1. Quality of HIV Care for Veterans with Unhealthy Alcohol Use
Kevin Kraemer, MD, MSc
Kathleen McGinnis, MS
P. Todd Korthuis, MD, MPH
David Fiellin, MD, MPH
Adam Gordon, MD, MPH
Amy Justice, MD, PhD
and “Quality of HIV Care for Veterans with Substance Use” Writing Group

2. Background
Prevalence of unhealthy alcohol use is high among HIV-infected patients
Alcohol has many potential adverse effects in HIV-infected patients but little is known about the influence of alcohol use on the quality of HIV care
Although the VA has long been a leader in quality improvement for HIV-infected veterans, it is not known how this extends to veterans with unhealthy alcohol use

3. Objective/Hypothesis
Objective: To compare the quality of HIV care among HIV-infected veterans with and without unhealthy alcohol use
Hypothesis: Quality of HIV care will be lower for HIV-infected veterans with unhealthy alcohol use than for those without unhealthy alcohol use

4. Methods Design: cross-sectional analysis of VACS baseline data
Sites: all 8 VACS sites
Participants: all HIV-infected veterans in VACS

5. Independent Variables and Covariates
Main independent variable – Unhealthy alcohol use
Measured by the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C)
Defined as AUDIT-C score of 4 or more and alcohol use in past year
Covariates – demographics, illicit drug use, tobacco use, CD4, viral load

6. Outcomes - Quality of HIV Care Indicators
Quality Indicator (QI) definitions (each dichotomously coded)
Receipt of HAART if CD4 nadir < 350 or history of AIDS-defining illness
PCP prophylaxis if CD4 < 200 during past 12 months
MAC prophylaxis if CD4 < 50 during past 12 months
Two or more CD4 counts, at least 3 mo apart, during past 12 months
Two or more HIV clinic visits, at least 3 mo apart, during past 12 months
Primary Outcome
Summary Quality Score = ∑ (QI received/QI eligible) x 100

7. Analysis
Two-sample t-test, chi-square, and Wilcoxon rank sum used, as appropriate, to compare baseline demographics, clinical characteristics, summary quality score, and individual quality indicators among HIV-infected veterans with and without unhealthy alcohol use
Multivariate logistic regression
Assess independent association of unhealthy alcohol use with the outcome of achieving at least 80% of quality indicators
Adjusted for age, gender, race/ethnicity, and illicit drug use

8. Results – Characteristics of Sample
AUDIT-C 4+ and drank in past year (n=864)
AUDIT-C < 4
or did not drink
in past year
(n=2483)
P-value
Mean age 48 49
< .001
Male (%) 98 97
< .05
African-American (%) 68 67 ns
CD4 < 200 (%) 25 24
HIV RNA > 500 (%) 57
Current tobacco use (%) 47
Illicit drug use, past year (%)
     Opiates
Cocaine
     Stimulants
     Marijuana 13 38 6 39 8 16 4
.001

9. Results – Quality of HIV Care Indicators
AUDIT-C 4+ and drank in past year
(n=864)
AUDIT-C <4 or didn’t drink in past year
(n=2483)
P-value
Mean Summary Quality Score (SD)
80 (31)
86 (27)
< .001
No. Eligible
% Received
HAART
459 89
1295 90 ns
PCP prophy.
210 91
559 92
MAC prophy. 52
138 84
≥ 2 CD4 Counts
864 72
2483 80
≥ 2 HIV Visits 83

10. Results – Achieving At Least 80% of Quality Indicators
72% of total sample achieved at least 80% of quality indicators
> 80% quality indicators completed
(n=2396)
< 80% quality indicators
completed
(n=951)
P-value
Alcohol use (%)
AUDIT-C 4+ and
drank in past year
AUDIT-C < 4 or did not drink in past year 65 74 35 26
< .001

11. Results – Association with Achieving At Least 80% of Quality Indicators
Odds Ratio (95% CI)
P-value
Age 50+ (ref.: age < 50)
1.17 (1.00 – 1.37)
.046
Male gender (ref.: female)
2.05 (1.31 – 3.18)
.002
Race (ref.: white)
Black
Latino
Other/Unknown
0.72 (0.58 – 0.88)
0.81 (0.59 – 1.12)
0.46 (0.31 – 0.69) ns
< .001
AUDIT-C 4+ and drank in past year (ref.: AUDIT-C < 4 or no drink in past year)
0.71 (0.60 – 0.85)
Illicit drug use (ref.: no illicit drug use)
0.73 (0.62 – 0.87)

12. Limitations Cross-sectional
Analysis does not include a number of quality of HIV care indicators
Does not account for out-of-VA care

13. Conclusions
Unhealthy alcohol use is associated with lower quality of HIV care in HIV-infected veterans
Primarily due to fewer HIV clinic visits and CD4 counts
Independent from effect of concurrent illicit drug use
Age < 50 years and African-American race also associated with lower quality of HIV care

14. Significance/Implications
Completed analyses will:
Improve understanding of the influence of alcohol and its treatment on quality of HIV care
Identify potential targets for improving quality of HIV care among high-needs veterans

15. Next Steps
Continue planned quality of HIV care analyses for both unhealthy alcohol use and illicit drug use
Add additional quality indicators to analyses
Tier 2 (adherence assessment and counseling, HIV risk counseling, Hepatitis B vaccination, oral exam, and screening for cervical cancer, Hepatitis C, lipids, syphilis, and TB)
Tier 3 (alcohol counseling for HCV/HIV coinfected, tobacco cessation; vacccination for influenza and pneumococcus; and screening for chlamydia, gonorrhea, Hepatitis B, toxoplasma, mental health, and substance use)
Determine the impact of substance abuse treatment services on the quality of HIV care for HIV-infected veterans with substance use disorders

16. Acknowledgements PI and Co-PI: AC Justice, DA Fiellin
Scientific Officer (NIAAA): K Bryant
Participating VA Medical Centers: Atlanta (D. Rimland), Baltimore (KA Oursler, R Titanji), Bronx (S Brown, S Garrison), Houston (M Rodriguez-Barradas, N Masozera), Los Angeles (M Goetz, D Leaf), Manhattan-Brooklyn (M Simberkoff, D Blumenthal, H Leaf, J Leung), Pittsburgh (A Butt, E Hoffman), and Washington DC (C Gibert, R Peck)
Core Faculty: K Mattocks (Deputy Director), K Akgun, S Braithwaite, C Brandt, K Bryant, R Cook, K Crothers, J Chang, S Crystal, N Day, R Dubrow, M Duggal, J Erdos, M Freiberg, M Gaziano, M Gerschenson, A Gordon, J Goulet, N Kim, M Kozal, K Kraemer, V LoRe, S Maisto, P Miller, P O’Connor, C Parikh, C Rinaldo, J Samet
Staff: H Bathulapalli, T Bohan, D Cohen, A Consorte, P Cunningham, A Dinh, C Frank, K Gordon, J Huston, F Kidwai, F Levin, K McGinnis, C Rogina, J Rogers, L Sacchetti, M Skanderson, J Tate, E Williams
Major Collaborators: VA Public Health Strategic Healthcare Group, VA Pharmacy Benefits Management, Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Yale Center for Interdisciplinary Research on AIDS (CIRA), Center for Health Equity Research and Promotion (CHERP), ART-CC, NA-ACCORD, HIV-Causal
Major Funding by: National Institutes of Health: NIAAA (U10-AA13566), NIA (R01-AG029154), NHLBI (R01-HL095136; R01-HL090342; RCI-HL100347) , NIAID (U01-A ), NIMH (P30-MH062294), and the Veterans Health Administration Office of Research and Development (VA REA ) and Office of Academic Affiliations (Medical Informatics Fellowship).

17. Questions?