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Ohl M. Rural Residence is Associated with Delayed Care Entry and Increased Mortality among Veterans with Human Immunodeficiency Virus (HIV) Infection. Paper presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 6; Portland, ME.
Rural persons face many barriers to care, but little is known about rural-urban variation in HIV outcomes. The objective of this study was to determine the association between rural residence and outcomes for veterans with HIV infection. Methods Design, Setting, and Patients: Retrospective cohort study of all cause mortality among persons initiating HIV care in Veterans Administration (VA) during fiscal years 1998-2007, with mortality follow up through fiscal year 2008. Rural residence was determined using Rural Urban Commuting Area codes, collapsed into urban and rural categories. Using a previously validated case finding algorithm, we identified 23,131 persons entering VA care with a diagnosis of HIV during 1998-2007. A viral load and CD4 were available within 180 days of the first contact with an HIV diagnosis for 12,827. Exclusion of 3,131 with viral load 400 at baseline and 698 with antiretroviral prescription before first viral load left 8,998 persons with no evidence of combination antiretroviral therapy (cART) use at care entry. Outcome Measure: Time to death following care entry. Analysis: Multivariate proportional hazards regression with robust variance estimates accounting for clustering of patients in facilities. Results Of the 8,998 persons entering care, 745 (8.3%) were rural. At care entry rural persons were less likely than urban persons to have drug use problems (10.5% vs. 19.0%, p < 0.001) or hepatitis C (34.6% vs. 40.8%, p = 0.001), but had more advanced HIV infection (median CD4 186 vs. 247, p < 0.001). Rural persons were more likely than urban to be diagnosed with an AIDS defining illness within 180 days of care entry (15.3% vs. 11.9%, p = 0.006). Overall, 7,187 persons (79.9%) initiated cART during 1998-2008 (83.0% of rural vs. 79.6% of urban, p = 0.03). Six years after entering care there were 2,078 deaths (203 rural and 1,875 urban), with a crude mortality rate of 27.2% for rural and 22.7% for urban persons (p = 0.005). The hazards of death were higher for rural than urban persons (Hazard ratio 1.24 , 95% confidence interval 1.05-1.48). The mortality hazard ratio decreased to 1.16 (0.99-1.32) after adjusting for age, CD4 count, AIDS defining illnesses, drug or alcohol use problems, and hepatitis B or C at baseline, and cART use as a time dependent covariate. Implications The observed difference in CD4 count at care entry between rural and urban persons corresponds to an approximately 1 year relative delay in care entry for rural persons. Future studies should explore the person, care system, and community level determinants of delayed care entry and increased mortality for veterans with HIV. Increased understanding of these factors is necessary to guide interventions to reduce survival disparities for rural veterans with HIV. Impacts In an effort to increase HIV diagnosis and link HIV positive veterans to care, VA has recently recommended routine HIV testing for all veterans. Findings from this study have been shared with Public Health Strategic Healthcare Group (PHSHG) and HIV / Hepatitis C QUERI, who are currently evaluating implementation of routine HIV testing policies in urban and rural VA care settings.