title: Quality of initial HIV care in Canada: extension of a composite programmatic assessment tool for HIV therapy.
abstract: To document the quality of initial HIV care in Canada using the Programmatic Compliance Score (PCS), to explore the association of the PCS with mortality, and to identify factors associated with higher quality of care.
  
  
  
  We analysed data from the Canadian Observational Cohort Collaboration (CANOC), a multisite Canadian cohort of HIV-positive adults initiating combination antiretroviral therapy (ART) from 2000 to 2011. PCS indicators of noncompliance with HIV treatment guidelines include: fewer than three CD4 count tests in the first year of ART; fewer than three viral load tests in the first year of ART; no drug resistance testing before initiation; baseline CD4 count < 200 cells/mm3; starting a nonrecommended ART regimen; and not achieving viral suppression within 6 months of initiation. Indicators are summed for a score from 0 to 6; higher scores indicate poorer care. Cox regression was used to assess the association between PCS and mortality and ordinal logistic regression was used to explore factors associated with higher quality of care.
  
  
  
  Of the 7460 participants (18% female), the median score was 1.0 (Q1-Q3 1.0-2.0); 21% scored 0 and 8% scored ≥ 4. In multivariable analysis, compared with a score of 0, poorer PCS was associated with mortality for scores > 1 [score = 2: adjusted hazard ratio (AHR) 1.64; 95% confidence interval (CI) 1.13-2.36; score = 3: AHR 2.02; 95% CI 1.38-2.97; score ≥ 4: AHR 2.14; 95% CI 1.43-3.21], after adjustments for age, sex, province, ART start year, hepatitis C virus (HCV) coinfection, and baseline viral load. Women, individuals with HCV coinfection, younger people, and individuals starting ART earlier (2000-2003) had poorer scores.
  
  
  
  Our findings further validate the PCS as a predictor of all-cause mortality. Disparities identified suggest that further efforts are needed to ensure that care is equitably accessible.
authors.affiliation: British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.
authors.forename: S
authors.initials: S
authors.lastname: Kesselring
authors.affiliation: Northern Ontario School of Medicine, Sudbury, ON, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Cescon
authors.affiliation: British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.
authors.forename: G
authors.initials: G
authors.lastname: Colley
authors.affiliation: British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.
authors.forename: C
authors.initials: C
authors.lastname: Osborne
authors.affiliation: British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.
authors.forename: W
authors.initials: W
authors.lastname: Zhang
authors.affiliation: Toronto General Research Institute, University Health Network, Toronto, ON, Canada.|University of Toronto, Toronto, ON, Canada.
authors.forename: J M
authors.initials: JM
authors.lastname: Raboud
authors.affiliation: CATIE, Toronto, ON, Canada.
authors.forename: S R
authors.initials: SR
authors.lastname: Hosein
authors.affiliation: University of Toronto, Toronto, ON, Canada.|Ontario HIV Treatment Network, Toronto, ON, Canada.
authors.forename: A N
authors.initials: AN
authors.lastname: Burchell
authors.affiliation: University of Ottawa, Ottawa, ON, Canada.
authors.forename: C
authors.initials: C
authors.lastname: Cooper
authors.affiliation: McGill University, Montreal, QC, Canada.
authors.forename: M B
authors.initials: MB
authors.lastname: Klein
authors.affiliation: University of Toronto, Toronto, ON, Canada.|Women's College Research Institute, Toronto, ON, Canada.|Maple Leaf Medical Clinic, Toronto, ON, Canada.
authors.forename: M
authors.initials: M
authors.lastname: Loutfy
authors.affiliation: Clinique médicale l'Actuel, Montreal, QC, Canada.
authors.forename: N
authors.initials: N
authors.lastname: Machouf
authors.affiliation: British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.|University of British Columbia, Vancouver, BC, Canada.
authors.forename: Jsg
authors.initials: J
authors.lastname: Montaner
authors.affiliation: Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Rachlis
authors.affiliation: McGill University, Montreal, QC, Canada.
authors.forename: C
authors.initials: C
authors.lastname: Tsoukas
authors.affiliation: British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.|Simon Fraser University, Burnaby, BC, Canada.
authors.forename: R S
authors.initials: RS
authors.lastname: Hogg
authors.affiliation: British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.|University of British Columbia, Vancouver, BC, Canada.
authors.forename: V D
authors.initials: VD
authors.lastname: Lima
mesh_terms: D002170:Canada; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000401:mortality; D006302:Health Services Research; D011787:Quality of Health Care
keywords: 
  HIV
  ; Canada; antiretroviral therapy; mortality; quality of care; treatment guidelines.