Patients who don't visit their HIV clinic regularly have increased risk of death

Michael Carter
Published: 10 May 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, 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

Giordano TP et al. Retention to care: a challenge to survival in HIV care. Clin Infect Dis 44 (online edition), 2007.

Cheever LW. Engaging HIV-infected patients in care: their lives depend on it. Clin Infect Dis 44 (online edition), 2007.

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