Electronic Patient Portal Access, Retention in Care, and Viral Suppression Among People Living With HIV in Southeastern United States: Observational Study.

BACKGROUND: Approximately 1.1 million people living with HIV live in the United States, and the incidence is highest in Southeastern United States. Electronic patient portal prevalence is increasing and can improve engagement in primary medical care. Retention in care and viral suppression-measures of engagement in HIV care-are associated with decreased HIV transmission, morbidity, and mortality. OBJECTIVE: We aimed to determine if patient portal access among people living with HIV was associated with retention and viral suppression. METHODS: We conducted an observational cohort study among people living with HIV in care at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee) from 2011-2016. Individual access was defined as patient portal account registration at any point in the year prior. Retention was defined as ≥2 kept appointments or HIV lab measurements ≥3 months apart within a 12-month period. Viral suppression was defined as the last viral load in the calendar year <200 copies/mL. We calculated adjusted prevalence ratios (aPRs) and 95% CIs using modified Poisson regression with generalized estimating equations to estimate the association of portal access with retention and viral suppression. RESULTS: We included 4237 people living with HIV contributing 16,951 person-years of follow-up (median 5, IQR 3-5 person-years). The median age was 43 (IQR 33-50) years. Of the 4237 people living with HIV, 78.1% (n=4237) were male, 40.8% (n=1727) were Black non-Hispanic, and 56.5% (n=2395) had access. Access was independently associated with retention (aPR 1.13, 95% CI 1.10-1.17) and viral suppression (aPR 1.18, 95% CI 1.14-1.22). CONCLUSIONS: In this population, patient portal access was associated with retention and viral suppression. Future prospective studies should assess the impact of increasing portal access among people living with HIV on these HIV outcomes.

Mood Disorders and Increased Risk of Noncommunicable Disease in Adults With HIV.

BACKGROUND: People living with HIV (PLWH) experience high rates of mood disorders (major depression and bipolar affective disorder) which in the general population have been associated with noncommunicable disease (NCD) risk. We examined whether prevalent mood disorders are associated with incident NCDs and multimorbidity (accumulation of ≥2 NCDs) in PLWH. SETTING: Adult HIV clinic cohort in Nashville, Tennessee, between 1998 and 2015. METHODS: PLWH with ≥1 year of follow-up in the clinic were assessed for cardiovascular disease, metabolic syndrome (any 3 of hypertension, hyperlipidemia, diabetes, or obesity), chronic kidney and liver disease, non-AIDS-defining cancers, and dementia. Only mood disorders documented during the first year of care were included. Cumulative incidence and adjusted subhazard ratios (aSHRs) were calculated for risk of NCDs and multimorbidity with death as a competing risk. Multivariable Cox models estimated mortality risk after multimorbidity. RESULTS: Of 4140 adults, 24% had a mood disorder diagnosed in the first year of care, 51% had ≥1 NCD at baseline, and there were 2588 incident NCDs during the study period. Mood disorders were associated with increased risk of first NCD (aSHR = 1.29, 95% confidence interval: 1.06 to 1.57), incident multimorbidity (aSHR ranging from 1.04 to 1.42), and metabolic syndrome (aSHR = 1.29, 95% confidence interval: 1.02 to 1.64). Mood disorders were not conclusively associated with mortality risk after multimorbidity. CONCLUSIONS: PLWH with mood disorders were at increased risk of incident NCDs and multimorbidity, particularly metabolic syndrome. Focused prevention and treatment of NCDs may reduce the burden of multimorbidity in this high-risk group.

CD4/CD8 Ratio and CD4 Nadir Predict Mortality Following Noncommunicable Disease Diagnosis in Adults Living with HIV.

Incidence of noncommunicable diseases (NCDs), including cardiovascular disease (CVD), cirrhosis, and non-AIDS-defining cancers (NADCs), have been associated with HIV viremia, CD4 cell counts, and CD4/CD8 ratio in persons living with HIV (PLWH). This study examined the importance of these markers to mortality risk following NCD diagnosis. We examined factors associated with mortality following incident CVD, cirrhosis, or NADCs in a clinical cohort of PLWH between 1998 and 2015. We calculated Kaplan-Meier estimates and used multivariable Cox proportional hazard models. We included 341 patients with NCDs (CVD = 169, cancer = 103, and cirrhosis = 67), of whom 129 died. Median age at NCD diagnosis was 49 years and median proportion of time before NCD with virologic suppression was 64%. Median survival after CVD was longer than for cancer or cirrhosis (11.6 years vs. 4.8 and 3.4 years, respectively; log rank test p < .001). In multivariable Cox proportional hazard models, higher CD4/CD8 ratio preceding NCD (adjusted hazard ratio [aHR] per 0.1 increase = 0.92 [95% confidence interval 0.85-0.99]) and higher CD4 nadir (aHR per 100 cells/µL = 0.84 [0.72-0.97]) were associated with decreased mortality risk. Neither CD4 cell count before NCD nor HIV viremia was statistically associated with mortality in adjusted models. When restricted to 116 patients with virologic suppression for ≥80% of time before NCD, only CD4 nadir was associated with mortality risk. Low CD4/CD8 ratio and CD4 nadir were associated with increased mortality risk after NCD, suggesting that prior immunosuppression or ongoing immune imbalance remain important for outcomes following serious NCDs.