Rural Residence and Adoption of a Novel HIV Therapy in a National, Equal-Access Healthcare System

Ohl M, Richardson KK, Goetz K, Justice M, Vaughan-Sarrazin MS, Perencevich EN. Rural Residence and Adoption of a Novel HIV Therapy in a National, Equal-Access Healthcare System. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD.

Objectives: Raltegravir, the first HIV integrase inhibitor, received FDA approval on October 12, 2007 for treatment of antiretroviral experienced persons with detectable HIV viremia on therapy. Raltegravir has improved outcomes for persons with drug-resistant HIV. This study examined urban vs. rural variation in raltegravir adoption in VHA. Methods: We used VA's HIV Clinical Case Registry (CC R) to identify a cohort of persons with clinical indication for raltegravir at time of approval. Criteria included 1) prior exposure to 3 antiretroviral classes; 2) antiretroviral use in prior year; and 3) detectable HIV viral load ( > 400 copies / ml). Dependent variables were raltegravir adoption within 180, 360, and 720 days. The primary independent variable was urban vs. rural patient residence defined by VA criteria. For each endpoint, we fitted multivariable logistic regression models that included an urban residence indicator and adjusted for patient-level covariates, including demographics, CD4 count, HIV viral load, AIDS defining illnesses, substance use diagnosis, and years of prior antiretroviral exposure in VA. To determine whether care site effects contributed to the association between urban residence and raltegravir adoption, additional models adjusted for care site through inclusion of random intercepts for facilities and indicators for facility HIV patient volume. Results: We identified 1,871 raltegravir eligible veterans (326 rural, 17.4%). Urban persons were more likely than rural to initiate raltegravir within 180 days (13.3% vs. 8.6%, p = 0.01) and 360 days (21.6% vs. 16.6%, p = 0.03), but this gap narrowed by 720 days (29.6% vs. 27.6%, p = 0.46). In multivariable analysis adjusting for patient characteristics, urban residence predicted raltegravir adoption within 180 and 360 days, but not 720 days (odds ratio for early adoption, defined as within 180 days, waS 1.74, 95% confidence interval 1.10 - 2.74). Adjustment for care site effects led to a small decrease in the association between urban residence and early adoption (OR 1.61, 95% CI 1.01 - 2.59). Results were not sensitive to varying definitions of raltegravir eligibility. Implications: Even in a single payer system, geographic disparities may exist in access to new HIV therapies. Impacts: Efforts are needed to ensure rapid diffusion of innovations in HIV care to rural veterans