Date Published: March 13, 2019
Publisher: Public Library of Science
Author(s): Anna Lucie Fournier, Yazdan Yazdanpanah, Renaud Verdon, Sylvie Lariven, Claude Mackoumbou-Nkouka, Bao-Chau Phung, Emmanuelle Papot, Jean-Jacques Parienti, Roland Landman, Karen Champenois, Marcel Yotebieng.
With HIV treatment as a prevention strategy, retention in care remains a key for sustained viral suppression. We sought to identify HIV-infected patients at risk for medical care interruption (MCI) in a high-income country.
The HIV-infected patients enrolled had to attend the clinic at least twice between January 2010 and October 2014 and were followed up until May 2016. MCI was defined as patients not seeking care in or outside the clinic for at least 18 months, regardless of whether they returned to care after the interruption. The association between MCI and sociodemographic, clinical, and immuno-virological characteristics at HIV diagnosis and during follow-up was assessed using Cox models.
The incidence rate of MCI was 2.5 per 100 persons-years (95% confidence interval [CI] = 2.3–2.7). MCI was more likely in patients who accessed care >6 months after diagnosis (hazard ratio [HR] = 1.30, 95% CI = 1.10–1.54 vs. ≤6 months) or did not report a primary care physician (HR = 2.40; 95% CI = 2.03–2.84). MCI was less likely in patients born in sub-Saharan Africa (HR = 0.75, 95% CI = 0.62–0.91 vs. born in France). During follow-up, the risk of MCI increased when the last CD4 count was ≤350 (HR = 2.85, 95% CI = 2.02–4.04 vs. >500 cells/mm3) and when the patient was not on antiretroviral therapy (HR = 3.67, 95% CI = 2.90–4.66).
The incidence of MCI is low in this hospital that serves a large proportion of migrants. Low or no recorded CD4 counts for a medical visit could alert of a higher risk of MCI, even more in patients who accessed HIV care late or did not report a primary care physician.
Antiretroviral treatment (ART) allows people living with HIV (PLHIV) to achieve a life expectancy close to that of the general population [1,2]. The international CASCADE cohort showed a dramatic decrease in mortality rate due to HIV from 40.8 for 1,000 person-years in 1996 to 6.1 in 2004 thanks to the advent of highly active antiretroviral therapy . A French study found AIDS as the cause of death in 2.2 of 1,000 HIV-infected patients during follow-up in 2010 . Now that HIV has become a chronic disease with lifelong treatment, in addition to HIV diagnosis, one of the challenges is to maintain, enhance, and facilitate retention of HIV-infected patients in the care system.
Between January 2010 and October 2014, 4,796 patients had at least two encounters at the Bichat Hospital. Sociodemographic, clinical, biological, and therapeutic characteristics are shown in Table 1. Most were men (63%). Participants were born in France (38%), sub-Saharan Africa (40%), or elsewhere (20%). Heterosexual men and women transmission group represented almost half (48%) of participants: 30% were men who have sex with men (MSM), and 5% were people who inject drugs (PWID).
Among the 4,796 patients who received follow-up for their HIV infection in this French clinical cohort from 2010 to 2016, the incidence rate of having at least one MCI ≥18 months was estimated at 2.5 per 100 person-years. Patients had an increasing risk of MCI if they lived in the neighborhood surrounding the hospital, were born in France, accessed care more than 6 months after the HIV diagnosis or reported no primary care physician. The risk was also higher if, during follow-up, they did not receive ART and had a CD4 count that was either ≤500 cells/mm3 or was not recorded in the electronic medical file.