Wawrzyniak Andrew J, Rodríguez Allan E, Falcon Anthony E, Chakrabarti Anindita, Parra Alexa, Park Jane, Mercogliano Kathleen, Villamizar Kira, Kolber Michael A, Feaster Daniel J, Metsch Lisa R
*Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL; †Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL; ‡School of Nursing and Health Studies, University of Miami, Coral Gables, FL; §Florida Department of Health in Miami-Dade County, Miami, FL; ‖Department of Public Health Sciences, Biostatistics Division, University of Miami Miller School of Medicine, Miami, FL; and ¶Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY.
J Acquir Immune Defic Syndr. 2015 May 1;69 Suppl 1(0 1):S63-72. doi: 10.1097/QAI.0000000000000572.
Barriers to retention in HIV care are detrimental to patients' progress along the HIV continuum of care. Previous literature has focused on individual, client-level barriers, and interventions to address them. In contrast, less work has examined the role of system-level barriers on HIV care outcomes. This study seeks to understand how individual and systemic barriers individually are associated with clinic appointment attendance and virologic suppression in HIV-infected patients attending the largest HIV clinic in Miami-Dade, FL. In addition, we examined the synergistic effects of these barriers as potential syndemic factors on these health outcomes. Barriers to clinic attendance were determined in a face-to-face study interview with 444 HIV-infected outpatients (187 regular attenders, 191 irregular attenders, and 66 nonattenders) identified from electronic medical records. Compared with the other attendance groups, nonattenders had higher viral loads, were less likely to be virologically suppressed, had lower CD4 counts, had higher depressive symptoms, life chaos, lower quality of life, and higher rates of food insecurity, and recent drug use. Additionally, nonattenders compared with regular attenders had lower physician relationship ratings, had lower medical information clarity and more often reported transportation as a barrier to clinic attendance. When viewed as a syndemic, compared with patients not reporting any barriers, patients with 3 or more individual-level barriers were more likely to have a detectable viral load (odds ratio = 3.60, 95% CI: 1.71 to 7.61). Our findings suggest that patients presenting to the clinic with multiple barriers should be prioritized for assistance and future interventions to improve retention in care. Interventions should address multiple individual and system-level barriers simultaneously with particular attention to addressing depressive symptoms, organizational skills, relationship with the physician, and HIV-related health education.
艾滋病毒护理留存率的障碍不利于患者在艾滋病毒护理连续过程中的进展。以往的文献主要关注个体层面的障碍以及针对这些障碍的干预措施。相比之下，较少有研究探讨系统层面的障碍对艾滋病毒护理结果的影响。本研究旨在了解在佛罗里达州迈阿密 - 戴德县最大的艾滋病毒诊所就诊的艾滋病毒感染者中，个体障碍和系统障碍分别与门诊预约就诊率和病毒学抑制之间的关联。此外，我们还研究了这些障碍作为潜在共病因素对这些健康结果的协同作用。通过对从电子病历中识别出的444名艾滋病毒感染门诊患者（187名定期就诊者、191名不定期就诊者和66名未就诊者）进行面对面研究访谈，确定了就诊障碍。与其他就诊组相比，未就诊者的病毒载量更高，病毒学抑制可能性更低，CD4细胞计数更低，抑郁症状更严重，生活混乱，生活质量更低，粮食不安全率和近期吸毒率更高。此外，与定期就诊者相比，未就诊者对医生关系的评分更低，医疗信息清晰度更低，更多人报告交通是就诊的障碍。当被视为共病时，与未报告任何障碍的患者相比，有3种或更多个体层面障碍的患者更有可能有可检测到的病毒载量（比值比 = 3.60，95%置信区间：1.71至7.61）。我们的研究结果表明，对于存在多种障碍前来诊所就诊的患者，应优先提供帮助和未来干预措施，以提高护理留存率。干预措施应同时解决多个个体和系统层面的障碍，尤其要关注解决抑郁症状、组织能力、与医生的关系以及艾滋病毒相关的健康教育。
