Moving HIV care is associated with poorer outcomes - many patients not connecting with new clinics

Patients who move and have to find a new HIV clinic have poorer outcomes than people who remain in continuous care at the same treatment centre, Canadian research published in the May 1^st edition of the Journal of Acquired Immune Deficiency Syndromes suggests.

Investigators in Alberta compared CD4 cell counts and rates of AIDS-defining illnesses between individuals who received continuous care from at their clinic and those who moved away – necessitating a change of treatment centre – but subsequently returned.

“We found that when compared with remaining patients, the majority of returning patients had experienced a significant and measurable reduction in health as proxied by both a reduced CD4 cell count and a proportional increase in new AIDS events,” comment the investigators.

They suggest that these poorer outcomes were probably because individuals who moved were not connecting with a new HIV treatment centre. “Patients who disengage are, in effect, allowing HIV infection to run its natural course, at least in the short term.”

In many countries with universal access to health care it is possible for patients to move their care between HIV treatment centres. It is well known that individuals who are lost to follow-up have poorer outcomes than individuals who remain in care. However, the impact of moving care on HIV disease progression has not been examined.

Investigators at the Southern Alberta Clinic in Calgary therefore looked at the records of all 836 patients who received care between 2000 and 2009.

These individuals were divided into three categories:

• Remained at the clinic and received continuous care.

• Left the clinic because they moved to another region, or if they were lost to follow-up. Patients were categorised as moving if they informed the clinic of their plans, and/or if their medical records were requested by another clinic.

• Patients who had left the clinic, either because they moved or were lost to follow-up, but then returned.

A total of 465 patients (56%) remained in continuous care. Of the 371 patients who left care at some point, 177 discontinued their care and did not return. However, 142 individuals – including 57 who had moved and 85 who were lost to follow-up – returned to the clinic.

Transfer to a new HIV treatment centre was verified for 63% of patients who said they were moving but who did not return. By contrast, only a third of patients who moved and returned had their notes requested by a new clinic.

The investigators speculate that the other patients “may never have connected for HIV care in their new location”. They acknowledge, however, that it is possible that “the new clinic relied on patient recall of previous laboratory results and interventions rather than requesting records”, but add this “is against standard practice”.

Patients who moved were absent for a median of 194 days before returning, whereas average absence was significantly longer – 574 days – for patients who were lost to  follow-up.

Two-thirds of individuals who moved, and 41% of patients who were lost to follow-up, were taking antiretroviral drugs at the time they ceased to receive care from the South Alberta Clinic. Their median CD4 cell count at this time was 405 cells/mm³.

However, on returning, their median CD4 cell count was just 270 cells/mm³.

Patients who moved had a decrease from a median of 424 cells/mm³ to 339 cells/mm³ – a fall of 7.2 cells each 30 days of absence.

People who were lost to follow-up experienced a fall in their CD4 cell count from a median of 382 cells/mm³ to 240 cells/mm³, meaning that in each month of absence, their CD4 cell count fell by a median of 8.1 cells/mm³.

In contrast, patients who remained in care experienced a median increase of 4.3 cells/mm³ every 30 days.

These differences in immune function were reflected in higher rates of disease progression in the patients who moved or were lost to follow-up.

A new AIDS-defining event was recorded in 7% of patients who remained in continuous care, compared to 15% of returning patients.

Only 7% of patients who moved, and none of those who were lost to follow-up, received three months of antiretrovirals to ensure they had sufficient treatment while they made the transition to a new clinic.

“The adverse effect on HIV health is apparent in those who returned; the decline in CD4 cell counts for both those who ‘moved’ and those LTFU [lost to follow-up] is very similar and likely driven by lack of antiretroviral therapy,” comment the investigators.

They conclude, “efforts to transfer care seamlessly to other HIV care centres needs to be reinforced to avoid negative health consequences.”

The authors also believe their findings have implications for wider efforts to control the epidemic, commenting: “recognizing and addressing patient mobility, both planned and unplanned, may be another challenge for the ‘seek and treat’ strategy being discussed.”

Krentz HB et al. Adverse health effects for individuals who move between HIV care centers. J Acquir Immune Defic Syndr, 57: 51-54, 2011 (click here for the free abstract).