The HIV Care Cascade Measured Over Time and by Age, Sex, and Race in a Large National Integrated Care System.

HIV care cascades can evaluate programmatic success over time. However, methodologies for estimating cascade stages vary, and few have evaluated differences by demographic subgroups. We examined cascade performance over time and by age, sex, and race/ethnicity in Kaiser Permanente, providing HIV care in eight US states and Washington, DC. We created cascades for HIV+ members' age ≥13 for 2010-2012. We measured "linkage" (a visit/CD4 within 90 days of being diagnosed for new patients; ≥1 medical visit/year if established); "retention" (≥2 medical visits ≥60 days apart); filled ART (filled ≥3 months of combination ART); and viral suppression (HIV RNA <200 copies/mL last measured in year). The cascades were stratified by calendar year, sex, age, and race/ethnicity. We found men had statistically (p < 0.05) higher percent linkage, filled ART, and viral suppression for 2010 and 2011 but not for 2012. Women had significantly greater retention for all years. Annually, older age was associated (p < 0.05) with retention, filled ART, and viral suppression but not linkage. Latinos had greater (p < 0.05) retention than whites or blacks in all years, with similar retention comparing blacks and whites. Filled ART and viral suppression was increased (p < 0.05) for whites compared with all racial/ethnic groups in all years. Cascade methodology requiring success at upstream stages before measuring success at later stages (i.e., "dependent" methodology) underreported performance by up to 20% compared with evaluating each stage separately ("independent"). Thus, care results improved over time, but significant differences exist by patient demographics. Specifically, retention efforts should be targeted toward younger patients and blacks; women, blacks, and Latinos require greater ART prescribing.

Effects of depression and selective serotonin reuptake inhibitor use on adherence to highly active antiretroviral therapy and on clinical outcomes in HIV-infected patients.

OBJECTIVES: To determine the impact of depression on highly active antiretroviral therapy (HAART) adherence and clinical measures and investigate if selective serotonin reuptake inhibitors (SSRIs) improve these measures. DESIGN: Retrospective cohort study. METHODS: In 2 large health maintenance organizations, we measured the effects of depression (with and without SSRI use) on adherence and changes in viral and immunologic control among HIV-infected patients starting a new HAART regimen. HAART adherence, HIV RNA levels, and changes in CD4 T-cell counts through 12 months were measured. RESULTS: A total of 3359 patients were evaluated; 42% had a depression diagnosis, and 15% used SSRIs during HAART. Depression without SSRI use was associated with significantly decreased odds of achieving > or =90% adherence to HAART (odds ratio [OR] = 0.81, 95% confidence interval [CI]: 0.70 to 0.98; P = 0.03). Depression was associated with significantly lower odds of an HIV RNA level <500 copies/mL (OR = 0.77, 95% CI: 0.62 to 0.95; P = 0.02). Depressed patients compliant with SSRI medication (>80% adherence to SSRI) had HAART adherence and viral control statistically similar to nondepressed HIV-infected patients taking HAART. Comparing depressed with nondepressed HIV-infected patients, CD4 T-cell responses were statistically similar; among depressed patients, those compliant with SSRI had statistically greater increases in CD4 cell responses. CONCLUSIONS: Depression significantly worsens HAART adherence and HIV viral control. Compliant SSRI use is associated with improved HIV adherence and laboratory parameters.

Effect of clinical pharmacists on utilization of and clinical response to antiretroviral therapy.

OBJECTIVE: To determine the association of clinical pharmacists with health outcomes and utilization measures among HIV-infected patients. METHODS: Observational study of 1571 HIV-infected patients prescribed their initial highly active antiretroviral therapy (HAART) regimen in clinics with and without a clinical pharmacist. Outcomes analyzed were changes in plasma HIV RNA level, CD4 T-cell counts, and service utilization (hospital days, emergency department visits, and office visits) over 24 months based on exposure to a clinical pharmacist. RESULTS: Patients exposed to a clinical pharmacist tended to be more likely to achieve an HIV RNA level <500 copies/mL at 12 months (adjusted odds ratio [OR] = 2.01, 95% confidence interval [CI]: 0.92 to 4.37). At 24 months, however, results depended on the provider panel size; the ORs for panel sizes < or =50 and >50 HIV-infected patients were 1.67 (95% CI: 0.60 to 4.62) and 0.97 (95% CI: 0.39 to 2.41), respectively. CD4 T-cell counts were modestly but nonsignificantly higher for the patients exposed to a clinical pharmacist. Utilization also depended on the provider panel size; pharmacist exposure was associated with 64% (95% CI: 30% to 108%) and 9% (95% CI: -11% to 33%) increases in total hospital days for panel sizes < or =50 and >50 HIV-infected patients, respectively. Pharmacist exposure was also associated with a 19% (95% CI: -13% to -24%) decrease in office visits for panel sizes < or =50 HIV-infected patients, with minimal effect for larger panel sizes. CONCLUSION: Clinical pharmacists seem to contribute to lower office visit rates in antiretroviral-naive patients initiating HAART.