Kimmel April D, Bono Rose S, Pan Zhongzhe, Kiernan Jessica S, Belgrave Faye Z, Nixon Daniel E, Sabik Lindsay, Dahman Bassam
Department of Health Policy, School of Public Health, Virginia Commonwealth University, Richmond, Virginia, USA.
Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, Richmond, Virginia, USA.
J Rural Health. 2025 Jan;41(1):e12877. doi: 10.1111/jrh.12877. Epub 2024 Sep 16.
Less than 50% of people with HIV (PWH) in the United States are retained in care, a key step along the HIV care continuum. We examined the impact of geographic access to care on retention in care for urban and rural PWH.
We used Medicaid claims and clinician data (Medicaid Analytic eXtract and MAX Provider Characteristics, 2009-2012) for 13 Southern states plus the District of Columbia. We calculated drive time from the enrollees' ZIP Code Tabulation Area to their usual source of care. We used generalized estimating equations to examine the association between drive time to care >30 min (versus ≤30 min) and retention in care, overall and stratified by rurality. In sensitivity analysis, we examined the definition of retention in care, states included in the analysis, and enrollee- and care-related characteristics.
The sample included 49,596 PWH. Overall, the association between drive time >30 min and retention was significant, but small (adjusted odds ratio [aOR] 1.01, 95% confidence interval [CI] 1.00, 1.01) and was not significant in urban areas; however, the significance and direction of the association differed in sensitivity analysis. In rural areas, driving >30 min to care was associated with 7% higher odds of retention in care (aOR 1.07, 95% CI 1.05, 1.08) and this association remained significant and positive in nearly all sensitivity analyses.
For PWH in rural areas, greater drive time is consistently associated with greater retention in care. Disentangling the mechanisms of this relationship is a future research priority.
在美国，不到50%的艾滋病毒感染者（PWH）持续接受治疗，这是艾滋病毒治疗连续过程中的关键一步。我们研究了就医的地理可及性对城市和农村PWH持续治疗的影响。
我们使用了13个南部州以及哥伦比亚特区的医疗补助报销和临床医生数据（医疗补助分析提取物和MAX提供者特征，2009 - 2012年）。我们计算了从参保者的邮政编码分区到其常规就医地点的驾车时间。我们使用广义估计方程来研究就医驾车时间>30分钟（与≤30分钟相比）与持续治疗之间的关联，总体情况以及按农村地区分层的情况。在敏感性分析中，我们研究了持续治疗的定义、分析中纳入的州以及参保者和就医相关特征。
样本包括49,596名PWH。总体而言，驾车时间>30分钟与持续治疗之间的关联具有显著性，但程度较小（调整后的优势比[aOR]为1.01，95%置信区间[CI]为1.00，1.01），在城市地区不显著；然而，在敏感性分析中，该关联的显著性和方向有所不同。在农村地区，驾车30分钟以上就医与持续治疗的几率高7%相关（aOR为1.07，95%CI为1.05，1.08），并且在几乎所有敏感性分析中，这种关联仍然显著且呈正向。
对于农村地区的PWH，更长的驾车时间始终与更高的持续治疗率相关。厘清这种关系的机制是未来研究的重点。
