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Hoang T, Goetz MB, Rossman B, Anaya H, Knapp H, Yano E, Gifford AL, Asch SM. Comprehensive Care Clinic Visits are Associated with Better Control of HIV. Paper presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
Objectives: Adherence to highly active antiretroviral therapy (HAART) improves HIV patient outcomes. Many HIV patients have significant comorbidities (e.g. mental and substance abuse disorders), and models for ensuring adherence in such patients have been problematic. The VA has implemented one such model; comprehensive care clinics integrate programs to address comorbidities into HIV primary care. However, no study has evaluated the impact on HIV treatment outcomes. Methods: We conducted a retrospective cohort study using administrative and clinical data from the VISN22 data warehouse from October 1999 to March 2006 to identify HIV positive patients from five sites in VISN22. We interviewed the chiefs of the HIV clinics at these VA sites in order to rank the degree of comprehensiveness of their clinics on a 1 - 4 scale. These rankings were applied to patient visits to form an index of comprehensive care utilization. Using survival analysis, we estimated the association of comprehensive care utilization on time from first receipt of HAART to first achievement of viral load 400 copies/mL or less (VL400-). VL400- is associated with reduced opportunistic infections and is an accepted standard for treatment success. We controlled for patient exposure to antiretroviral medication, HCV risk factors, and baseline severity of disease. Results: 759 HIV positive patients who were followed up for more than three months and whose baseline viral loads were at least 5,000 copies/mL were included in the analysis. Utilization of comprehensive HIV care was significantly associated with time to VL400- (hazard ratio HR = 1.05, p < .03). Other significant predictors included frequency of HAART refills (HR = 1.55, p < .02), HCV risk factors (HR = 0.87, p < .01), baseline viral load (HR = 0.96, p < .03), and baseline CD4 count (HR = 1.02, p < .001). Implications: Patients who utilized comprehensive care clinics more regularly were more likely to achieve VL400-, even when controlled for their exposure to medication and severity of disease. We hypothesize that comprehensive care clinics address comorbid conditions and encourage drug adherence. Impacts: Our data support channeling HIV patients to comprehensive care clinics. Future research should investigate which elements of comprehensive care clinics are most associated with viral load control and what role provider experience plays in this association.