http://www.eatg.org/news/newsitem.php?id=1667
Patients who don't visit their HIV clinic regularly have increased
risk of death
Thursday, May 10, 2007
   
Patients who do not attend for regular HIV care are significantly more
likely to die than those who maintain good contact with their HIV
clinic.

By Michael Carter

Patients who do not attend for regular HIV care are significantly more
likely to die than those who maintain good contact with their HIV
clinic, according to an American study published in the June 1st
edition of Clinical Infectious Diseases. Investigators from the
Department of Veterans’ Affairs found that, compared to patients who
attended all of their follow-up visits in the year after commencing
HIV therapy, those who missed one quarterly visit had an increased
risk of death of 42%, with those who missed three quarterly visits
being 95% more likely to die.

Potent HIV therapy has dramatically improved the prognosis of
HIV-positive patients in industrialised countries. But to gain the
maximum benefit from HIV treatment, it is necessary for an
HIV-positive person to have their infection diagnosed before they have
developed advanced immune suppression, and to indefinitely receive
specialist HIV care.

Although it is intuitive that HIV-positive patients who receive
regular care will live longer, this has not been previously been
demonstrated for HIV or any other chronic illness.

Investigators used the registry of the Department of Veterans’
Affairs, the largest provider of HIV care in the United States, to
test the hypothesis that poor retention in HIV care is associated with
a worse clinical outcome, including death.

The study population included all HIV-positive individuals entered
onto the registry in 1997 and 1998. The main outcome was survival from
one year after entering care. Data were collected to the end of 2004.
Information was also gathered on changes in CD4 cell count and viral
load one year after commencing HIV therapy.

US treatment guidelines recommend that HIV-positive patients should
visit their HIV doctor at quarterly intervals, and the investigators
looked at survival and treatment outcome according to the number of
quarterly visits made during the first year of HIV care.

A total of 2,619 men were included in the study. HIV disease was
significantly advanced in most patients at the time of diagnosis,
median CD4 cell count being 228 cells/mm3.

In the first year after HIV diagnosis, 64% of patients attended all
four outpatient appointments, 18% attended three of their quarterly
appointments, 11% attended two appointments, and 6% attended only one
quarterly appointment.

Factors significantly associated with attending more appointments were
older age (p < 0.01), more advanced immune suppression at the time of
HIV diagnosis (p < 0.01), and receiving antiretroviral therapy (p =
0.05). Patients who were coinfected with hepatitis C virus (p <
0.001), abused alcohol (p < 0.0010, or used hard drugs (p < 0.001)
were significantly less likely to attend for regular follow-up.

A year after starting HIV therapy, CD4 cell count increased by a
median of 100 cells/mm3 from baseline in patients who attended all
their quarterly visits in the year following diagnosis, but only by a
median of 49 cells in patients who visited their HIV clinic once in
the year following diagnosis, a highly significant difference (p <
0.001). Similarly, the fall in viral load was significantly greater
the more follow-up visits a patient kept (p < 0.001).

A total of 425 patients died after their first year of HIV care. After
adjusting for factors such as race, age, CD4 cell count, use of
anti-HIV therapy and hepatitis C coinfection, the investigators found
that poor retention in HIV care significantly increased the risk of
death. Compared to patients who kept all their quarterly visits in the
year after diagnosis, those who missed just one had a 42% increased
risk of death (p < 0.001), those who missed two, a 67% increased risk
(p < 0.001), and those who missed three, a 95% increased risk of death
(p < 0.001).

“Patients out of care for as little as three months…had worse
survival”, write the investigators.

The findings of this study are particularly interesting as the study
population was eligible for free HIV treatment and care from the VA,
meaning that financial considerations were not a barrier to access.

The investigators conclude, “strategies to retain persons in long-term
care need to be developed, tested and implemented to maximize the
benefit from currently available medical care.”

The author of an accompanying editorial notes “multiple studies have
shown that patients who access case management, transportation, mental
health support, drug treatment and other supportive services are more
likely to be retained in care than those who do not.” She adds there
is also a need to “assist patients to develop a positive relationship
with health care providers and to improve their knowledge of HIV
infection and dispel negative health beliefs.”

Reference
1. Giordano TP et al. Retention to care: a challenge to survival in
HIV care. Clin Infect Dis 44 (online edition), 2007.
2. Cheever LW. Engaging HIV-infected patients in care: their lives
depend on it. Clin Infect Dis 44 (online edition), 2007.

SOURCE: NAM