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Www.aids2012.org Washington D.C., USA, JULY 22-27 2012 Rulin C. Hechter 1 MD,PhD Jean Q. Wang 1 PhD Margo A. Sidell 1 ScD William J. Towner 2 MD 1 Dept.

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Presentation on theme: "Www.aids2012.org Washington D.C., USA, JULY 22-27 2012 Rulin C. Hechter 1 MD,PhD Jean Q. Wang 1 PhD Margo A. Sidell 1 ScD William J. Towner 2 MD 1 Dept."— Presentation transcript:

1 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 Rulin C. Hechter 1 MD,PhD Jean Q. Wang 1 PhD Margo A. Sidell 1 ScD William J. Towner 2 MD 1 Dept. of Research and Evaluation Kaiser Permanente Southern California 2 Infectious Disease Kaiser Los Angeles Medical Center July 27 th, 2012 Disclosure: No potential conflict of interest Impact of Depression on Retention in Care and Viral Suppression in a Large Cohort of Insured HIV-infected Patients

2 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 HYPOTHESIS poor retention in HIV Care Depression less optimal viral control Depressive symptoms are prevalent in HIV patients (~50%), affect adherence to ART Bing EG, et al, Arch Gen Psychiatry. 2001; Horberg MA, et al. J Acquir Immune Defic Syndr., 2008; Hartzell JD et al. J Acquir Immune Defic Syndr 2007; AIM1: To examine the impact of depression on retention in HIV primary care. AIM2: To examine the impact of depression on viral suppression among patients on ART.

3 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 STUDY SETTING Study Setting: Kaiser Permanente Southern California (KPSC)--3.49 million health plan members Team-based integrated HIV primary care Electronic HIV patient registry --- over 12,500 registered HIV patients in KPSC since 01/01/2000 Inclusion criteria: AIM1: HIV+ adults with at least 8 months health plan membership in 2010 AIM2: 1) on ≥ 3 ARVs for ≥ 6 months (≥ 2 refills), and 2) ≥ 1 HIV viral load test in 2010

4 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 SAMPLE SIZE 6455 pts ≥ 8 months membership 183 pts missing HIV RNA measurement (4%) 4403 pts with ≥ 1 HIV RNA measurement (96%) 1869 pts not on ART ≥ 6 month (29%) 4586 pts on ART ≥ 6 month (71%) AIM 1 AIM 2

5 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 MEASUREMENTS Predictor: Depressive symptoms (time-updated) Major depression; Dysthymia; Anxiety and phobic disorders; Adjustment disorder with anxiety and depression. Outcomes: AIM1: Retention in 2010 ≥2 CD4 and/or HIV-1 viral load tests at least 90 days apart AIM2: Viral suppression at the last visit in 2010 viral load <50 copies/mL

6 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 STATISTICAL ANALYSES Modeling: AIM1: Poisson regression with robust error variances AIM2: Logistic regression Covariates (multivariable analyses): age, gender, race/ethnicity, mode of HIV infection, ever AIDS diagnosis, medical center of care, and retention (AIM2 only) Stratified analyses: By gender (AIM1&2), and retention (AIM2)

7 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 RESULTS-AIM1 (BASELINE, 01/01/2010) Baseline characteristics Total N (column %) Retained N (row %) P-value Total6455 (100)4980 (77.2) Age ≥50 years2634 (40.8)2144 (81.4)<.0001 <50 years3819 (59.2)2835 (74.2) Gender Male5823 (90.2)4500 (77.3)0.70 Female628 (9.7)476 (75.8) Race/ethnicity White3174 (49.2)2488 (78.4)<.0001 Hispanic1766 (27.4)1375 (77.9) African American1088 (16.9)821 (75.5) Asian230 (3.5)183 (79.6) Others/unknown197 (3.0)112 (56.9) AIDS Yes3384 (52.4)2695(79.6)<.0001 no3071 (47.6)2284(74.4)

8 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 RESULTS-AIM1 IMPACT OF DEPRESSION ON RETENTION 0.89 (0.86-0.91)0.89 (0.87-0.92) 0.82 (0.75-0.89) RR (95% CI) Adjusted Among Males Among Females

9 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 RESULTS-AIM2 VIRAL SUPPRESSION AT LAST TEST IN 2010 PredictorsSuppressed N (row %) Not suppressed N (row %) P-value Total (N=4403)3798 (86.3)605 (13.7) Age ≥50 years1735 (87.0)260 (13.0)0.21 <50 years2063 (85.7)345 (14.3) Gender Male3447 (86.0)562 (14.0)0.19 Female347 (89.0)43(11.0) Race/ethnicity White1969(87.9)270 (12.1)0.001 Hispanic1056 (85.6)177 (14.4) African American538 (81.3)124 (18.7) Asian143 (89.9)16 (10.1) Others/unknown92 (76.7)18(23.3)

10 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 RESULTS-AIM2 IMPACT ON MAXIMAL VIRAL CONTROL OR (95% CI) Fig 2. Association between diagnosed depression and failure of viral suppression at the last test in 2010 1.0

11 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 RESULTS-AIM2 IMPACT OF DEPRESSION ON VIRAL SUPPRESSION Stratified by gender Stratified by retention Adjusted OR (95% CI) 2.65 (1.30-5.39) Fig 3. Association between diagnosed depression and failure of viral suppression at the last test in 2010 1.0

12 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 LIMITATIONS Insured HIV patients Small sample size of female patients (n= 628) Potential misclassification Potential residual confounding Rx-antidepressant /counseling therapy Illicit substance use Adherence to ART

13 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 CONCLUSION Depressive symptoms were prevalent (over 50%) Depressive symptoms were negatively associated with retention in care in primary HIV care setting Depressive symptoms may compromise viral control among patients on ART. Clinical Implication: Early and regular screening for depression in HIV primary care setting Intervention / Referral for mental health services

14 www.aids2012.org Washington D.C., USA, JULY 22-27 2012 ACKNOWLEDGEMENTS Drs. Jean Wang, Margo Sidell (Kaiser Permanente Southern California) Dr. William Towner (Kaiser Los Angeles Medical Center) Dr. Michael Horberg (Kaiser Permanente Mid-Atlantic States) Dr. Michael Silverberg (Kaiser Permanente Northern California) Dr. Chun Chao (Kaiser Permanente Southern California) Beth Tang (Kaiser Permanente Southern California, HIV registry) The International AIDS Society Kaiser Permanente Southern California, Research and Evaluation Thank you! Rulin Hechter Kaiser Permanente Southern California Rulin.C.Hechter@kp.org

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