Similar Challenges with Retention in Care Issues

To the Editor—We read with interest the article by Giordano et al. [1]. We have conducted a similar retrospective analysis of HIV-infected patients within the Southern Alberta HIV Cohort. This program has a different demographic composition than that of the cohort described by Giordano et al. [1] but is similar to the US Department of Veteran Affairs, providing access with few financial barriers to a universal health care system. We included all patients with baseline CD4+ cell count data who initiated HAART from 1997 through 2005 (350 patients) and who had at least 1 subsequent clinic visit. Patients were followed up for at least 12 months. We stratified patients into 4 groups based on the number of clinic visits per year: <1.5, ⩾1.5 but <2.5, 2.5–3.5, and >3.5 visits per year. In contrast with the population treated by the US Department of Veterans Affairs, our population was younger (median age, 39 years) and predominantly white (68%), and 15% of our patients were female. In our population, 192 (55%) of patients were employed, 238 (68%) had at least a high school education, 59 (17%) were coinfected with hepatitis C virus, and 84 (24%) reported injection drug use. The median CD4+ cell count at HAART initiation was 195 cells/mm3 (interquartile range, 84–340 cells/mm3). Similar to Giordano et al. [1], we found profound gradients in some of the sociodemographic, clinical, and outcome variables. In our cohort, 62% of the patients attended >3.5 visits per year, 19% attended 2.5–3.5 visits per year, 13% attended ⩾1.5 but <2.5 visits per year, and 7% attended <1.5 visits per year. Our most economically disadvantaged population, Native or Aboriginal Canadians, exhibited the greatest disparity in clinic visits, with only 7% attending >3.5 visits per year and 25% attending <1.5 visits per year. Overall, 54% of patients with the least number of visits were injection drug users. Patients with lower CD4+ cell counts attended visits more regularly (P < .01). Patients who were employed also attended visits more regularly (P < .05). We did find a geographic gradient based on residency, with 85% of city residents attending >3.5 visits per year, compared with only 58% of rural residents. No statistically significant difference in mortality between the groups was seen, although very few deaths occurred (19 patients died). However, patients attending >3.5 visits per year had almost double the increase in CD4+ cell count (median increase, 129 cells/mm3 vs. 65 cells/mm3) and achieved an undetectable viral load more often than did patients with <1.5 visits per year (77% vs. 63%; P < .01). Our results, obtained from a cohort in a different country and under a different universal health care system, are remarkably similar to those reported by Giordano et al. [1]. These results suggest that, despite the absence of financial barriers, poor retention in HIV care is widely problematic and leads to worse outcomes. In Canada, low socioeconomic status and drug use are major contributors to inconsistent HIV care. We are in complete agreement with Giordano et al. [1] that optimal methods to retain these patients in care need to be developed if they are to achieve the full benefit of the health care opportunities available to them. Potential conflicts of interest. All authors: no conflicts.

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