latesha elopre, md1, andrew o. westfall, ms1

The Association of HIV Status Disclosure to Retention in Care and Viral Load Suppression
1
MD ,
LATESHA ELOPRE,
ANDREW O. WESTFALL,
MICHAEL J MUGAVERO,
ANNE ZINSKI,
GREER BURKHOLDER, MD 1, EDWARD W. HOOK, MD1, AND NICHOLAS VAN WAGONER, MD PHD1.
1Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham AL.
The 1917 Clinic
At UAB
1
MS ,
• Over > 1.1 million people in the United States are living with HIV.1
• Less than half are consistently engaged in care
• 37% are prescribed ART
• 30% achieve viral load suppression2
• Social support leads to better retention in care and medication adherence. 3
• Disclosure of HIV status is a prerequisite for social support.4
• Poor retention in care and viremia correlate with higher health-care costs and
poor health outcomes.5
OBJECTIVE
• To evaluate whether nondisclosure and selective disclosure of HIV status are
associated with poor retention in HIV care and viremia.
Figure 1. Hypothesis: Disclosure of HIV Leads to Better Retention in Care and Viral Load Suppression
• Engagement in
care
• ART Adherence
Discloses
Viral load
suppression
Total = 508
N (%)
Characteristics
Median Age, years (Q1-Q3)
Population: Individuals> 19 years old entering HIV care for the first time
33 (26.0, 43.0)
Caucasian
186 (37.3)
African American (AA)
313 (63.7)
Gender/Sexual Behavior
MSM (Males, sex with men)
307 (60.4)
MSW (Male, sex with women)
109 (21.5)
WSM (Female, sex with men)
92 (18.1)
> 350
307 (60.4)
200-350
109 (21.5)
< 200
92 (18.1)
Data Analysis:
• Pearson’s χ2 and Wilcoxon rank sum tests were performed.
• Univariate and multivariable modeling to identify predictors of poor retention in
care and viremia (results shown as adjusted odds ratios).
• Statistical significance: α = 0.05.
Selective Discloser
Referent
AA: AOR 1.7 (1.0, 2.7)
WSM: AOR 2.1 (1.1, 3.9)
Non-discloser
AA: AOR 4.0 (1.8, 8.9)
CD4 < 200:
AOR 2.1 (1.0,4.3)
Educationc
Diploma/GED or less
203 (41.1)
Some college or more
291 (58.9)
Friends Only:
College: AOR 2.1 (1.2,3.8)
Significant Other Only:
Disclosured
None
65 (13.3)
Partner/Spouse/Significant Other
44 (9.0)
Family Only
85 (17.3)
Friends Only
111 (22.7)
More than one group
a. Frequency missing = 9
c. Frequency missing 14
185 (37.8)
b. Frequency missing = 5
d. Frequency missing = 18
WSM: AOR 3.0 (1.3, 7.1)
MSW: AOR 2.7 (1.3, 5.7)
CD4 < 200: AOR 2.5 (1.3, 4.9)
WSM: AOR 4.2 (1.3, 13.1)
Reference: Elopre et al (submitted)
CDC Prevention poster
Characteristics
Poor Retention in Care
AOR (95% CI)
N = 457
Viremia#
AOR (95% CI)
N = 382
Age, per 10 years
0.8 (0.7, 1.0)
1.1 (0.8, 1.6)
Ref
Ref
0.7 (0.4, 1.1)
3.0 (1.3, 7.0)**
Ref
Ref
MSW (Male, sex with women)
2.4 (1.4, 4.2)**
0.5 (0.2, 1.3)
WSM (Female, sex with men)
1.4 (0.8, 2.7)
0.7 (0.2, 1.8)
Ref
Ref
200-350
1.1 (0.7, 1.9)
0.4 (0.1, 0.9)*
< 200
0.7 (0.4, 1.1)
1.1 (0.5, 2.3)
Diploma/GED or less
Ref
Ref
Some college or more
0.7 (0.5, 1.2)
0.5 (0.2, 0.9)*
Private
Ref
Ref
Public
2.0 (1.0, 3.9)*
1.5 (0.6, 4.2)*
None
1.5 (0.9, 2.4)
1.1 (0.5, 2.4)
Alone
Ref
Ref
Family
0.7 (6.4, 1.2)
3.3 (1.2, 8.9)**
Partner/Spouse/SO
0.5 (0.3, 0.9)*
1.4 (0.5, 3.9)
Friends/Other
0.6 (0.3, 1.3)
2.6 (0.8, 8.3)
No
Ref
Ref
Yes
1.1 (0.7, 1.8)
0.5 (0.2, 0.9)*
Ref
Ref
Selective
0.9 (0.6, 1.5)
2.6 (1.2, 5.5)**
No one
2.1 (1.1, 4.1)*
1.2 (0.4, 3.6)
Race
Caucasian
Gender/Sexual Behavior
MSM (Males, sex with men)
CD4 count
Education
Insurance Status
Living Arrangement
Church Attendance
Disclosure
More than one group
• 3-Level Disclosure Model
• Retention in Care
• Nondisclosure was associated with poor retention in care
• Selective disclosure was not associated with poor retention in care
• Viremia
• Nondisclosure was not associated with viremia
• Selective disclosure was associated with uncontrolled viremia, with
association remaining significant in sensitivity analysis
• 5-Level Disclosure Model (data not shown)
• Additional predictors of viremia:
• Disclosure to family only AOR 2.9 (1.7, 7.5)
• Disclosure to friend only AOR 2.6 (1.0, 6.5)
Family Only:
Table 2. Characteristics Associated with Poor Retention in Care & Viremiaa
> 350
Independent Variables :
• Age, gender, sexual behavior, race, baseline CD4 + T lymphocyte count, church
attendance, education, insurance status, living arrangement, initiation of ART
• Primary analysis: 3-level disclosure
• Nondisclosure – disclosure to no one
• Selective Disclosure – disclosure to only one group (family only, friends only,
and significant other only)
• Broad Disclosure – Disclosure to more than one group
• Secondary analysis: 5-level disclosure with selective disclosure divided into
disclosure to family only, disclosure to friends only, and disclosure to significant
other only
Discloser
countb
African American
Outcomes (measured at 12 months from 1st orientation visit):
• Poor retention in care (>180 days gap between arrived PCP visit)
• Viremia (viral load > 200 copies/mL ) – Missing viral loads treated as missing
Figure 2. Characteristics Associated with Reporting
Selective Disclosure and Nondisclosure
Racea
METHODS
Study Design: Retrospective analysis of 12-month prospectively collected data
CONCLUSIONS
Table 1. Characteristics of Study Population
CD4
• Structural Support
• Functional Support
1
PHD ,
RESULTS
INTRODUCTION
• Stable Living
Arrangement
• Quality Relationships
• Emotional Support
• Practical Support
1
MD ,
a. Model controlled for initiation of ART
** p-value < 0.01
* p-value <0.05
#Sensitivity Analysis: Viral loads were not missing at random, so a second model treating missing viral
loads as failure was performed. Selective Disclosure AOR 1.7 (1.0, 2.9). Nondisclosure AOR 1.5 (0.7, 3.3)
DISCUSSION
• Understanding HIV disclosure patterns at the time of entry into care may help
providers identify those at risk for poor retention in care.
• HIV social or peer-based support services may have particular distinct
benefits for non-disclosing individuals
• The lack of association between nondisclosure and viremia at 12 months may
have been influenced by the number of missing viral loads (N = 126) and
variation in missing viral loads from disclosure groups.
• Selective disclosure was linked with viremia at 12 months. This association was
driven by participants who selectively disclosed to family only.
• Possible explanations include:
• Persons disclosing to family only more often had CD4 counts < 200.
• Patients are symptomatic due to disease progression
• More barriers to adherence due to increased pill burden and
morbidity
• Disclosure that is planned versus disclosure that is necessary
• Future Directions:
• Qualitative studies to be understand driving forces for disclosure
• Further prospective trials focusing on potential mediators of disclosure
including depression, drug abuse and stigma.
• Limitations: Inability to measure quality of support, number of persons told
within selective disclosure groups, and missing viral loads.
ACKNOWLEDGEMENTS
•
•
•
•
Latesha Elopre is funded by NIH T-32 grant
Nicholas Van Wagoner is funded by K23 (1K23AI097267)
1917 Clinic RISC Group
The individuals who participated in the study and provided data for this analysis
REFERENCES
1. CDC. Estimated HIV incidence in the United States, 2007–2010. HIV Surveillance Supplemental Report2012;17(No.
4). Published December 2012.
2. Blair JM, Fagan JL, Frazier EL, et al. Behavioral and clinical characteristics of persons receiving medical care for
HIV infection—Medical Monitoring Project, United States, 2009. MMWR 2014;63(Suppl 5).
3. Samji H, Cescon A, Hogg RS, Modur SP, Althoff KN, Buchacz K, et al. Closing the gap: increases in life expectancy
among treated HIV-positive individuals in the United States and Canada. PloS one. 2013;8(12):e81355.
4. Smith R, Rossetto K, Peterson BL. A meta-analysis of disclosure of one's HIV-positive status, stigma and social
support. AIDS care. 2008;20(10):1266-75.
5. Chadborn TR, Delpech VC, Sabin CA, Sinka K, Evans BG. The late diagnosis and consequent short-term mortality
of HIV-infected heterosexuals (England and Wales, 2000-2004). AIDS 2006; 20:237-2379.