The Impact of Churn on HIV Outcomes in a Southern United States Clinical Cohort Restricted; Files Only

Abstract

Background. Persons with HIV (PWH) may experience a cycle of engaging and disengaging in care in a phenomenon designated as “churn.” While HIV churn is predicted to be more prevalent in the southern United States, it has not been well characterized in this region.

Methods. We conducted a retrospective cohort study involving PWH newly establishing care at a large, urban clinic in Atlanta, Georgia from 2012 to 2017 with follow-up data collected through 2019. The primary exposure was churn, defined as a ≥12-month gap between routine clinic visits or viral load measurements. We evaluated HIV metrics, clinical outcomes, and care continuum outcomes.

Results. Of 1303 PWH newly establishing care, 81.7% were male, 84.9% Black, and 200 (15.3%) experienced churn in 3.3 years of median follow-up time. The transmissible viremia (TV) rate increased from 28.6% pre-churn to 66.2% post-churn (p-value <.0001). The 122 PWH having TV on re-engagement had delayed time to subsequent VS (aHR 0.59, 95% CI 0.48 – 0.73), and PWH returning to care contributed disproportionately to the community viral load (CVL) (% of CVL / % of patients 1.96). Churn was not associated with increased AIDS-defining illness (aOR 0.61, 95% CI 0.35 – 1.07), mortality (aHR 1.00, 95% CI 0.66 – 1.50), subsequent churn (aOR 1.53, 95% CI 0.79 – 2.97) or loss to follow-up (aOR 1.04, 95% CI 0.60 – 1.79).

Conclusions. The rate of churn in a Southern clinic was high, and those who experienced churn had increased TV at re-entry and disproportionately contributed to the CVL without early clinical or care continuum consequence.

Table of Contents

Introduction........................................................1

Methods..............................................................6

Study Design and Participants.............................. 6

Cohort Assignment.............................................. 7

Exposure and Covariates.......................................8

Outcome Variables............................................... 8

Power Analysis................................................... 12

Statistical Analyses.............................................13

Results...............................................................14

General Characteristics.......................................14

HIV Metric Outcomes......................................... 15

Clinical and Care Continuum Outcomes...............17

Discussion......................................................... 19

General Characteristics.......................................19

HIV Metric Outcomes......................................... 20

Clinical and Care Continuum Outcomes............... 21

Limitations and Future Directions....................... 25

Conclusion.........................................................26

Figures and Tables..............................................27

References..........................................................37

About this Master's Thesis

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School	Laney Graduate School
Department	Clinical Research
Degree	M.S.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Medicine and Surgery Health Sciences, Epidemiology
Mot-clé	HIV care continuum Churn HIV in the South
Committee Chair / Thesis Advisor	Jonathan A. Colasanti, Emory University
Committee Members	Matthew Magee, Emory University N. Sarita Shah, Emory University

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