Retaining relevance: extending clinical retention measures to improve their utility in describing HIV care engagement in the United States

项目总结/摘要 艾滋病毒仍然是美国主要的公共卫生问题。艾滋病毒感染者的比例（PWH） 在2020年，知道自己的艾滋病毒状况，与护理有关，继续接受临床护理（50%）， 病毒载量（57%），乏善可陈。临床护理中的保留率是核心护理质量指标， 艾滋病毒护理连续体的阶段。次优临床保留与病毒学失败密切相关， 高风险行为和生存率降低。此外，据估计，43%的新艾滋病毒 传播者来自威尔斯亲王医院的失医者（比例最高的是来自任何一个连续护理阶段）。 在过去十年的多项公共卫生政策中，这意味着高保留率和 参与临床护理对于降低艾滋病毒相关的发病率和死亡率， 新感染艾滋病毒的人数。 然而，尽管一致认为"保留"照料至关重要，必须增加"参与"照料， 我们并不完全了解如何最好地衡量高收入患者的保留和参与， 特别是在现代抗逆转录病毒治疗时代， 2019冠状病毒病疫情。早期的研究表明，病情较重的患者（即，CD4低者） 可能会错过门诊。然而，最近的研究发现， 可以继续接受实验室监测服务;这很可能是一个迹象， (i.e., CD4水平较高的患者）病毒稳定抑制，符合更新的监测指南 这需要较少的诊所访问。然而，该领域尚未划定诊所的最佳频率 这些更健康的、病毒抑制的患者的访问与多个其他风险层的个体相反， 尽管应用单一度量而不考虑子群体可能会产生错误的保留不良结果， 临床稳定的个体中。在这方面，我们的建议确实是新颖的。 因此，拟议的研究将提取、协调和分析临床护理的现成数据 在北美最大的艾滋病毒队列中的模式：北美艾滋病队列协作， 研究和设计。我们将使用这些数据来描述保留和参与的模式（目标1）， 分离出预测存活率提高和病毒抑制的护理接受的多个量度（目标1和2）， 并评估对人群进行分层的多种方法，同时量化预期的因果影响， 在现有的和新的、优化的指标下，提高艾滋病毒结果的保留率（目标3）。公共卫生 根据特定人群的艾滋病毒临床护理参与情况，改进保留指标的影响将是 意义深远，特别是鉴于艾滋病毒疾病和合并症的临床管理和实验室 在初级保健模式下进行监测，以及在COVID-19大流行期间改变护理模式。 因此，这一建议具有独特的前景，使改善艾滋病毒护理连续测量在美国。

Project Summary / Abstract HIV remains a major public health concern in the United States. The proportions of people with HIV (PWH) in 2020 who knew their HIV status, were linked to care, retained in clinical care (50%), and had suppressed viral loads (57%), were lackluster. Retention in clinical care is a core quality-of-care indicator and the central stage of the HIV care continuum. Suboptimal clinical retention is strongly associated with virologic failure while on ART, high-risk behavior, and poorer survival. Furthermore, it is estimated that 43% of new HIV transmissions are from PWH who are out of care (the largest proportion from any one care continuum stage). The implication, echoed in multiple public health policies over the past decade, is that high retention and engagement in clinical care are critical for blunting the HIV-related morbidity and mortality and reducing the number of new HIV infections. However, despite consensus that “retention” in care is critical and “engagement” in care must be increased, we do not fully understand how best to measure retention and engagement among patients in high-income settings, particularly in the modern ART era and given changes in care delivery that were introduced during the COVID-19 pandemic. Earlier research indicated that sicker patients (i.e., those with lower CD4) were more likely to miss clinic visits. More recent work, though, found that patients attending clinic visits less frequently may continue to receive laboratory monitoring services; this could well be an indication that healthier patients (i.e., those with higher CD4) who are stably virally suppressed are compliant with newer monitoring guidelines which demand less frequent clinic visits. However, the field has yet to delineate the optimal frequency of clinic visits for these healthier, virally suppressed patients as opposed to individuals in multiple other risk strata, though applying a single metric regardless of sub-population could produce spurious findings of poor retention among clinically stable individuals. In this respect, our proposal is truly novel. The proposed research will therefore extract, harmonize, and analyze readily available data on clinical care patterns within the largest HIV cohort in North America: the North American AIDS Cohort Collaboration on Research and Design. We will use these data to describe patterns of retention and engagement (Aim 1), isolate multiple measures of care receipt (Aims 1 and 2) that predict improved survival and viral suppression, and assess multiple methods for stratifying populations while quantifying the expected causal impact of improved retention on HIV outcomes under existing and novel, optimized metrics (Aim 3). The public health impact of improved retention metrics, based on population-specific HIV clinical care engagement, would be profound, particularly in light of changes in HIV disease and comorbidity clinical management and laboratory monitoring under a primary care model, as well as changing care modalities during the COVID-19 pandemic. This proposal therefore holds unique promise, enabling improved HIV care continuum measurement in the US.