Penn study: Visits to multiple HIV clinics linked to poorer outcomes

(Press-News.org) PHILADELPHIA—Patients who received care at multiple HIV clinics—as opposed to only one— were less likely to take their medication and had higher HIV viral loads, a new study published in the journal AIDS and Behavior of almost 13,000 HIV patients in Philadelphia from Penn Medicine found. The findings reinforce the notion that continuous care with one provider/clinic is optimal for outcomes and even reducing transmissions, and can help cut down on duplicative HIV services that contribute to higher health care costs.

"It's about retention in care, but also continuity, two related, but distinct processes," said senior author Kathleen A. Brady, MD, an infectious disease physician at Pennsylvania Hospital and Medical Director/Medical Epidemiologist for the Philadelphia Department of Public Health's AIDS Activities Coordinating Office. "This paper helps to describe a group of patients in whom there is duplication of services but who also have worse outcomes. I'm hopeful that by providing this data to HIV clinicians, we can get a better understanding of why patients see multiple providers and make improvements to the system to achieve these goals."

The study was also led by Baligh R. Yehia, MD, MPP, MSHP, an assistant professor in the division of Infectious Diseases at the Perelman School of Medicine at the University of Pennsylvania.

Using data from the City of Philadelphia Department of Public Health, researchers tracked clinic attendance, use of antiretroviral therapy (ART), and HIV viral load suppression between 2008 and 2010 to the 26 Ryan White funded HIV clinics in Philadelphia.

Adjusting for sociodemographic factors, the team found that almost 1,000 of 13,000 patients visited multiple clinics and had poorer outcomes. They were less likely to take ART and had lower viral load suppression rates if they visited multiple clinics for treatment versus the rest who received care at one clinic. Over the study period, 69 percent of patients seeking care at multiple clinics received ART, with 68 percent suppressing HIV viral load. Comparably, 83 percent of patients in care at a single clinic were on ART, with 78 percent achieving viral suppression. What's more, the pattern of multiple clinic use continued year to year for 20 percent of the patients.

Patients who visited multiple clinics were more likely to be younger, black, women, on public insurance or without insurance, and in their first year of care, the researchers note.

The study addresses a larger question of how retention in care is assessed. Most past studies have compared patients consistently in care to those without regular care, but the use of multiple clinics and its impact on outcomes has never been examined. Current measures of retention in care are based solely on primary HIV visits and do not distinguish visits completed at different clinics. So today a patient may have one visit to two separate clinics over the course of a year and be considered "retained" by national standards.

While multiple-clinic visitors represent a minority of patients, this group is of particular interest to HIV providers and public health officials. For providers, it is critical to document care received at other locations, as this can lead to ART medication errors and unrecognized drug-drug interactions, resulting in harmful side effects and development of drug resistance. On the public health level, receiving care at multiple clinics can lead to duplicative and unnecessary services, resulting in higher health care costs.

"In times of diminishing resources, identifying ways to maximize resources and improve HIV outcomes is essential," said Dr. Brady.

For patients living with HIV, a continuous relationship with a provider has been associated with receiving ART, fewer HIV-related complications and lower risk of HIV transmission to others.

"Next, researchers should focus on better understanding the reasons behind multiple clinics visit, which could run the gamut," said Dr. Yehia. "Difficulty accepting the diagnosis and coping with stigma may play a role. Many people may move onto another clinic because of comorbidity, like hepatitis C and mental health treatments, which may not be offered at all clinics. Patient-provider interactions may also play a role. All of this information will help us better understand patient behaviors, which can help us improve HIV care."

### Other authors of the study from Penn Medicine include Robert Gross, MD, MSCE, and Ian Frank, MD.