HIV-infected patients and treatment outcomes: an equivalence study of community-located, primary care-based HIV treatment vs. hospital-based specialty care in the Bronx, New York

Abstract

The HIV-infected population in the USA is expanding as patients survive longer and new infections are identified. In many areas, particularly rural/medically underserved regions, there is a growing shortage of providers with sufficient HIV expertise. HIV services incorporated into community-based (CB), primary care settings may therefore improve the distribution and delivery of HIV treatment. Our objective was to describe/compare patients and treatment outcomes in two settings: a community-located, primary care-based HIV program, and a hospital-based (HB) specialty center. CB providers had on-site access to generalist HIV experts. The hospital center was staffed primarily by infectious disease physicians. This was a retrospective cohort study of 854 HIV-positive adults initiating care between 1/2005 and 12/2007 within an academic medical center network in the Bronx, NY. Treatment outcomes were virologic and immunologic response at 16–32 and 48 weeks, respectively, after combination antiretroviral therapy (cART) initiation. We found that HB subjects presented with a higher prevalence of AIDS (59% vs. 46%, p<0.01) and lower initial CD4 (385 vs. 437, p<0.05) than CB subjects. Among 178 community vs. 237 hospital subjects starting cART, 66% vs. 62% achieved virologic suppression (95% confidence interval (CI) difference –0.14–0.06) and 49% vs. 59% achieved immunologic success, defined as a 100 cell/mm³ increase in CD4 (95% CI difference 0.00–0.19). The multivariate-adjusted likelihoods of achieving viral suppression [OR=1.24 (95% CI 0.69–2.33)] and immunologic success [OR=0.76 (95% CI 0.47–1.21)] were not statistically significant for community vs. hospital subjects. Because this was an observational study, propensity scores were used to address potential selection bias when subjects presented to a particular setting. In conclusion, HIV-infected patients initiate care at CB clinics earlier and with less advanced HIV disease. Treatment outcomes are comparable to those at a HB specialty center, suggesting that HIV care can be delivered effectively in community settings.

Keywords:

• HIV primary care
• community-based health services
• HIV treatment outcomes

Acknowledgements

The authors gratefully acknowledge the support and helpful contributions of Jason Fletcher, Mimi Kim, Matt Anderson, Albert Einstein College of Medicine's Clinical Research Training Program, and the MMG/Bronx Community Health Network's CICERO program. This work was funded through the New York State Department of Health's Empire Clinical Research Investigator Program. In addition, it was made possible by CTSA Grants UL1 RR025750, KL2 RR025749, and TL1 RR025748 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessary represent the official view of the NCRR or NIH.