Clinic-level factors associated with time to antiretroviral initiation and viral suppression in a large urban cohort.

BACKGROUND: Using the results of a site assessment survey performed at clinics throughout Washington DC, we studied the impact of clinic-level factors on antiretroviral therapy (ART) initiation and viral suppression (VS) among people living with HIV (PLWH).

METHODS: This was a retrospective analysis from the DC Cohort, an observational clinical cohort of PLWH from 2011-2018. We included data from PLWH not on ART and not virally suppressed at enrollment. Outcomes were ART initiation and VS (HIV RNA <200 copies/mL). A clinic survey captured information on care delivery (clinical services, adherence services, patient monitoring services, e.g.) and clinic characteristics (types of providers, availability of evenings/weekends sessions, e.g.). Multivariate marginal Cox regression models were generated to identify factors associated with time to ART initiation and VS.

RESULTS: Multiple clinic-level factors were associated with ART initiation, including retention in care monitoring and medication dispensing review (aHR = 1.34 to 1.40, p<0.05 for both). Furthermore, multiple factors were associated with VS, including retention in HIV care monitoring, medication dispensing review, presence of a peer interventionist (aHR ranging from 1.35 to 1.72, p<0.05 for all). In multivariable models evaluating different combinations of clinic-level factors, enhanced adherence services (aHR 1.37 (95% CI 1.18, 1.58), medication dispensing review (aHR 1.22, 95% CI 1,10, 1.36), and availability of opioid treatment (aHR 1.26 (95% CI 1.01, 1.57) were all associated with time to VS.

CONCLUSIONS: The observed association between clinic-level factors and ART initiation/VS suggests that the presence of specific clinic services may facilitate achievement of HIV treatment goals.