Mpox Awareness, Risk Reduction, and Vaccine Acceptance among People with HIV in Washington, DC.

People with HIV (PWH) are disproportionally affected by mpox and at risk of severe complications. We assessed mpox knowledge, adoption of preventive behaviors, and vaccination attitudes among PWH enrolled in a longitudinal HIV cohort in Washington, DC, the DC Cohort. We conducted uni- and multivariable analyses comparing participants by vaccination status and HIV risk group, and multinomial regression to identify factors associated with vaccine acceptance. Among 430 PWH, 378 (87.9%) were aware of mpox. Among 373 participants with vaccination status data, 101 (27.1%) were vaccinated, 129 (34.6%) planned to vaccinate, and 143 (38.3%) did not plan to vaccinate. The three vaccination groups differed significantly by age, race, education, HIV risk group, recent STI status, and level of mpox worry (all p < 0.05). A higher proportion of men who have sex with men (MSM) reported limiting their number of sexual partners compared to non-MSM (p < 0.0001). Multinomial regression models comparing vaccinated to unvaccinated PWH found age, education, mode of HIV transmission/gender, and survey period were significantly associated with vaccination status (all p < 0.05). High levels of mpox awareness were observed among this cohort of PWH with more MSM employing risk reduction behaviors and being vaccinated. Ensuring that PWH, regardless of gender, sexual orientation, or age, understand the risks of mpox may improve vaccination uptake.

Mixed Methods Analysis of Telehealth Experience, Satisfaction, and Quality of Care During the COVID Pandemic Among Persons with HIV in Washington, DC.

The purpose of this study is to describe telehealth experiences and quality of HIV care provided to an urban population of people with HIV (PWH) in Washington, DC. We used self-reported survey data from a cohort of PWH in the DC Cohort longitudinal study linked to medical records (October 26, 2020-December 31, 2021). Analyses followed a mixed-methods approach, including prevalence estimates and multivariable logistic regression of telehealth use by demographic and HIV characteristics. We measured primary motivation, modes of engagement, and telehealth satisfaction. Qualitative responses to open-ended questions were coded using collaborative coding. A framework developed by the National Quality Forum (NQF) was applied to the results. Among 978 participants, 69% reported using telehealth for HIV care during the pandemic. High school graduates were less likely to use telehealth compared to those with college education (aOR 0.69, 95% CI 0.48, 0.98). PWH with > 1 co-morbid condition were more likely to use telehealth compared to those without (aOR 1.42, 95% CI 1.02, 1.95). The majority reported satisfaction with telehealth (81%). Qualitative analysis of telehealth satisfaction found that most responses were related to access to care and technology, effectiveness, and patient experience. PWH using telehealth during the pandemic were satisfied with their experience though use differed demographically. Telehealth was used effectively to overcome barriers to care engagement, including transportation, costs, and time. As we transition away from the emergency pandemic responses, it will be important to determine how this technology can be used in the future in an equitable manner to further strengthen HIV care engagement.

Site assessment survey to assess the impact of the COVID-19 pandemic on HIV clinic site services and strategies for mitigation in Washington, DC.

INTRODUCTION: The COVID-19 pandemic has created substantial interruptions in healthcare presenting challenges for people with chronic illnesses to access care and treatment services. We aimed to assess the impact of the pandemic on HIV care delivery by characterizing the pandemic-related impact on HIV clinic-level services and the mitigation strategies that were developed to address them. METHODS: The data comes from a site assessment survey conducted in the DC Cohort, an observational clinical cohort of PWH receiving care at 14 HIV outpatient clinics in Washington, D.C. Frequency counts and prevalence estimates of clinic-level survey responses about the impact of care delivery, COVID-19 testing, and vaccinations and mitigation strategies are presented. RESULTS: Clinics reported an increase in temporary clinic closures (n = 2), reduction in clinic hours (n = 5), telehealth utilization (n = 10), adoption of multi-month dispensation of antiretroviral (ARV) medication (n = 11) and alternative drug delivery via postal/courier service, home/community delivery or pick-up (n = 11). Clinics utilized strategies for PWH who were lost to follow-up during the pandemic including offering care to persons with any income level and insurance status (n = 9), utilizing e-prescribing for auto refills even if the patient missed visits (n = 8), and utilization of the regional health information exchange to check for hospitalizations of PWH lost to follow-up (n = 8). Most social services offered before the pandemic remained available during the pandemic; however, some support services were modified. CONCLUSIONS: Our findings demonstrate the extent of pandemic-era disruptions and the use of clinic-level mitigation strategies among urban HIV clinics. These results may help prepare for future pandemic or public health emergencies that disrupt healthcare delivery and access.

Impact of a Multi-Institutional Initiative to Engage Students and Early-Stage Scholars From Underrepresented Racial and Ethnic Minority Groups in HIV Research: The Centers for AIDS Research Diversity, Equity, and Inclusion Pathway Initiative.

BACKGROUND: The Centers for AIDS Research Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI) aims to establish programs to develop pathways for successful careers in HIV science among scholars from underrepresented racial and ethnic populations. This article describes cross-site evaluation outcomes during the first 18 months (July 2021-December 2022) across 15 programs. METHODS: The aims of the evaluation were to characterize participants, describe feasibility, challenges, and successes of the programs and provide a basis for the generalizability of best practices to Diversity, Equity, and Inclusion (DEI) programs in the United States. Two primary data collection methods were used: a quarterly programmatic monitoring process and a centrally managed, individual-level, participant quantitative and qualitative survey. RESULTS: During the first year of evaluation data collection, 1085 racially and ethnically diverse scholars ranging from the high school to postdoctoral levels applied for CDEIPI programs throughout the United States. Of these, 257 (23.7%) were selected to participate based on program capacity and applicant qualifications. Participants were trained by 149 mentors, teachers, and staff. Of the N = 95 participants responding to the individual-level survey, 95.7% agreed or strongly agreed with statements of satisfaction with the program, 96.8% planned to pursue further education, and 73.7% attributed increased interest in a variety of HIV science topics to the program. Qualitative findings suggest strong associations between mentorship, exposure to scientific content, and positive outcomes. CONCLUSIONS: These data provide evidence to support the feasibility and impact of novel DEI programs in HIV research to engage and encourage racially and ethnically diverse scholars to pursue careers in HIV science.

Centers for AIDS Research (CFAR) Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI): Developing Career Pathways for Early-Stage Scholars From Racial and Ethnic Groups Underrepresented in HIV Science and Medicine.

BACKGROUND: There is an urgent need to increase diversity among scientific investigators in the HIV research field to be more reflective of communities highly affected by the HIV epidemic. Thus, it is critical to promote the inclusion and advancement of early-stage scholars from racial and ethnic groups underrepresented in HIV science and medicine. METHODS: To widen the HIV research career pathway for early-stage scholars from underrepresented minority groups, the National Institutes of Health supported the development of the Centers for AIDS Research (CFAR) Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI). This program was created through partnerships between CFARs and Historically Black Colleges and Universities and other Minority Serving Institutions throughout the United States. RESULTS: Seventeen CFARs and more than 20 Historically Black Colleges and Universities and Minority Serving Institutions have participated in this initiative to date. Programs were designed for the high school (8), undergraduate (13), post baccalaureate (2), graduate (12), and postdoctoral (4) levels. Various pedagogical approaches were used including didactic seminar series, intensive multiday workshops, summer residential programs, and mentored research internship opportunities. During the first 18 months of the initiative, 257 student scholars participated in CDEIPI programs including 150 high school, 73 undergraduate, 3 post baccalaureate, 27 graduate, and 4 postdoctoral students. CONCLUSION: Numerous student scholars from a wide range of educational levels, geographic backgrounds, and racial and ethnic minority groups have engaged in CDEIPI programs. Timely and comprehensive program evaluation data will be critical to support a long-term commitment to this unique training initiative.

Trends in COVID-19 Vaccine Hesitancy and Uptake Among Persons Living With HIV in Washington, DC.

OBJECTIVE: The COVID-19 pandemic has disproportionately affected older people, people with underlying health conditions, racial and ethnic minorities, socioeconomically disadvantaged, and people living with HIV (PWH). We sought to describe vaccine hesitancy and associated factors, reasons for vaccine hesitancy, and vaccine uptake over time in PWH in Washington, DC. METHODS: We conducted a cross-sectional survey between October 2020 and December 2021 among PWH enrolled in a prospective longitudinal cohort in DC. Survey data were linked to electronic health record data and descriptively analyzed. Multivariable logistic regression was performed to identify factors associated with vaccine hesitancy. The most common reasons for vaccine hesitancy and uptake were assessed. RESULTS: Among 1029 participants (66% men, 74% Black, median age 54 years), 13% were vaccine hesitant and 9% refused. Women were 2.6-3.5 times, non-Hispanic Blacks were 2.2 times, Hispanics and those of other race/ethnicities were 3.5-8.8 times, and younger PWH were significantly more likely to express hesitancy or refusal than men, non-Hispanic Whites, and older PWH, respectively. The most reported reasons for vaccine hesitancy were side effect concerns (76%), plans to use other precautions/masks (73%), and speed of vaccine development (70%). Vaccine hesitancy and refusal declined over time (33% in October 2020 vs. 4% in December 2021, P < 0.0001). CONCLUSIONS: This study is one of the largest analyses of vaccine hesitancy among PWH in a US urban area highly affected by HIV and COVID-19. Multilevel culturally appropriate approaches are needed to effectively address COVID-19 vaccine concerns raised among PWH.

Psychosocial impacts of the COVID-19 pandemic from a cross-sectional Survey of people living with HIV in Washington, DC.

BACKGROUND: COVID-19 has not only taken a staggering toll in terms of cases and lives lost, but also in its psychosocial effects. We assessed the psychosocial impacts of the COVID-19 pandemic in a large cohort of people with HIV (PWH) in Washington DC and evaluated the association of various demographic and clinical characteristics with psychosocial impacts. METHODS: From October 2020 to December 2021, DC Cohort participants were invited to complete a survey capturing psychosocial outcomes influenced by the COVID-19 pandemic. Some demographic variables were also collected in the survey, and survey results were matched to additional demographic data and laboratory data from the DC Cohort database. Data analyses included descriptive statistics and multivariable logistic regression models to evaluate the association between demographic and clinical characteristics and psychosocial impacts, assessed individually and in overarching categories (financial/employment, mental health, decreased social connection, and substance use). RESULTS: Of 891 participants, the median age was 46 years old, 65% were male, and 76% were of non-Hispanic Black race/ethnicity. The most commonly reported psychosocial impact categories were mental health (78% of sample) and financial/employment (56% of sample). In our sample, older age was protective against all adverse psychosocial impacts. Additionally, those who were more educated reported fewer financial impacts but more mental health impacts, decreased social connection, and increased substance use. Males reported increased substance use compared with females. CONCLUSIONS: The COVID-19 pandemic has had substantial psychosocial impacts on PWH, and resiliency may have helped shield older adults from some of these effects. As the pandemic continues, measures to aid groups vulnerable to these psychosocial impacts are critical to help ensure continued success towards healthy living with HIV.

Risk of Severe COVID-19 Disease and the Pandemic's Impact on Service Utilization Among a Longitudinal Cohort of Persons with HIV-Washington, DC.

People with HIV (PWH) have a high burden of medical comorbidities, potentially putting them at increased risk for severe COVID-19. Additionally, during the COVID-19 pandemic, HIV care delivery has been restructured and the impact on HIV outcomes is unknown. The objectives of this study were first, to examine the risk of severe COVID-19 among PWH, using a definition incorporating clinical risk factors, and second, to examine the pandemic's impact on HIV care. We used data from the DC Cohort, a large cohort of people receiving HIV care in Washington, DC. We found that a high proportion of participants across all age groups qualified as increased (58%) or high risk (34%) for severe COVID-19. Between 2019 and 2020, encounters increased (17.7%, increasing to 23.5% of active DC Cohort participants had an encounter) while laboratory utilization decreased (14.4%, decreasing to 11.4% of active DC Cohort participants had an HIV RNA test performed). Implications of our work include the importance of protecting vulnerable people with HIV from acquiring COVID-19 and potentially manifesting severe complications through strategies including vaccination. Additionally, acknowledging that HIV service delivery will likely be changed long-term by the pandemic, adaptation is required to ensure continued progress towards 90-90-90 goals.

Clinical similarities and differences between two large HIV cohorts in the United States and Africa.

BACKGROUND: Washington, DC, and sub-Saharan Africa are both affected by generalized HIV epidemics. However, care for persons living with HIV (PLWH) and clinical outcomes may differ in these geographically and culturally diverse areas. We compared patient and clinical site characteristics among adult persons living with HIV (PLWH) enrolled in two longitudinal HIV cohort studies-the African Cohort Study (AFRICOS) and the DC Cohort. METHODS: The DC Cohort is a clinic-based city-wide longitudinal cohort comprised of PLWH attending 15 HIV clinics in Washington, DC. Patients' socio-demographic characteristics, clinical evaluations, and laboratory data are retrospectively collected from electronic medical records and limited manual chart abstraction. AFRICOS is a prospective observational cohort of PLWH and uninfected volunteers attending 12 select HIV care and treatment facilities in Nigeria, Kenya, Uganda and Tanzania. AFRICOS study participants are a subset of clinic patients who complete protocol-specific visits every 6 months with history and physical examination, questionnaire administration, and blood/sputum collection for ascertainment of HIV outcomes and comorbidities, and neurocognitive and functional assessments. Among participants aged ≥ 18 years, we generated descriptive statistics for demographic and clinical characteristics at enrollment and follow up and compared them using bivariable analyses. RESULTS: The study sample included 2,774 AFRICOS and 8,420 DC Cohort participants who enrolled from January 2013 (AFRICOS)/January 2011 (DC Cohort) through March 2018. AFRICOS participants were significantly more likely to be women (58.8% vs 27.1%) and younger (83.3% vs 61.1% aged < 50 years old) and significantly less likely to be MSM (only 0.1% of AFRICOS population reported MSM risk factor) than DC Cohort. Similar rates of current viral suppression (about 75% of both samples), hypertension, hepatitis B coinfection and alcohol use were observed. However, AFRICOS participants had significantly higher rates of CD4<200 and tuberculosis and significantly lower rates of obesity, DM, hepatitis C coinfection and syphilis. CONCLUSIONS: With similar viral suppression outcomes, but many differences between our cohorts noted, the combined sample provides unique opportunities to assess and compare HIV care and treatment outcomes in the U.S. and sub-Saharan Africa. Comparing these two cohorts may inform care and treatment practices and may pave the way for future pathophysiologic analyses.

The Mid-Atlantic Centers for AIDS Research Consortium: Promoting HIV Science Through Regional Collaboration.

The Centers for AIDS Research (CFAR) program was established by the National Institutes of Health in 1988 to catalyze and support high-impact HIV research and to develop the next generation of HIV investigators at academic institutions throughout the United States. In 2014, the Penn CFAR, the Johns Hopkins University CFAR and the District of Columbia CFAR developed a partnership-the Mid-Atlantic CFAR Consortium (MACC)-to promote cross-CFAR scientific collaboration, mentoring, and communication and to address the regional HIV epidemic. Over the past 6 years, the creation of the MACC has resulted in a rich web of interconnectivity, which has fostered scientific collaboration through working groups on the black men who have sex with men (MSM) and Latinx regional HIV epidemics, joint peer-reviewed publications, and successful collaborative grant applications on topics ranging from HIV prevention in young MSM, transgender women, implementation science, and clinical epidemiology; supported developmental activities through the MACC Scholars program, cross-CFAR mentoring, joint symposia, cross-CFAR seminar participation, and keynote speakers; and promoted strategic communication through advisory committees, best practices consultations, and the social and behavioral science research network. The MACC has been highly impactful by promoting HIV science through regional collaboration, supporting a diverse network of scholars across three cities and focusing on the epidemic in underrepresented and marginalized communities. Lessons learned from this consortium may have implications for scientific research centers beyond the field of HIV.

Integrase Inhibitor Prescribing Disparities in the DC and Johns Hopkins HIV Cohorts.

Integrase inhibitors (INSTIs) are recommended by expert panels as initial therapy for people with HIV. Because there can be disparities in prescribing and uptake of novel and/or recommended therapies, this analysis assessed potential INSTI prescribing disparities using a combined data set from the Johns Hopkins HIV Clinical Cohort and the DC Cohort. We performed multivariable logistic regression to identify factors associated with ever being prescribed an INSTI. Disparities were noted, including clinic location, age, and being transgender. Identifying disparities may allow clinicians to focus their attention on these individuals and ensure that therapy decisions are grounded in valid clinical reasons.

Highly variable trends in rates of newly diagnosed HIV cases in U.S. hotspots, 2008-2017.

The U.S. Ending the HIV Epidemic (EHE) initiative was announced in early 2019 and rapidly became a focal point for domestic HIV prevention and treatment programs. Using publicly available data from CDC, we examined historical trends in the average annual percent change (AAPC) in HIV diagnosis rates for the 57 EHE high incidence "hotspots" using Joinpoint analysis. We then assessed the ecologic association of various hotspot characteristics with changes in these rates over time using a multivariable regression model. From 2008-2017, the overall rate of newly diagnosed HIV cases in the U.S. declined from 19 to 14 per 100,000 persons, with the AAPC declining significantly in the U.S. overall (-3.1%; 95% CI: -3.7, -2.4) and in the 57 hotspots (-3.3%; 95% CI: -4.6, -2.8). There were large (AAPC <-5.0), moderate (-5.0 to -2.5) and small (-2.5 to 0.0) rates of decline in 14, 19 and 17 hotspots respectively, with increasing trends (AAPC >0.0) noted in seven hotspots. In the multivariable regression analysis, higher initial HIV diagnosis rate and location in the Northeast region were significantly associated with declining AAPC rates whereas no significant differences were found by hotspot gender, age, or race/ethnicity distribution. This analysis demonstrates that the rate of decline in HIV diagnosis rates in hotspots across the U.S. has been highly variable. Further exploration is warranted to assess the correlation between programmatic factors such as HIV testing and antiretroviral therapy and pre-exposure prophylaxis coverage with HIV trends across the hotspots.

Diabetes mellitus control in a large cohort of people with HIV in care-Washington, D.C.

With more effective antiretroviral therapy (ART), people with HIV (PWH) are living longer and have more chronic diseases, including diabetes mellitus (DM). The prevalence of DM has been estimated in PWH previously, however there is less research regarding DM control. Our objectives were to determine the prevalence of DM and DM control and determine factors associated with DM control in a large urban cohort of PWH in care. We examined DC Cohort participants aged ≥18 years old to determine DM prevalence and to assess DM control (HbA1c measurement <7.0%). Demographic, clinical, and HIV-related factors associated with DM control were identified using multivariate logistic regression. The cohort of 5876 participants was predominantly male (71.3%), Non-Hispanic Black (78.1%) and had a median age of 52.0 years. DM prevalence was 17.4% (1023/5876). Among participants with recent HbA1c data available (39.9%) the proportion with DM control was 60.0% (245/408). In multivariate analysis, higher BMI (aOR: 0.47; 95% CI 0.28, 0.79) and use of non-insulin DM medication (aOR 0.43, 95% CI 0.25, 0.73) or insulin (aOR 0.010, 95% CI 0.04,0.24) compared to no medication use. Our findings suggest that individuals on medication for their DM likely need enhanced support to reach their treatment goals.

SARS-CoV-2 and HIV: Epidemiology, Treatment, and Lessons Learned from HIV.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of COVID-19, was first detected in China in December 2019 and has rapidly spread throughout the world. Globally, the impact of COVID-19 has been severe with more than half a million deaths over 6 months; in contrast, the HIV pandemic has resulted in over 32 million deaths worldwide over 40 years. This paper reviews the current epidemiology of COVID-19, summarizes its relationship to HIV, identifies synergies in our response, and suggests actions that can be taken to curtail the spread of COVID-19 among persons living with HIV (PLWH). Our understanding of the epidemiology, clinical presentation, prevention, and treatment of COVID-19 has evolved rapidly as they did with HIV. Epidemiologically, there are similarities between the two viruses including asymptomatic spread, disproportionate impact on persons of color, need for rapid diagnostic testing, and lack of a cure or vaccine. PLWH do not appear generally to have an increased incidence of COVID-19 infection or a more severe course of disease. Clinical trials to identify potential treatment and prevention options for COVID-19 have included antiretrovirals used to treat HIV that have not been efficacious. Public health responses overlap between the two pandemics including the need for behavior change and containment strategies such as contact tracing. As the SARS-CoV-2 pandemic evolves, the path forward to controlling, preventing, and treating COVID-19 can be informed by lessons learned from HIV as we seek to control the spread of both viral pandemics.

Individual-Level and Clinic-Level Factors Associated With Achieving Glycemic Control in a Large Cohort of People With HIV in Care-Washington, DC.

BACKGROUND: Optimal management of noncommunicable diseases, including diabetes mellitus (DM), is crucially important as people with HIV (PWH) live longer with antiretroviral therapy. Our objective was to assess patient-level and clinic-level factors associated with achieving hemoglobin A1c (HbA1c) ≤7.0% among PWH and DM. SETTING: The DC Cohort, an observational clinical cohort of PWH, followed from 2011 to 2019 at 12 sites in Washington, DC. METHODS: Among PWH with diagnosed DM and elevated HbA1c (>7.0%), we examined the association between achieving HbA1c ≤7.0% and demographic and clinical factors, including time-updated medication data, and clinic-level factors related to services and structure. A multilevel marginal extended Cox regression model was generated to identify factors associated with time to HbA1c ≤7.0%. RESULTS: Over half (52.3%) of 419 participants achieved HbA1c ≤7.0%. Individual-level factors associated with HbA1c ≤7.0% included a diagnosis of DM after enrollment and a longer time since HIV diagnosis [hazard ratio (HR) = 2.65 and 1.13, P < 0.05 for both]. Attending a clinic with an endocrinologist was associated with the outcome [adjusted HR (aHR) = 1.41 95% confidence interval (CI): (1.01 to 1.97)]. In addition, comparing clinics that treat everyone, refer everyone or have a mix of treating and referring, showed an association between attending a clinic that treats everyone [aHR = 1.52 95% CI: (1.21 to 1.90)] or a clinic that refers everyone [aHR = 2.24 95% CI: (1.63 to 3.07)] compared with clinics with a mix in achieving glycemic control. CONCLUSION: Multiple factors are associated with achieving glycemic control in an urban cohort of PWH. Determining if specific services or structures improve DM outcomes may improve health outcomes for PWH and DM.

Comparison of Clinical Outcomes of Persons Living With HIV by Enrollment Status in Washington, DC: Evaluation of a Large Longitudinal HIV Cohort Study.

BACKGROUND: HIV cohort studies have been used to assess health outcomes and inform the care and treatment of people living with HIV disease. However, there may be similarities and differences between cohort participants and the general population from which they are drawn. OBJECTIVE: The objective of this analysis was to compare people living with HIV who have and have not been enrolled in the DC Cohort study and assess whether participants are a representative citywide sample of people living with HIV in the District of Columbia (DC). METHODS: Data from the DC Health (DCDOH) HIV surveillance system and the DC Cohort study were matched to identify people living with HIV who were DC residents and had consented for the study by the end of 2016. Analysis was performed to identify differences between DC Cohort and noncohort participants by demographics and comorbid conditions. HIV disease stage, receipt of care, and viral suppression were evaluated. Adjusted logistic regression assessed correlates of health outcomes between the two groups. RESULTS: There were 12,964 known people living with HIV in DC at the end of 2016, of which 40.1% were DC Cohort participants. Compared with nonparticipants, participants were less likely to be male (68.0% vs 74.9%, P<.001) but more likely to be black (82.3% vs 69.5%, P<.001) and have a heterosexual contact HIV transmission risk (30.3% vs 25.9%, P<.001). DC Cohort participants were also more likely to have ever been diagnosed with stage 3 HIV disease (59.6% vs 47.0%, P<.001), have a CD4 <200 cells/µL in 2017 (6.2% vs 4.6%, P<.001), be retained in any HIV care in 2017 (72.9% vs 59.4%, P<.001), and be virally suppressed in 2017. After adjusting for demographics, DC Cohort participants were significantly more likely to have received care in 2017 (adjusted odds ratio 1.8, 95% CI 1.70-2.00) and to have ever been virally suppressed (adjusted odds ratio 1.3, 95% CI 1.20-1.40). CONCLUSIONS: These data have important implications when assessing the representativeness of patients enrolled in clinic-based cohorts compared with the DC-area general HIV population. As participants continue to enroll in the DC Cohort study, ongoing assessment of representativeness will be required.

Clinic-Level Factors Associated With Time to Antiretroviral Initiation and Viral Suppression in a Large, Urban Cohort.

BACKGROUND: Using the results of a site assessment survey performed at clinics throughout Washington, DC, we studied the impact of clinic-level factors on antiretroviral therapy (ART) initiation and viral suppression (VS) among people living with human immunodeficiency virus (HIV; PLWH). METHODS: This was a retrospective analysis from the District of Columbia (DC) Cohort, an observational, clinical cohort of PLWH from 2011-2018. We included data from PLWH not on ART and not virally suppressed at enrollment. Outcomes were ART initiation and VS (HIV RNA < 200 copies/mL). A clinic survey captured information on care delivery (eg, clinical services, adherence services, patient monitoring services) and clinic characteristics (eg, types of providers, availability of evenings/weekends sessions). Multivariate marginal Cox regression models were generated to identify those factors associated with the time to ART initiation and VS. RESULTS: Multiple clinic-level factors were associated with ART initiation, including retention in care monitoring and medication dispensing reviews (adjusted hazard ratios [aHRs], 1.34 to 1.40; P values < .05 for both). Furthermore, multiple factors were associated with VS, including retention in HIV care monitoring, medication dispensing reviews, and the presence of a peer interventionist (aHRs, 1.35 to 1.72; P values < .05 for all). In multivariable models evaluating different combinations of clinic-level factors, enhanced adherence services (aHR, 1.37; 95% confidence interval [CI], 1.18-1.58), medication dispensing reviews (aHR, 1.22; 95% CI, 1.10-1.36), and the availability of opioid treatment (aHR, 1.26; 95% CI, 1.01-1.57) were all associated with the time to VS. CONCLUSIONS: The observed association between clinic-level factors and ART initiation/VS suggests that the presence of specific clinic services may facilitate the achievement of HIV treatment goals.