Social determinants of health and retention in HIV care in a clinical cohort in Ontario, Canada

ABSTRACT

Continuous HIV care supports antiretroviral therapy initiation and adherence, and prolongs survival. We investigated the association of social determinants of health (SDH) and subsequent retention in HIV care in a clinical cohort in Ontario, Canada. The Ontario HIV Treatment Network Cohort Study is a multi-site cohort of patients at 10 HIV clinics. Data were collected from medical charts, interviews, and via record linkage with the provincial public health laboratory for viral load tests. For participants interviewed in 2009, we used three-category multinomial logistic regression to identify predictors of retention in 2010–2012, defined as (1) continuous care (≥2 viral loads ≥90 days in all years; reference category); (2) discontinuous care (only 1 viral load/year in ≥1 year); and (3) a gap in care (≥1 year in 2010–2012 with no viral load). In total, 1838 participants were included. In 2010–2012, 71.7% had continuous care, 20.9% had discontinuous care, and 7.5% had a gap in care. Discontinuous care in 2009 was predictive (p < .0001) of future retention. SDH associated with discontinuous care were Indigenous ethnicity, being born in Canada, being employed, reporting hazardous drinking, and non-injection drug use. Being a heterosexual male was associated with having a gap in care, and being single and younger were associated with discontinuous care and a gap in care. Various SDH were associated with retention. Care discontinuity was highly predictive of future gaps. Targeted strategic interventions that better engage those at risk of suboptimal retention merit exploration.

Abbreviations: AOR: adjusted odds ratio; ART: antiretroviral therapy; AUDIT: Alcohol Use Disorders Identification Test; CES-D: Center for Epidemiologic Studies Depression Scale; CIs: confidence intervals; HIV: human immunodeficiency virus; IQR: interquartile range; MSM: men who have sex with men; NA-ACCORD: North American AIDS Cohort Collaboration on Research and Design; OCS: Ontario HIV Treatment Network Cohort Study; OHTN: Ontario HIV Treatment Network; OR: odds ratio; PHOL: Public Health Ontario Laboratories; REB: Research Ethics Board; SDH: social determinants of health; US: United States

KEYWORDS:

• Retention
• gaps in care
• social determinants of health
• HIV
• Canada
• clinical cohort

Acknowledgements

We gratefully acknowledge all of the people living with HIV who volunteered to participate in the OHTN Cohort Study and the work and support of the past and present members of the OCS Governance Committee: Adrian Betts, Anita C. Benoit, Breklyn Bertozzi, Lisungu Chieza, Les Bowman, Tracey Conway, Patrick Cupido (Chair), Tony Di Pede, Brian Finch, Michael J. Hamilton, Brian Huskins, Rick Kennedy, Ken King, Nathan Lachowsky, Joanne Lindsay, Shari Margolese, Mark McCallum, John McTavish, Colleen Price, Lori Stoltz, Darien Taylor, Rosie Thein, and Drs Ahmed Bayoumi, Evan Collins, Curtis Cooper, Clemon George, Troy Grennan, Claire Kendall, and Greg Robinson. We thank all the interviewers, data collectors, research associates and coordinators, nurses, and physicians who provide support for data collection and extraction. The authors wish to thank the OCS staff for data management, IT support, and study coordination: Sarath Pillai, Madison Kopansky-Giles, Jason Globerman, Beth Rachlis, Robert Hudder, Lucia Light, Veronika Moravan, and Nahid Qureshi. The OHTN Cohort Study is supported by the Ontario Ministry of Health and Long-Term Care.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The Ontario HIV Treatment Network (OHTN) Cohort Study is funded by the AIDS Bureau, Ontario Ministry of Health and Long-Term Care. Other supports include a Canadian Institutes of Health Research (CIHR) New Investigator award to A.N.B., T.A., and C.K.; an OHTN Applied HIV Research Chair to C.C.; an OHTN Chair in Biostatistics and support from the Toronto and Western Hospital Foundation Skate the Dream Fund to J.R.