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in+care CampaignMeet the Author

May 30, 2013

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Welcome & Introductions

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Michael Hager, MPH MA

NQC Manager,in+care Campaign ManagerNew York, NY

Tim Minniear, MDResearch AssociateInfectious Diseases DepartmentSt. Jude Children’s Research HospitalMemphis, TN

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Agenda Welcome & Introductions, 5min Delayed Entry Into and Failure to Remain In Care

Among HIV-Infected Adolescents, 30min―Background―Population and Methods―Results―Conclusions―Translating Research into Practice

Updates & Reminders, 5min Q & A Session, 20min

Delayed Entry into and Failure to Remain in HIV Care AmongHIV-Infected Adolescents

TD Minniear, AH Gaur, A Thridandapani, C Sinnock, EA Tolley, and PM Flynn. AIDS Research and Human

Retroviruses. January 2013, 29(1): 99-104. doi:10.1089/aid.2012.0267

Disclosures

I have no conflicts of interest to disclose.

BACKGROUND

Four Components of Engagement

Adhere to Medical

Instructions

Utilize HIVCare Services

Learn of HIVPositive Status

Enter HealthCare Services

Linkage Retention

Cheever. CID 2007Horstmann et al. CID 2010

The HIV/AIDS Epidemic in the USA

1.2 Million PeopleLiving with HIV

25% Unawareof Diagnosis

900,000Aware ofDiagnosis

33% Not Linkedinto Care

600,000Linked to Care 400,000

Actively Engaged

33% Fall out of Care

• Includes 20-30,000 adolescents• ~ 26,000 new infections annually

Del Rico et al. CROI 2001, Marks et al. AIDS 2006Hall et al. JAMA 2008, Campsmith et al. JAIDS 2010

The HIV/AIDS Epidemic in the USA

600,000 People Living with HIV Not Yet Engaged in Care

200,000 People Living with HIV Inadequately Engaged

Take Home Point: 2/3rds of All People Living with HIV in the United States Are NOT Adequately Engaged in Care

Primary Study Objectives

1. Identify factors associated with delaying entry into care (DEC) after diagnosis of HIV infection.

2. Identify factors associated with falling to remain in care (FRC) after initial engagement.

POPULATION & METHODS

Population & Methods

• Adolescents (13-21 years of age)– Infected via High-Risk Behavior– Diagnosed between 1996 and 2010– Exclusions:

• Diagnosed during pregnancy• Transferred in from another clinic

• Large, urban comprehensive HIV clinic– Memphis, Tennessee, USA

• 650,000 people• 64% Minority (61% African-American, 3% Hispanic)• 21% live below the poverty level

Definition of Outcomes

Delayed Entry into HIV Care•Lag >60 days from diagnosis to first kept appointment at the adolescent HIV clinic

– Centers for Disease Control & Prevention’s Strategic Plan– Standard of care for outreach at our institution

Failing to Remain in HIV Care•Not returning to clinic ≥6 months and missing at least 1 scheduled visit

– After engaging in care for at least 1 year (making 1 visit in each quarter)

Definition of Outcomes

Failing to Remain in HIV Care•Not returning to clinic ≥6 months and missing at least 1 scheduled visit

3 Months 3 Months 3 Months

S NS S

3 Months

S: Show; NS: No Show

3 Months 1 1 1

S NS SNS

6 Months 3 Months

S S

3 Months

OUT

IN

IN

Statistical Analysis

• Descriptive statistics

• Univariate analysis– Student’s t-test, Wilcoxon rank sum,

chi-square as appropriate

• Multivariate log-linear regression

• Analyses performed with SAS 9.1.3 (Cary, North Carolina, USA)

Statistical Analysis

• Multivariable Model– Analyzed each outcome separately– Included all factors with significance <0.15

• Forced gender into the FRC model in order to adjust for the greater likelihood of a female having custody of a child

– Estimated adjusted relative risks (rather than odds ratios) using a log-linear regression and assuming a Poisson distribution (GENMOD)

RESULTS

Case Assignment

No correlation between DEC & FRC

38% (76/202) delayed entry into care

30% (53/178) failed to remain engaged

coefficient = -0.01 (p=0.93)

Baseline CharacteristicsDelayed Entry into Care (N = 202)

 Delayed Entry

(n = 76)Prompt Entry

(n = 126)P value

Race, Black 71 (93%) 121 (96%) 0.41Self-Identified Sexual OrientationMale, bisexualMale, heterosexualMale, homosexualFemale, heterosexual

  7 ( 9%) 10 (13%) 29 (38%) 30 (39%)

  6 ( 5%) 22 (17%) 52 (41%) 46 (37%)

0.52

Baseline Age (years)Mean (sd)

18.6 (1.5) 18.4 (1.8) 0.43

Clinical StageABC

  62 (82%) 9 (12%) 5 (6.6%)

 107 (85%) 8 (6.4%) 11 (8.7%)

0.36

Distance from Clinic (miles)Median (IQR)

7.7 (4.3-14.4) 9.5 (6.3-12.6) 0.45

Factors Associated withDelaying Entry into HIV Care

Prompt Entry (n = 126)

Delayed Entry (n = 76)

Unadjusted RR

(95%-CI)

Adjusted RRa

(95%-CI)

Unstable Residence 30 (39%) 29 (23%) 1.6 (1.1–2.2) 1.5 (1.0–2.1)No Supervising Adult 31 (41%) 36 (29%) 1.4 (1.0–2.0) 1.2 (0.9–1.8)Education•High School Drop Out•High School Student•High School Graduate•College Student

 33 (43%)13 (17%)15 (20%)15 (20%)

 59 (47%)34 (27%)25 (20%) 8 ( 6%)

 0.6 (0.4–0.8)0.4 (0.2–0.7)0.6 (0.3–0.9)Reference

 0.4 (0.3–0.7)0.4 (0.2–0.7)0.5 (0.3–0.9)Reference

Residing within 5 Miles of the HIV Clinic

23 (30%) 19 (15%) 1.7 (1.2–2.4) 1.7 (1.2–2.5)

a Relative risk was adjusted for unstable residence, living alone, education, and distance from clinic.

Baseline CharacteristicsFailed to Remain in Care (N = 177)

 Failed to Remain

(n = 52)Remained(n = 125)

P value

Race, Black 50 (96%) 118 (94%) 0.63Self-Identified Sexual OrientationMale, bisexualMale, heterosexualMale, homosexualFemale, heterosexual

  2 ( 4%) 12 (23%) 18 (35%) 20 (38%)

  8 ( 6%) 17 (14%) 52 (42%) 48 (38%)

0.41

Baseline Age (years)Mean (sd)

18.6 (2) 18.4 (1.6) 0.63

Clinical StageABC

  44 (85%) 5 (9%) 3 (6%)

 100 (80%) 12 (10%) 13 (10%)

0.59

Distance from Clinic (miles)Median (IQR)

8.9 (5.4-12.4) 9.2 (5.2-13.2) 0.98

HIV Disease CharacteristicsFailed to Remain in Care (N = 177)

 Failed to Remain

(n = 52)Remained(n = 125)

P value

Baseline CD4 441 (240) 431 (237) 0.80Most Recent CD4 549 (266) 595 (274) 0.31Most Recent CD4% 28 (8.9) 30 (11) 0.34Change in CD4 109 (210) 164 (304) 0.23Baseline HIV Log Viral Load

9.3 (2.6) 9.8 (2.6) 0.28

Most Recent HIV Log Viral Load

7.1 (3.3) 5.5 (3.6) 0.006

Reduction in HIV Log Viral Load

2.4 (3.5) 4.4 (4.4) 0.004

Values Presented as Mean (sd)

Factors Associated withFalling out of HIV Care (N = 177)

 Failed to Remain

(n = 52)Remained(n = 125)

Unadjusted RR(95%-CI)

Adjusted RRa (95%-CI)

Insurance•No Insurance•Public•Private

 23 (44%)25 (48%) 4 (16%)

 28 (22%)76 (61%)21 (17%)

 2.8 (1.1–7.3)1.5 (0.6–4.0)Reference

 2.8 (1.1–6.9)1.2 (0.5–3.2)Reference

Custody of a Child 11 (21%) 11 (8.8%) 1.9 (1.2–3.1) 1.8 (1.0–3.1)Education•High School Drop Out•High School Student•High School Graduate•College Student

 29 (56%)12 (23%) 9 (17%) 2 ( 4%)

 53 (42%)27 (22%)27 (22%)18 (14%)

 3.5 (0.9–13.6)3.1 (0.8–12.4)2.5 (0.6–10.5)Reference

 4.0 (1.1–15)4.5 (1.2–17.5)3.0 (0.8–12.0)Reference

a Relative risk was adjusted for insurance status, custody of a child, gender, and education.

CONCLUSIONS

Delay does not predict falling out

• Adolescents who delayed entering care did not necessarily later fall out of care.

• The only predictor in common between delayed entry and failing to remain in care was education (in opposite directions).– However, each had at least one possible

surrogate for poor socioeconomic status.

Free access and transportation do not guarantee attendance

• Despite the close proximity to the HIV clinic and despite free, non-stigmatized transportation, adolescents and young adults living closest to the clinic were at greater risk for delaying entry into HIV care.

Free access and transportation do not guarantee attendance

• Despite the fact that our clinic does never charges a patient and we help obtain Ryan White assistance for qualifying patients, not having insurance was associated with failing to remain in care.

Free access and transportation do not guarantee attendance

• We did not have objective measures of socioeconomic status for our patients.

• Both residing within 5 miles of the clinic and lack of insurance could be surrogates for low socioeconomic status.

• Covering the costs of care and transportation is not sufficient to overcome the barriers intrinsic to living in a low socioeconomic strata.

The perplexing effect of education

• Youth in college were more likely to delay entry into HIV care than youth with any lower level of education.

• In contrast, once finally engaged, youth in college were more likely to remain engaged in HIV care.

The perplexing effect of education

• One—and not the only—explanation for the flip in association is that the demands or lifestyle of attending college lead youth to procrastinate making contact with the HIV clinic.

• Once at the clinic, they may better understand the risks of non-compliance or be more motivated to maintain their health.

TRANSLATING RESEARCH FINDINGS INTO PRACTICE

Lessons Learned

• Devote resources to linking “high-risk” youth to HIV care– Meet the youth where they are (e.g. school

health clinics)– Outreach to no shows sooner rather than later

• Strong social work and outreach support are key to keeping youth engaged in care

Improving Linkage to Care

• As part of Connect to Protect, we have expanded our outreach and follow-up of newly diagnosed youth to include not only the health department but also the city school system, several community and faith based organizations, and university health clinics.

Improving Retention

• Initiated a home visit program for established patients to bring them back into care sooner.

• Assisted in establishing community advisory boards.

Acknowledgements

Infectious Diseases

Patricia Flynn, MD

Aditya Gaur, MD

Biostatistics

Elisabeth Tolley, PhD

Data Managers

Wally Bitar

Anil Thridandipani

Psychology & Social Work

Patricia Garvie, PhD

Christine Sinnock

Melanie Copeland

Funding & Support

St. Jude Children’s Research Hospital & ALSAC

Questions?

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Announcements

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Upcoming Webinars: ― Partners in+care | Spanish Language Webinar | June 24,

2013 2pm ET

― in+care Campaign | Latinos & Retention | June 25, 2013 1pm ET

― Partners in+care Webinar | Adolescents and Retention | To be Scheduled

Data Collection Submission Deadline: June 3, 2013

Improvement Update Submission Deadline: June 17, 2013

Upcoming Events and Deadlines

― June – Latinos and Retention

― July – Patient Navigation

― August – Migrants, Refugees and Retention

― September – Women and Retention

Upcoming Monthly Topics

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Time for Questions and Answers

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