-level variables were also predictive. Absent additional data, PLWH with previous missed visits should be prioritized by interventions to improve visit adherence.

Healthcare disparities contribute to missed follow-up visits after cataract surgery in the USA: results from the perioperative care for intraocular lens study

ObjectiveTo identify factors that contribute to missed cataract surgery follow-up visits, with an emphasis on socioeconomic and demographic factors.MethodsIn this retrospective cohort study, patients who underwent cataract extraction by phacoemulsification at Massachusetts Eye and Ear between 1 January and 31 December 2014 were reviewed. Second eye cases, remote and international patients, patients with foreign insurance and combined cataract cases were excluded.ResultsA total of 1931 cases were reviewed and 1089 cases, corresponding to 3267 scheduled postoperative visits, were included. Of these visits, 157 (4.8%) were missed. Three (0.3%) postoperative day 1, 40 (3.7%) postoperative week 1 and 114 (10.5%) postoperative month 1 visits were missed. Age<30 years (adjusted OR (aOR)=8.2, 95% CI 1.9 to 35.2) and ≥90 years (aOR=5.7, 95% CI 2.0 to 15.6) compared with patients aged 70–79 years, estimated travel time of >2 hours (aOR=3.2, 95% CI 1.4 to 7.4), smokers (aOR=2.7, 95% CI 1.6 to 4.8) and complications identified up to the postoperative visit (aOR=1.4, 95% CI 1.0 to 2.1) predicted a higher rate of missed visits. Ocular comorbidities (aOR=0.7, 95% CI 0.5 to 1.0) and previous visit best-corrected visual acuity (BCVA) of 20/50–20/80 (aOR=0.4, 95% CI 0.3 to 0.7) and 20/90–20/200 (aOR=0.4, 95% CI 0.2 to 0.9), compared with BCVA at the previous visit of 20/40 or better, predicted a lower rate of missed visits. Gender, race/ethnicity, language, education, income, insurance, alcohol use and season of the year were not associated with missed visits.ConclusionsMedical factors and demographic characteristics, including patient age and distance from the hospital, are associated with missed follow-up visits in cataract surgery. Additional studies are needed to identify disparities in cataract postoperative care that are population-specific. This information can contribute to the implementation of policies and interventions for addressing them.

Abstract 17207: Impact of Racial Differences in Treatment Intensification and Missed Visits on Disparities in BP Control

Introduction: Hypertensive black patients have the lowest rates of blood pressure (BP) control. It is unknown to what extent variation in healthcare processes like treatment intensification (TI) and missed visits explain this disparity. Hypothesis: We hypothesized there would be no racial differences in TI but missed visits would be more frequent among black patients and mediate a sizable percentage of BP control disparities. Methods: We used a structural equation multivariate regression model to estimate the likelihood of BP control (BP<140/90 mm Hg) in black vs. white hypertensive patients, mediated by TI and missed visits. We included 6,556 patients who had diagnosis of hypertension and at least one clinic visit with uncontrolled BP (≥140/90 mm Hg) in 12 safety-net clinics in San Francisco from 2015-2017.We used the standard-based method (SBM), which is predictive of BP control, to calculate TI (dose increase or medication addition). We measured missed visits as the number of “no-shows” in the four weeks after an uncontrolled BP. BP control was defined based on the most recent BP as of Nov 15, 2017. The model adjusted for gender, age, first recorded BP between Jan 2015 and Nov 2017, visit frequency, and diagnosis of diabetes. Results: The mean (SD) age was 57.0 (11.2), 41% were female, and 44% were black. Compared to whites, blacks had more missed opportunities for TI (β=-0.02, p<0.001) and missed more visits (β=0.37, p<0.001). After accounting for these differences, black patients remained less likely than whites to achieve BP control (β=0.16, OR=0.85, 95% CI=0.76-0.95). The indirect effect of decreased TI and missed visits accounted for 22% and 13% of the total effect of black race on BP control, respectively (Figure). Conclusion: Racial inequities in treatment intensification may be responsible for over 20 percent of racial disparities in hypertension. Efforts to ensure more equitable treatment intensification may reduce black-white disparities in BP control.

Consequences of the COVID-19 pandemic on the continuum of care in a cohort of people living with HIV followed in a single center of Northern Italy

Introduction During the COVID-19 pandemic, hospitals faced increasing pressure, where people living with HIV risked to either acquire SARS-CoV-2 and to interrupt the HIV continuum of care. Methods This is a retrospective, observational study. We compared the numbers of medical visits performed, antiretroviral drugs dispensed and the number of new HIV diagnosis and of hospitalizations in a cohort of people living with HIV (PLWH) followed by the Spedali Civili of Brescia between the bimester of the COVID-19 pandemic peak and the bimester of October–November 2019. Data were retrieved from administrative files and from paper and electronic clinical charts. Categorical variables were described using frequencies and percentages, while continuous variables were described using mean, median, and interquartile range (IQR) values. Means for continuous variables were compared using Student’s t-tests and the Mann–Whitney test. Proportions for categorical variables were compared using the χ2 test. Results As of December 31st, 2019, a total of 3875 PLWH were followed in our clinic. Mean age was 51.4 ± 13 years old, where 28% were females and 18.8% non-Italian. Overall, 98.9% were on ART (n = 3834), 93% were viro-suppressed. A total of 1217 and 1162 patients had their visit scheduled at our out-patient HIV clinic during the two bimesters of 2019 and 2020, respectively. Comparing the two periods, we observed a raise of missed visits from 5 to 8% (p < 0.01), a reduction in the number of new HIV diagnosis from 6.4 in 2019 to 2.5 per month in 2020 (p = 0.01), a drop in ART dispensation and an increase of hospitalized HIV patients due to COVID-19. ART regimens including protease inhibitors (PIs) had a smaller average drop than ART not including PIs (16.6 vs 21.6%, p < 0.05). Whether this may be due to the perception of a possible efficacy of PIs on COVID19 is not known. Conclusions Our experience highlights the importance of a resilient healthcare system and the need to implement new strategies in order to guarantee the continuum of HIV care even in the context of emergency.