Connection between social determinants and viral suppression
Abstract Format : The purpose of this study is to address the following questions: (1) what proportion of participants drop out of HIV medical care for one or more periods after initial entry into care? (2) who drops out? (3) what predicts dropping out compared to sustained engagement, and (4) what are the reasons participants give for dropping out of care? Understanding the factors that prevent PWH from engaging in care will inform interventions targeting the issue.
Methods : This study used the NYC CHAIN study data from 2002 to 2015. CHAIN is an ongoing cohort study of a probability sample of persons with HIV (PWH).
The sample includes 820 NYC respondents with 3,153 observation points, with the average number of interviews completed per person was 4.0. At each interview, study participants were asked about experiences of dropping out of care or not having an appointment for HIV medical care for more than 6 months prior to interview.
Random effects logit models are used to estimate the predictors of dropping out of care, adjusting for correlation among repeated observations on individuals. In the regression analyses, interactions between service need and service use are explored.
Two-by-two interaction variables are created for food, transportation, AOD treatment, and mental health service needs and utilization categories. These interaction variables are used to explore the impact of service needs on dropping out, as well as to explore the effect of service receipts on reverting that impact.
Results : Overall 25% of NYC HAIN participants reported at least one episode of dropping out of care since HIV diagnosis. Demographic characteristics were less strongly associated with dropping out than situational considerations and receipt of supportive services.
Participants experiencing financial hardship in the past six months (very low income, food insecurity, needing transportation services, those reporting active problem substance use, and those with lower mental health functioning had higher odds of dropping out. Receipt of food, transportation, and mental health services reduced the odds of dropping out to the equivalent level among individuals without these challenges. Receipt of alcohol and drug treatment, on the other hand, did not reduce the odds of dropping out to the level of individuals without the substance use challenges.
The qualitative results revealed the reasons for dropping out of HIV care. They include lack of perceived need for or intentional resistance to HIV treatment, substance abuse or mental health issues, competing needs and life stressors, and dissatisfaction with doctor, organization, or care.
Conclusions : This study found dropping out to be significantly associated with recent problem substance use, low mental health functioning, poverty, housing instability, transportation service needs, and food insecurity. This is consistent with the co‐occurring conditions recognized in the National HIV/AIDS Strategy as barriers to accessing and remaining in HIV care.
We also found that working full‐time or part‐time increases the odds of disengagement in care. This may reflect competing priorities, especially when the work does not provide paid time off and/or there are disclosure concerns associated with attending medical appointments.
Delaying or avoiding disease progression requires maintaining HIV care and adhering to prescribed treatments. The risk factors for dropping out of care direct our attention to promising points of intervention: clearly communicating the importance of consistent engagement in medical care, and providing the supportive services such as food and transportation, necessary to sustain engagement. Substance abuse prevention and intervention appear to be a key factor in this effort. Only when service needs and health beliefs have been addressed will we see individual and public health outcomes that approach the collective goal of ending the epidemic.