HIV Psychiatry

Annotated Abstracts of Journal Articles
2014, 4th Quarter

HIV Psychiatry

Annotations by Oliver Freudenreich, MD, FAPM and Mary Ann Cohen, MD, FAPM
December 2014

  1. Beyond core indicators of retention in HIV care: Missed clinic visits are independently associated with all-cause mortality

Also of interest:

  • Bradley H, Hall HI, Wolitski RJ: Vital signs: HIV diagnosis, care, and treatment among persons living with HIV—United States, 2011
    MMWR Morb Mortal Wkly Rep 2014; 63(47):1113-7This brief article provides concisely the most recent (2011) data for the HIV care cascade (i.e., how many patients are diagnosed with HIV, how many are linked and retained in care, and how many achieve virological suppression). Out of an estimated 1.2 million people living with HIV in the US, 86% were diagnosed with HIV. Discouragingly, only 4 out of 10 people living with HIV were in care, and only 3 out of 10 were virologically suppressed. Psychiatrists can help patients achieve viral suppression by working on those psychological and psychiatric factors that are obstacles along the full HIV care cascade (e.g., depression leading to poor adherence). The CDC figures are also a reminder that social determinants of health matter as much as the science, even in cases where effective treatments are available.
  • Tavakkoli M, Cohen MA, Alfonso CA, Batista SM, Tiamson-Kassab ML, Meyer P: Caring for persons with early childhood trauma, PTSD, and HIV: A curriculum for clinicians
    Acad Psychiatry 2014; 38(6):696-700Childhood adversity and trauma can become major obstacles later in life with regards to HIV risk reduction and HIV care. Clinicians who care for patients with HIV are often unsure about how to elicit a trauma history or make a diagnosis of PTSD and how to use the information obtained for ongoing clinical care, including improving adherence to medical care and antiretroviral medications, and risk reduction. The authors developed a 4-hour curriculum to fill this educational gap. The curriculum’s length lends itself to a workshop for interested providers who feel they need more training in this area. In particular, it is expected that upon completion of the curriculum, participants will be able to:

    1. Integrate the assessment for early childhood and other trauma into routine history taking.
    2. Understand and interpret the signs and symptoms of trauma sequelae.
    3. Diagnose PTSD.
    4. Develop a differential diagnosis of psychiatric disorders associated or concomitant with PTSD.
    5. Formulate treatment approaches for their HIV-positive persons living with a history of trauma.
    6. Improve adherence to risk reduction, medical care, and antiretrovirals.
    7. Enhance the therapeutic alliance with traumatized patients.
  • HIV Clinical Resource, New York State Department of Health AIDS Institute: HIV prophylaxis following occupational exposure, 2014 PDF
    The guideline on HIV prophylaxis following occupational exposures (post-exposure prophylaxis or PEP) has been updated by the New York State Department of Health AIDS Institute. The initial triple therapy recommendations include tenofovir + emtricitabine (or lamivudine) plus either raltegravir or dolutegravir as the preferred initial PEP regimen because of its excellent tolerability, proven potency in established HIV infection, and ease of administration. AZT is no longer recommended. The recommendations differ from the current CDC guideline on PEP; Appendix B (pp.32-33) of the New York guideline contrasts the recommendations with those by the CDC for psychiatrists who are interested in details about PEP.
  • CDC Stacks: Recommendations for HIV prevention with adults and adolescents with HIV in the United States, 2014

    The Centers for Disease Control and Prevention, in collaboration with several other agencies and partner organizations, updated and expanded their 2003 recommendations regarding HIV prevention in the US. This is one of the available documents on the CDC’s website for clinical providers.

PUBLICATION #1 — HIV Psychiatry
Beyond core indicators of retention in HIV care: missed clinic visits are independently associated with all-cause mortality
Mugavero MJ, Westfall AO, Cole SR, et al
Clin Infect Dis 2014; 59(10):1471-9

ANNOTATION (Freudenreich & Cohen)

The Finding: Using data from eight Centers for AIDS Research (CFAR) sites that collectively form a clinical cohort (called CNICS), the authors showed an increased in all-cause mortality if patients failed to achieve retention in clinical care (which was operationally defined using measures from IOM and DHHS). In addition, missed visits independently increased mortality risk in those patients considered retained in care.

Strength and Weaknesses: This analysis was novel in that it combined two measures of engagement in care (overall retention in care, which is traditionally based on attended visits, versus missed clinical visits). However, the study follow-up period was rather short (only two years). The study also does not tell us how to prioritize patients who have missed clinic visits.

Relevance: In the US, only a minority of patients (30% based on 2011 data from the CDC) achieve the important surrogate marker goal of viral suppression. While testing will identify patients who are unaware that they are infected, linking patient to care and retaining them are equally critical elements of the HIV care cascade where our system is clearly failing many patients. The current study adds an easily measurable metric (“no-show visits”) that clinicians can use as points of discussion with established patients who miss visits, particularly if there are clinical concerns about the no-show visits (not all no-show visits will be equally concerning).


Background:  The continuum of care is at the forefront of the domestic human immunodeficiency virus (HIV) agenda, with the Institute of Medicine (IOM) and Department of Health and Human Services (DHHS) recently releasing clinical core indicators. Core indicators for retention in care are calculated based on attended HIV care clinic visits. Beyond these retention core indicators, we evaluated the additional prognostic value of missed clinic visits for all-cause mortality.

Methods: We conducted a multisite cohort study of 3672 antiretroviral-naive patients initiating antiretroviral therapy (ART) during 2000-2010. Retention in care was measured by the IOM and DHHS core indicators (2 attended visits at defined intervals per 12-month period), and also as a count of missed primary HIV care visits (no show) during a 24-month measurement period following ART initiation. All-cause mortality was ascertained by query of the Social Security Death Index and/or National Death Index, with adjusted survival analyses starting at 24 months after ART initiation.

Results: Among participants, 64% and 59% met the IOM and DHHS retention core indicators, respectively, at 24 months. Subsequently, 332 patients died during 16 102 person-years of follow-up. Failure to achieve the IOM and DHHS indicators through 24 months following ART initiation increased mortality (hazard ratio [HR] = 2.23; 95% confidence interval [CI], 1.79-2.80 and HR = 2.36; 95% CI, 1.89-2.96, respectively). Among patients classified as retained by the IOM or DHHS clinical core indicators, >2 missed visits further increased mortality risk (HR = 3.61; 95% CI, 2.35-5.55 and HR = 3.62; 95% CI, 2.30-5.68, respectively).

Conclusions: Beyond HIV retention core indicators, missed clinic visits were independently associated with all-cause mortality. Caution is warranted in relying solely upon retention in care core indicators for policy, clinical, and programmatic purposes.

Editorial commentary:
Armstrong WS, Del Rio C: Falling through the cracks and dying: missed clinic visits and mortality among HIV-infected patients in care
Clin Infect Dis 2014; 59(10):1480-2

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