Testing, Linking, Retaining: An HIV Clinician's Perspective
An Interview With Michael J. Mugavero, M.D.
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Michael J. Mugavero, M.D. is associate professor of medicine at the University of Alabama at Birmingham and project director of the University of Alabama at Birmingham 1917 Clinic Cohort.
Dr. Mugavero is one of a handful of HIV clinicians who closely studies discontinuities in HIV care from diagnosis through referral and retention, both in the 1917 Clinic Cohort at the University of Alabama at Birmingham and through analysis of other research. His recent publications include work on temporal trends in presentation for outpatient HIV medical care in the past decade, health care system and policy factors influencing engagement in HIV medical care, and underutilization of the AIDS Drug Assistance Program (ADAP).
Mascolini: To give readers perspective on your insights based on experience at your own clinic, can you outline the demographics of your patient population?
Mugavero: The University of Alabama (UAB) 1917 Clinic Cohort includes patients who are in care at the UAB 1917 Clinic. We currently have over 1800 patients receiving primary HIV medical care, in addition to other supportive and specialty care. Our clinic population is roughly 50% white and 50% African American, although 80% of our women are African American and 20% are white. In terms of transmission risk, slightly more than 40% of our patients are men who have sex with men, with the majority of the rest reporting heterosexual transmission. Injection drug use explains HIV transmission in less than 10% of our clinic population. Roughly 35% of new patients in our clinic have private health insurance. The remaining patients have either public health insurance or are uninsured, and insurance status is roughly split between those other two categories.
Mascolini: The CDC estimates that 20% of HIV-positive people in the United States remain unaware of their infection.1 What's your perspective on the scope of this problem from experience at your clinic and from your understanding of data across the US?
Mugavero: The CDC has wonderful surveillance and epidemiology teams that use sophisticated approaches to track and estimate the number of individuals who are HIV positive and unaware. In our clinic, since 2006 we've observed a dramatic increase in the number of new HIV patients coming in. It's hard to say whether we can attribute that increase to implementation of the CDC's revised HIV testing recommendations2 or to other factors. For example, the Alabama Department of Public Health put into place a new program to enhance referral for treatment services, and we developed a new patient orientation program in our clinic.
It's also hard to say whether the recent increase in new HIV patients in our clinic corresponds to the CDC revising its estimate of infected-but-unaware people from 25% to 20%.1 Regardless of the cause, this influx of new patients is encouraging. At the same time, we've found that our new patients are coming into care earlier in the course of infection in terms of CD4 count and presence of opportunistic infections. Through 2006, roughly half of our patients presenting for HIV care and never seen elsewhere had a presenting CD4 counts below 200, and about one third had an opportunistic infection before or at presentation to care. From 2006 through the end of 2010, we saw a steady and continuous decline in presentations with low CD4 counts or opportunistic diseases. In the most recent years, 31% of new patients are coming in with a CD4 count below 200, and well below 20% are coming in with an opportunistic infection.
Again, it's hard to say what factors are associated with these changes, but the trend over time is encouraging, and the bolus of new patients coming in earlier supports the idea that we're doing a better job identifying infected people and getting them into care more expeditiously.
Mascolini: Are clinicians you know at other HIV centers across the country telling you they're having the same experience?
Mugavero: I've heard mixed anecdotal feedback from different sites. But an NA-ACCORD cohort analysis of US and Canadian patients from 1997 to 2007 also showed a steady increase in median CD4 count among new patients entering care and a decrease in the proportion of patients presenting with a CD4 count below 350,3 which until recently was the prevailing recommendation of when to start therapy. These changes were less dramatic than our single-site findings, but NA-ACCORD appears to be the largest national study that suggests persons newly entering care are doing so at an earlier disease stage.
Mascolini: Your study of late diagnosis at Duke University in North Carolina found associations between late diagnosis and both older age and female gender.4 What explains those associations and what other factors contribute to late diagnosis in the United States?
Mugavero: First it's important to note that this was a fairly small, single-site study.4 We assessed about 100 patients in that study. The findings for older age and late diagnosis have been seen fairly consistently across different settings in recent years.5-8
Several factors may contribute to that association. First, perceived likelihood of becoming infected with HIV probably declines with age among individuals as well as their health care providers. There may well be a misconception that older individuals are less likely to be at risk. The other factor that may contribute is length of time since infection: Some people diagnosed with HIV infection at an older age probably became infected years earlier, so they had had more time to experience CD4 decline and more advanced infection at the time of testing positive.
The gender finding in our study is interesting.4 We found that women were more likely than men to be diagnosed with HIV during hospitalization (adjusted odds ratio 6.74, 95% confidence interval 2.08 to 21.81, P = 0.001). We didn't have enough details to know whether some of those hospitalizations might be related to pregnancy or what specifically caused those hospitalizations. We did not see that women had lower CD4 counts than men at presentation. Actually, a number of studies found that women are often diagnosed at a higher CD4 count than men.5,6,9 I think part of that success can be explained by the long-standing recommendation for routine HIV screening during pregnancy, which was in place long before the CDC's 2006 recommendation for general opt-out screening.2
TLC+: Best Practices to Implement Enhanced HIV Test, Link-to-Care, Plus Treat (TLC-Plus) Strategies in Four U.S. Cities
This article was provided by The Center for AIDS. It is a part of the publication Research Initiative/Treatment Action!. Visit CFA's website to find out more about their activities and publications.
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