Sabin, CA;
Howarth, A;
Jose, S;
Hill, T;
Apea, V;
Morris, S;
Burns, F;
(2017)
Association between engagement in-care and mortality in HIV-positive persons: a cohort study.
AIDS
, 31
(5)
pp. 653-660.
10.1097/QAD.0000000000001373.
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Abstract
OBJECTIVE: To assess associations between engagement in-care and future mortality. DESIGN:: UK-based observational cohort study. METHODS:: HIV-positive participants with >1 visit after 1/1/2000 were identified. Each person-month was classified as being in- or out-of-care based on the dates of the expected and observed next care visits. Cox models investigated associations between mortality and a) the cumulative proportion of months spent in-care (%IC, lagged by 1 year), and b) cumulative %IC prior to antiretroviral treatment (ART) in those attending clinic for >1 year, with adjustment for age, CD4/viral load (VL), year, sex, infection mode, ethnicity, and receipt/type of ART. RESULTS:: The 44,432 individuals (27.8% female; 50.5% homosexual, 28.9% black African; median age 36 years) were followed for a median of 12.9 years, over which time 2279 (5.1%) people died. Higher %IC was associated with lower mortality both before (relative hazard 0.91 [95% Confidence Interval 0.88–0.95]/10% higher, p?=?0.0001) and after (0.90 [0.87–0.93], p?=?0.0001) adjustment. Adjustment for future CD4 changes revealed that the association was explained by poorer CD4 counts in those with lower %IC. 8730 participants under follow-up for >1 year initiated ART of whom 237 (2.7%) died. Higher values of %IC prior to ART initiation were associated with a reduced risk of mortality before (0.29 [0.17–0.47]/10%, p?=?0.0001) and after (0.36 [0.21–0.61]/10%, p?=?0.0002) adjustment; the association was again explained by poorer post-ART CD4/VL in those with lower pre-ART %IC. CONCLUSIONS:: Higher levels of engagement in-care are associated with reduced mortality at all stages of infection, including in those who initiate ART.
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