Quarterly outpatient visits for HIV care improve the chances of long-term survival.

When HIV infection started to evolve into a chronic, treatable disease in the late 1990s, data began to emerge indicating poor rates of access to and retention in long-term HIV care. Now, for the first time, researchers have demonstrated an association between maintenance of medical care and better chances of survival.

The Veterans Affairs (VA) hospital database was used to identify 2619 HIV-infected men who received their first VA prescription for antiretroviral therapy (ART) after January 1, 1997, during a VA clinic visit and who survived at least 1 year beyond that visit. CD4-cell–count data were available for all study participants. The analysis focused on overall survival, starting 1 year beyond the first clinic appointment, and stratified outcomes based on the number of quarters during which participants saw an outpatient HIV provider in the first year after their initial clinic appointment.

Approximately 64% of study participants had visits in all four quarters, 18% in three quarters, 11% in two quarters, and 6% in one quarter. In univariate analyses, a higher number of quarters in which visits occurred positively correlated with more-advanced disease, older age, and increased ART use — and negatively correlated with prevalence of hepatitis C virus (HCV) coinfection, alcohol abuse, and illicit drug use. The more quarters in which patients had visits, the greater the increase in median CD4-cell count and the greater the drop in median viral load. In a multivariate analysis, mortality risk during the study increased by 42%, 67%, or 95% among patients who had visits in three quarters, two quarters, or one quarter, respectively, compared with those who had visits in all four quarters. Other indicators of survival included lower baseline CD4-cell count, older age, HCV coinfection, and a greater number of other comorbidities.

Comment: This study is the first to demonstrate an association between consistent HIV care and improved survival and to critically examine the correlates of poor retention in care. Although the generalizability of the results is questionable given the VA-specific sample and the exclusion of women, these limitations likely make the results even more conservative than they would be in a broader HIV-infected population. Indeed, data suggest that free access to care (i.e., through a VA) and male gender only serve to improve care-retention rates (J Acquir Immune Defic Syndr 2002; 29:69). Clearly, we must strengthen our efforts at HIV case identification through routine HIV testing programs and dedicate specific attention to patients who missed their last clinic appointment. Keeping these patients engaged in care will significantly improve their chances of long-term survival.

— Rochelle P. Walensky, MD, MPH

Dr. Walensky is Associate Director of the Program in Epidemiology and Outcomes Research at the Center for AIDS Research at Harvard Medical School and an Infectious Disease Specialist at Massachusetts General Hospital and Brigham and Women’s Hospital in Boston.

Published in AIDS Clinical Care June 4, 2007