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Rural Residence is Associated with Increased Mortality among Veterans Initiating Highly Active Antiretroviral Therapy for HIV Infection

Ohl M, Guggal M, Skanderson M, Scothch M, Kaboli PJ, Vaughan-Sarrazin MS. Rural Residence is Associated with Increased Mortality among Veterans Initiating Highly Active Antiretroviral Therapy for HIV Infection. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 29; Minneapolis, MN.

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Background: Rural persons living with HIV face many barriers to care, but little is known about rural-urban variation in HIV outcomes. We used national Veterans Administration (VA) electronic health record (EHR) and administrative data to determine the association between rural residence and HIV outcomes. Methods: Retrospective cohort study of veterans initiating highly active antiretroviral therapy (HAART) in the United States during fiscal years (FY) 1998-2007 (October 1, 1997 - September 30, 2007). The primary outcome was all cause six-year mortality following HAART initiation. Mortality follow-up was through FY 2008. Rural residence was determined using Rural Urban Commuting Area codes. Hazard ratios were estimated using proportional hazards regression with 95% confidence intervals based on robust variance estimates accounting for correlated data structure due to clustering of persons in care facilities. Results: Using a previously validated case finding algorithm, we identified 23,131 persons entering VA care with a diagnosis of HIV during FY 1998-2007. A viral load was available within 180 days of the first contact with an HIV related ICD-9 code for 15,134. Exclusion of 1,945 with HAART prescription before first viral load and 2,672 with viral load 400 at baseline left 10,517 persons with no evidence of HAART use at care entry (883 rural, 8.4%). Compared to urban persons, rural persons were less likely to have diagnoses of drug use problems (10.5% vs. 18.8%, p < 0.0001) or hepatitis C (35.3% vs. 40.6%, p = 0.002), but had evidence of more advanced HIV infection at care entry (median CD4 186 vs. 247, p < 0.001). Rural persons were more likely to have an AIDS defining illness diagnosed within 1 year (16.4% vs. 13.2%, p = 0.007). Most initiated HAART during the observation period (77.5% of rural vs. 74.7% of urban, P = 0.07). Among 7,874 veterans initiating HAART during FY 1998-2007, rural residence was associated with increased mortality (hazard ratio 1.27, 1.08-1.45). A previously validated mortality risk adjustment index that uses EHR data and includes HIV severity and comorbidity measures ("VACS index") was available for 4,151 veterans initiating HAART between 1998 and 2002. In this subgroup, mortality was higher for rural persons before (hazard ratio 1.30, 1.08-1.56) and after adjustment for illness severity at baseline (hazard ratio 1.20, 1.01-1.41). Conclusions: Rural persons enter VA care with more advanced HIV infection and have higher mortality following HAART initiation. Extrapolating from available data on the average rate of CD4 decline in untreated HIV infection, the difference in CD4 count at presentation between rural and urban veterans corresponds to an approximately 1 year relative delay in care entry. Future studies should explore person and care system level determinants of late care entry and worse treatment outcomes for rural persons with HIV.

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