title: The Vermont model for rural HIV care delivery: eleven years of outcome data comparing urban and rural clinics.
abstract: BACKGROUND
  Provision of human immunodeficiency virus (HIV) care in rural areas has encountered unique barriers.
  
  
  OBJECTIVE
  To compare medical outcomes of care provided at 3 HIV specialty clinics in rural Vermont with that provided at an urban HIV specialty clinic.
  
  
  METHODS
  This was a retrospective cohort study.
  
  
  RESULTS
  Over an 11-year period 363 new patients received care, including 223 in the urban clinic and 140 in the rural clinics. Patients in the 2 cohorts were demographically similar and had similar initial CD4 counts and viral loads. There was no difference between the urban and rural clinic patients receiving Pneumocystis carinii prophylaxis (83.5% vs 86%, P= .38) or antiretroviral therapy (96.8% vs 97.5%, P= .79). Both rural and urban cohorts had similar decreases in median viral load from 1996 to 2006 (3,876 copies/mL to <50 copies/mL vs 8,331 copies/mL to <50 copies/mL) and change in percent of patients suppressed to <400 copies/mL (21.4%-69.3% vs 16%-71.4%, P= .11). Rural and urban cohorts had similar increases in median CD4 counts (275/mm(3)-350/mm(3) vs 182 cells/mm(3)-379/mm(3)). A repeated measures regression analysis showed that neither fall in viral load (P= .91) nor rise in CD4 count (P= .64) were associated with urban versus rural site of care. Survival times, using a Cox proportional hazards model, were similar for urban and rural patients (hazard ratio for urban = 0.80 [95% CI, 0.39-1.61; P= .53]).
  
  
  CONCLUSIONS
  This urban outreach model provides similar quality of care to persons receiving care in rural areas of Vermont as compared to those receiving care in the urban center.
authors.affiliation: Infectious Diseases Unit, Fletcher Allen Health Care, Burlington, Vermont 05401, USA. Christopher.grace@vtmednet.org
authors.forename: Christopher
authors.initials: C
authors.lastname: Grace
authors.forename: Deborah
authors.initials: D
authors.lastname: Kutzko
authors.forename: W Kemper
authors.initials: WK
authors.lastname: Alston
authors.forename: Mary
authors.initials: M
authors.lastname: Ramundo
authors.forename: Louis
authors.initials: L
authors.lastname: Polish
authors.forename: Turner
authors.initials: T
authors.lastname: Osler
mesh_terms: D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D008297:Male; D017146:Models, Organizational; D017063:Outcome Assessment, Health Care / Q000379:methods*; D012189:Retrospective Studies; D019035:Rural Health Services / Q000592:standards; D019037:Urban Health Services / Q000592:standards; D014707:Vermont / Q000453:epidemiology