title: HIV-infected patients and treatment outcomes: an equivalence study of community-located, primary care-based HIV treatment vs. hospital-based specialty care in the Bronx, New York.
abstract: The HIV-infected population in the USA is expanding as patients survive longer and new infections are identified. In many areas, particularly rural/medically underserved regions, there is a growing shortage of providers with sufficient HIV expertise. HIV services incorporated into community-based (CB), primary care settings may therefore improve the distribution and delivery of HIV treatment. Our objective was to describe/compare patients and treatment outcomes in two settings: a community-located, primary care-based HIV program, and a hospital-based (HB) specialty center. CB providers had on-site access to generalist HIV experts. The hospital center was staffed primarily by infectious disease physicians. This was a retrospective cohort study of 854 HIV-positive adults initiating care between 1/2005 and 12/2007 within an academic medical center network in the Bronx, NY. Treatment outcomes were virologic and immunologic response at 16-32 and 48 weeks, respectively, after combination antiretroviral therapy (cART) initiation. We found that HB subjects presented with a higher prevalence of AIDS (59% vs. 46%, p<0.01) and lower initial CD4 (385 vs. 437, p<0.05) than CB subjects. Among 178 community vs. 237 hospital subjects starting cART, 66% vs. 62% achieved virologic suppression (95% confidence interval (CI) difference -0.14-0.06) and 49% vs. 59% achieved immunologic success, defined as a 100 cell/mm³ increase in CD4 (95% CI difference 0.00-0.19). The multivariate-adjusted likelihoods of achieving viral suppression [OR=1.24 (95% CI 0.69-2.33)] and immunologic success [OR=0.76 (95% CI 0.47-1.21)] were not statistically significant for community vs. hospital subjects. Because this was an observational study, propensity scores were used to address potential selection bias when subjects presented to a particular setting. In conclusion, HIV-infected patients initiate care at CB clinics earlier and with less advanced HIV disease. Treatment outcomes are comparable to those at a HB specialty center, suggesting that HIV care can be delivered effectively in community settings.
authors.affiliation: Department of Family and Social Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA. cchu@montefiore.org
authors.forename: C
authors.initials: C
authors.lastname: Chu
authors.forename: G
authors.initials: G
authors.lastname: Umanski
authors.forename: A
authors.initials: A
authors.lastname: Blank
authors.forename: R
authors.initials: R
authors.lastname: Grossberg
authors.forename: P A
authors.initials: PA
authors.lastname: Selwyn
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D003151:Community Health Centers / Q000458:organization & administration / Q000592:standards*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009518:New York; D010044:Outpatient Clinics, Hospital / Q000458:organization & administration / Q000592:standards*; D010342:Patient Acceptance of Health Care / Q000523:psychology; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D019380:Anti-HIV Agents
references.citation: Mayo Clin Proc. 2008 Jul;83(7):747-57
references.pmid: 18613991
references.citation: AIDS. 2007 Oct 18;21(16):2201-7
references.pmid: 18090047
references.citation: Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004910
references.pmid: 17636778
references.citation: Ann Intern Med. 1999 Jul 20;131(2):81-7
references.pmid: 10419445
references.citation: J Gen Intern Med. 2003 Apr;18(4):233-41
references.pmid: 12709089
references.citation: Int J Drug Policy. 2007 Aug;18(4):255-61
references.pmid: 17689373
references.citation: AIDS Care. 2003 Apr;15(2):231-7
references.pmid: 12856344
references.citation: AIDS. 1999 Apr 16;13(6):F35-43
references.pmid: 10397555
references.citation: J Acquir Immune Defic Syndr. 2001 Dec 1;28(4):385-92
references.pmid: 11707677
references.citation: J Acquir Immune Defic Syndr. 2005 Jan 1;38(1):96-103
references.pmid: 15608532
references.citation: Arch Intern Med. 2005 May 23;165(10):1179-84
references.pmid: 15911733
references.citation: MMWR Morb Mortal Wkly Rep. 2008 Oct 3;57(39):1073-6
references.pmid: 18830210
references.citation: Ann Intern Med. 2001 Dec 4;135(11):954-64
references.pmid: 11730396
references.citation: AIDS Care. 2006;18 Suppl 1:S45-50
references.pmid: 16938674
references.citation: HIV Clin Trials. 2008 May-Jun;9(3):186-91
references.pmid: 18547905
references.citation: MMWR Recomm Rep. 2006 Sep 22;55(RR-14):1-17; quiz CE1-4
references.pmid: 16988643
references.citation: J Acquir Immune Defic Syndr. 2007 Jan 1;44(1):30-7
references.pmid: 17106280
references.citation: Arch Intern Med. 2005 May 23;165(10):1133-9
references.pmid: 15911726
references.citation: J Gen Intern Med. 2008 Dec;23(12):2046-52
references.pmid: 18830770
references.citation: J Health Care Poor Underserved. 2004 Aug;15(3):413-25
references.pmid: 15453178
references.citation: HIV Med. 2006 Sep;7(6):404-10
references.pmid: 16903986