The HIV Care Cascade Measured Over Time and by Age, Sex, and Race in a Large National Integrated Care System.
HIV care cascades can evaluate programmatic success over time. However, methodologies for estimating cascade stages vary, and few have evaluated differences by demographic subgroups. We examined cascade performance over time and by age, sex, and race/ethnicity in Kaiser Permanente, providing HIV care in eight US states and Washington, DC. We created cascades for HIV+ members' age ≥13 for 2010-2012. We measured "linkage" (a visit/CD4 within 90 days of being diagnosed for new patients; ≥1 medical visit/year if established); "retention" (≥2 medical visits ≥60 days apart); filled ART (filled ≥3 months of combination ART); and viral suppression (HIV RNA <200 copies/mL last measured in year). The cascades were stratified by calendar year, sex, age, and race/ethnicity. We found men had statistically (p < 0.05) higher percent linkage, filled ART, and viral suppression for 2010 and 2011 but not for 2012. Women had significantly greater retention for all years. Annually, older age was associated (p < 0.05) with retention, filled ART, and viral suppression but not linkage. Latinos had greater (p < 0.05) retention than whites or blacks in all years, with similar retention comparing blacks and whites. Filled ART and viral suppression was increased (p < 0.05) for whites compared with all racial/ethnic groups in all years. Cascade methodology requiring success at upstream stages before measuring success at later stages (i.e., "dependent" methodology) underreported performance by up to 20% compared with evaluating each stage separately ("independent"). Thus, care results improved over time, but significant differences exist by patient demographics. Specifically, retention efforts should be targeted toward younger patients and blacks; women, blacks, and Latinos require greater ART prescribing.
1 Division of Infectious Diseases, Kaiser Permanente Mid-Atlantic States , Washington, District of Columbia.|2 Kaiser Permanente, Mid-Atlantic Permanente Research Institute , Rockville, Maryland.|3 Kaiser Permanente HIV Initiative , Oakland, California.
Michael Alan
MA
Horberg
3 Kaiser Permanente HIV Initiative , Oakland, California.|4 Division of Research , Kaiser Permanente Northern California, Oakland, California.
Leo Bartemeier
LB
Hurley
3 Kaiser Permanente HIV Initiative , Oakland, California.|5 Division of Infectious Diseases , Kaiser Permanente Northern California, Hayward, California.
Daniel Benjamin
DB
Klein
3 Kaiser Permanente HIV Initiative , Oakland, California.|6 Kaiser Permanente Southern California, Los Angeles Medical Center , Los Angeles, California.
William James
WJ
Towner
1 Division of Infectious Diseases, Kaiser Permanente Mid-Atlantic States , Washington, District of Columbia.|3 Kaiser Permanente HIV Initiative , Oakland, California.
Peter
P
Kadlecik
3 Kaiser Permanente HIV Initiative , Oakland, California.|7 Immunodeficiency Clinic , Kaiser Permanente Northwest, Portland, Oregon.
Diana
D
Antoniskis
3 Kaiser Permanente HIV Initiative , Oakland, California.|8 Division of Infectious Diseases, Kaiser Permanente Colorado , Denver, Colorado.
Miguel
M
Mogyoros
3 Kaiser Permanente HIV Initiative , Oakland, California.|9 Division of Infectious Diseases, Kaiser Permanente Georgia , Atlanta, Georgia .
Philip Sigmund
PS
Brachman
10 Kaiser Permanente , Oakland, California.
Carol Louise
CL
Remmers
10 Kaiser Permanente , Oakland, California.
Rebecca Claire
RC
Gambatese
2 Kaiser Permanente, Mid-Atlantic Permanente Research Institute , Rockville, Maryland.|3 Kaiser Permanente HIV Initiative , Oakland, California.
Jackie
J
Blank
3 Kaiser Permanente HIV Initiative , Oakland, California.|4 Division of Research , Kaiser Permanente Northern California, Oakland, California.
Courtney Georgiana
CG
Ellis
3 Kaiser Permanente HIV Initiative , Oakland, California.|4 Division of Research , Kaiser Permanente Northern California, Oakland, California.
Michael Jonah
MJ
Silverberg
D000328:Adult; D017677:Age Distribution; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D044383:Black People / Q000706:statistics & numerical data; D018791:CD4 Lymphocyte Count; D003266:Continuity of Patient Care / Q000458:organization & administration*; D005006:Ethnicity; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000208:ethnology / Q000821:virology*; D054625:Healthcare Disparities / Q000208:ethnology*; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D044469:Racial Groups / Q000706:statistics & numerical data*; D017678:Sex Distribution; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D019562:Viral Load; D044465:White People / Q000706:statistics & numerical data; D055815:Young Adult; D001741:Black or African American
D019380:Anti-HIV Agents