Retaining relevance: extending clinical retention measures to improve their utility in describing HIV care engagement in the United States

保留相关性：扩大临床保留措施，以提高其在描述美国艾滋病毒护理参与方面的效用

• 批准号: 10759655
• 负责人: Keri Nicole Althoff
• 金额: $ 68.11万
• 依托单位: VANDERBILT UNIVERSITY MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-07-20 至 2028-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10759655
• 关键词: Acquired Immunodeficiency Syndrome; American; Benchmarking; Black Populations; CD4 Lymphocyte Count; COVID-19 pandemic; Caring; Categories; Cells; Classification; Clinic Visits; Clinical; Clinical Management; Collaborations; Consensus; Continuity of Patient Care; Critical Care; Data; Disease; Disease Management; Disease Outcome; Disparity; Ethnic Origin; Failure; Frequencies; Growth; Guidelines; HIV; HIV Infections; HIV disparities; HIV-1; Health Policy; Hispanic Populations; Income; Individual; Laboratories; Light; Link; Measurement; Measures; Methods; Modality; Modeling; Modernization; Monitor; Morbidity - disease rate; North America; Outcome; Patients; Pattern; Patterns of Care; Persons; Policies; Population; Primary Care; Public Health; Quality of Care; RNA; Race; Recommendation; Research; Risk; Services; Techniques; Time; United States; Update; Viral; Viral Load result; Visit; Work; care delivery; clinical care; cohort; comorbidity; design; eVisit; epidemiological model; experience; health disparity; high risk behavior; improved; men who have sex with men; mortality; novel; population stratification; primary care visit; programs; public health relevance; sexual risk behavior; telehealth; theories; transmission process

Project Summary / Abstract HIV remains a major public health concern in the United States. The proportions of people with HIV (PWH) in 2020 who knew their HIV status, were linked to care, retained in clinical care (50%), and had suppressed viral loads (57%), were lackluster. Retention in clinical care is a core quality-of-care indicator and the central stage of the HIV care continuum. Suboptimal clinical retention is strongly associated with virologic failure while on ART, high-risk behavior, and poorer survival. Furthermore, it is estimated that 43% of new HIV transmissions are from PWH who are out of care (the largest proportion from any one care continuum stage). The implication, echoed in multiple public health policies over the past decade, is that high retention and engagement in clinical care are critical for blunting the HIV-related morbidity and mortality and reducing the number of new HIV infections. However, despite consensus that “retention” in care is critical and “engagement” in care must be increased, we do not fully understand how best to measure retention and engagement among patients in high-income settings, particularly in the modern ART era and given changes in care delivery that were introduced during the COVID-19 pandemic. Earlier research indicated that sicker patients (i.e., those with lower CD4) were more likely to miss clinic visits. More recent work, though, found that patients attending clinic visits less frequently may continue to receive laboratory monitoring services; this could well be an indication that healthier patients (i.e., those with higher CD4) who are stably virally suppressed are compliant with newer monitoring guidelines which demand less frequent clinic visits. However, the field has yet to delineate the optimal frequency of clinic visits for these healthier, virally suppressed patients as opposed to individuals in multiple other risk strata, though applying a single metric regardless of sub-population could produce spurious findings of poor retention among clinically stable individuals. In this respect, our proposal is truly novel. The proposed research will therefore extract, harmonize, and analyze readily available data on clinical care patterns within the largest HIV cohort in North America: the North American AIDS Cohort Collaboration on Research and Design. We will use these data to describe patterns of retention and engagement (Aim 1), isolate multiple measures of care receipt (Aims 1 and 2) that predict improved survival and viral suppression, and assess multiple methods for stratifying populations while quantifying the expected causal impact of improved retention on HIV outcomes under existing and novel, optimized metrics (Aim 3). The public health impact of improved retention metrics, based on population-specific HIV clinical care engagement, would be profound, particularly in light of changes in HIV disease and comorbidity clinical management and laboratory monitoring under a primary care model, as well as changing care modalities during the COVID-19 pandemic. This proposal therefore holds unique promise, enabling improved HIV care continuum measurement in the US.

项目概要/摘要 艾滋病毒仍然是美国的一个主要公共卫生问题 艾滋病毒感染者 (PWH) 的比例。 2020 年，他们知道自己的 HIV 状况、与护理相关、保留在临床护理中 (50%)，并且已抑制 病毒载量（57%）表现平淡，临床护理的保留是护理质量的核心指标和核心。 HIV 护理连续体的阶段不理想的临床保留与病毒学失败密切相关。 此外，据估计，43% 的新发艾滋病毒患者的生存率较低。 传播来自脱离护理的感染者（在任何一个护理连续体阶段中所占比例最大）。 这在过去十年的多项公共卫生政策中得到了体现，即高保留率和 参与临床护理对于降低艾滋病毒相关发病率和死亡率以及减少艾滋病毒感染率至关重要 新发艾滋病毒感染人数。 然而，尽管人们一致认为护理的“保留”至关重要并且必须增加护理的“参与度”， 我们不完全了解如何最好地衡量高收入患者的保留率和参与度 环境，特别是在现代 ART 时代，以及考虑到护理服务的变化 早期研究表明，病情较重的患者（即 CD4 较低的患者）的感染率更高。 不过，最近的研究发现，患者去诊所就诊的频率较低。 可能会继续接受实验室监测服务；这很可能表明患者更健康 病毒受到稳定抑制的（即 CD4 较高的人）符合新的监测指南 然而，该领域尚未确定最佳的就诊频率。 拜访这些更健康、病毒受到抑制的患者，而不是处于多个其他风险阶层的个人， 尽管无论子群体如何，应用单一指标可能会产生保留率低的虚假结果 在这方面，我们的建议确实是新颖的。 因此，拟议的研究将提取、协调和分析现有的临床护理数据 北美最大的艾滋病队列中的模式：北美艾滋病队列合作 研究和设计。我们将使用这些数据来描述保留和参与的模式（目标 1）， 隔离多种护理接受措施（目标 1 和 2），预测生存率提高和病毒抑制， 并评估对人群进行分层的多种方法，同时量化预期的因果影响 根据现有的和新颖的、优化的指标，提高对艾滋病毒结果的保留（目标 3）。 基于特定人群的艾滋病毒临床护理参与，改进保留指标的影响将是 广泛，特别是考虑到艾滋病毒疾病和合并症临床管理和实验室的变化 初级保健模式下的监测，以及在 COVID-19 大流行期间改变护理方式。 因此，该提案具有独特的前景，能够改善美国艾滋病毒护理的连续测量。