title: Retention in care is more strongly associated with viral suppression in HIV-infected patients with lower versus higher CD4 counts.
abstract: BACKGROUND
  Retention in care is important for all HIV-infected patients, but may be more important for people with advanced HIV disease. We evaluated whether the association between retention in care and viral suppression differed by HIV disease severity.
  
  
  METHODS
  A repeated cross-sectional analysis (2006-2011) involving 35,433 adults at 18 US HIV clinics. Multivariable logistic regression models examined associations between retention measures [Health Resources and Services Administration (HRSA) retention measure, 6-month gap, and 3-month visit constancy] and viral suppression (HIV-1 RNA ≤ 400 copies/mL) for HIV disease severity groups defined by CD4 counts: ≤ 200, 201-350, 351-500, and >500 cells per cubic millimeter.
  
  
  RESULTS
  Overall, patients met the HRSA measure in 84% of person-years, did not have a 6-month gap in 76%, and had visits in all 4 quarters in 37%; patients achieved viral suppression in 72% of person-years. The association between retention in care and viral suppression differed by disease severity, and was strongest for patients with lower CD4 counts: ≤ 200 [adjusted odds ratio (AOR) = 2.33, 95% confidence interval (CI): 2.16 to 2.51], 201-350 (AOR = 1.96, CI: 1.81 to 2.12), 351-500 (AOR = 1.65, CI: 1.53 to 1.78), and >500 cells per cubic millimeter (AOR = 1.22, CI: 1.14 to 1.30) using the HRSA retention measure as a representative example.
  
  
  CONCLUSIONS
  This is one of the first studies to report the impact of HIV disease severity on retention in care and viral suppression, demonstrating that retention in care is more strongly associated with viral suppression in patients with lower CD4 counts. These results have important implications for improving the health of patients with advanced HIV disease and for test and treat approaches to HIV prevention.
authors.affiliation: *Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; †Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; ‡Philadelphia Veterans Affairs Center for Health Equity Research and Promotion, Philadelphia, PA; §Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; ‖Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Rockville, MD; ¶Department of Medicine, Massachusetts General Hospital, Boston, MA; #Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and **Department of Medicine, Oregon Health and Sciences University, Portland, OR.
authors.forename: Baligh R
authors.initials: BR
authors.lastname: Yehia
authors.forename: Benjamin
authors.initials: B
authors.lastname: French
authors.forename: John A
authors.initials: JA
authors.lastname: Fleishman
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Metlay
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Berry
authors.forename: P Todd
authors.initials: PT
authors.lastname: Korthuis
authors.forename: Allison L
authors.initials: AL
authors.lastname: Agwu
authors.forename: Kelly A
authors.initials: KA
authors.lastname: Gebo
mesh_terms: D000293:Adolescent; D000328:Adult; D018791:CD4 Lymphocyte Count; D015496:CD4-Positive T-Lymphocytes / Q000276:immunology*; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000821:virology; D015497:HIV-1 / Q000302:isolation & purification*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012720:Severity of Illness Index; D014481:United States; D019562:Viral Load; D055815:Young Adult; D016903:Drug Monitoring