High retention in HIV care at a tertiary care centre in Toronto, Canada^*

* This work was presented in part at the International Women and HIV Conference, in Washington DC in January 2014, and the Canadian Association for HIV Research Conference in Toronto, Ontario in May 2015.

ABSTRACT

Poor retention in HIV care is associated with poor clinical outcomes and mortality. Previous studies of predictors of poor retention have been conducted with a wide variety of populations, using different measures of retention, and occasionally have conflicting results. We studied demographic and psychosocial factors associated with inter-visit interval length in a setting of universal health care and modern cART. Patients attending ≥2 appointments with an HIV specialist at the Toronto General Hospital Immunodeficiency Clinic from 2004 to 2013 were studied. A sub-analysis included psychosocial measures from annual questionnaires for Ontario HIV Treatment Network Cohort Study (OCS) participants. Median inter-visit interval and constancy (percentage of 4-month intervals with ≥1 visit) were calculated by patient. Multivariable generalized estimating equation models identified factors associated with inter-visit interval length and intervals ≥12 months. 1591 patients were included. 615 patients completed an OCS questionnaire and were more likely to be older white MSM from Canada with a viral load (VL) <50 copies/ml. The median (IQR) of patients’ median inter-visit intervals was 3.15 (2.78, 3.84) months and median (IQR) constancy was 90% (71%, 100%). Two percent of inter-visit intervals were ≥12 months and 25% of patients had ≥1 interval ≥12 months. Longer inter-visit intervals were associated with younger age, white race, earlier calendar year, longer duration of HIV, VL < 50 copies/mL and higher CD4 counts. Patients who were younger, white, had injection drug use as a risk factor, had a longer duration of HIV, and had VL ≥50 copies/mL were more likely to have an inter-visit interval ≥12 months. In the OCS sub-analysis including psychosocial variables, lower levels of depression were associated with longer inter-visit intervals. Retention at this tertiary care centre was high. Efforts to maximize attendance should focus on younger patients and those with substance abuse issues.

KEYWORDS:

• HIV
• retention
• inter-visit interval

Acknowledgements

We would like to thank Sherine Sterling for her work in securing the scheduling data and management of the Immunodeficiency Clinic database.

The OHTN Cohort Study Team consists of Drs. Sean B. Rourke (Principal Investigator), University of Toronto, St. Michael’s Hospital, and OHTN; Kevin Gough, St. Michael’s Hospital; Jeffrey Cohen, Windsor Regional Hospital; Curtis Cooper, Ottawa General Hospital; Don Kilby, University of Ottawa Health Services; Fred Crouzat and Mona Loutfy, Maple Leaf Medical Clinic; Anita Rachlis and Nicole Mittmann, Sunnybrook Health Sciences Centre; Janet Raboud and Irving Salit, Toronto General Hospital; Michael Silverman, St. Joseph’s Health Care; and Roger Sandre, Sudbury Regional Hospital.

We gratefully acknowledge all of the people living with HIV who volunteer to participate in the OHTN Cohort Study. We also acknowledge the work and support of OCS Governance Committee and Scientific Steering Committee members: Adrian Betts, Anita C. Benoit, Breklyn Bertozzi, Les Bowman, Lisungu Chieza, Tracey Conway, Patrick Cupido, Brian Huskins, Joanne Lindsay, Mark McCallum, John McTavish, Colleen Price, Rosie Thein, Barry Adam, David Brennan, Claire Kendall, Tony Antoniou, Ann Burchell, Curtis Cooper, Trevor Hart, Mona Lofty, Kelly O’Brien, Janet Raboud, and Anita Rachlis. The OHTN Cohort Study also acknowledges the work of past Governance Committee and Scientific Steering Committee members.

We thank all interviewers, data collectors, research associates, coordinators, nurses, and physicians who provide support for data collection. The authors wish to thank OCS staff for data management, IT support, and study coordination: Madison Kopansky-Giles, Jason Globerman, Beth Rachlis, Robert Hudder, Gokul Kalaimani, Lucia Light, Veronika Moravan, and Nahid Qureshi.

We also acknowledge the Public Health Laboratories, Public Health Ontario, for supporting linkage with the HIV viral load database.

The opinions, results and conclusions are those of the authors only. No endorsement by the Ontario HIV Treatment Network or Public Health Ontario is intended or should be inferred.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

* This work was presented in part at the International Women and HIV Conference, in Washington DC in January 2014, and the Canadian Association for HIV Research Conference in Toronto, Ontario in May 2015.

Additional information

Funding

AB was supported by a CIHR New Investigator award. JR was supported by the OHTN Chair in Biostatistics. SW was supported by an Applied Health Research Chair from the OHTN. The OHTN Cohort Study is funded by the AIDS Bureau, Ontario Ministry of Health and Long-Term Care.