Use of Recommended Preventive Health Care Services and Variations in HIV Care Among Women With HIV in the United States, 2013–2014

Opportunities for Expanded Partnerships in Support of Ending the HIV Epidemic

William R. Short, MD, MPH; Madeline Y. Sutton, MD, MPH; Qingwei Luo, MS; Emma L. Frazier, PhD, MS

Disclosures

J Acquir Immune Defic Syndr. 2019;82(3):234-244. 

In This Article

Abstract and Introduction

Abstract

Background: Despite recommendations for preventive health services and routine HIV care for HIV-positive women, limited data are available regarding uptake of recommendations.

Methods: We used data from the 2013–2014 data cycles of the Medical Monitoring Project. We calculated weighted estimates and used multivariable logistic regression with adjusted prevalence ratios and 95% confidence intervals to examine associations between preventive health screenings, routine HIV care [based on viral load (VL) and CD4 measures as proxies], and sociodemographic factors.

Results: Of 2766 women, 47.7% were 50 years and older, 61.7% non-Hispanic black, 37.2% had >high school education, 63.3% had been living with HIV for ≥10 years, 68.4% were living ≤the federal poverty level, 67.3% had public health insurance, 93.8% were prescribed antiretroviral therapy, and 66.1% had sustained/durable suppression (12 months). For women aged 18 years and older, cervical cancer, breast cancer, and sexually transmitted infection screenings were documented for 44.3%, 27.6%, and 34.7%, respectively; 26% did not meet 6-month, and 37% did not meet 12-month, VL and CD4 test measure goals. In multivariable analyses, women with no VLs in the past 6 months were less likely to be durably suppressed, and women who did not have ≥3 CD4 or VL tests (past 12 months) were less likely to be living above the poverty level and more likely to have public insurance compared with private health insurance (P < 0.05).

Conclusion: Receipt of recommended preventive care was suboptimal. Targeted interventions are warranted to help ensure access to comprehensive HIV care and prevention services for women.

Introduction

With the uptake of highly effective antiretroviral therapy (ART) regimens, persons with HIV are living longer lives and often developing health problems that are seen among the general population of aging adults, including cardiovascular disease, diabetes, hypertension, and some cancers.[1] As such, routine, preventive health care assessments and screenings are increasingly important as part of overall care for persons with HIV. Current recommendations are that persons with HIV see their care provider and, depending on factors such as length of time since diagnosis and whether they are on a suppressive ART regimen, the frequency for monitoring of key tests such as CD4 count and HIV viral load (VL) may be extended to either every 4 or 6 months.[2] The HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) also published evidence-based, primary care, and preventive health screening guidelines in 2009 (updated in 2013),[3] although the uptake of these guidelines among women living with HIV infection is unclear.

Women, who have unique preventive health care and screening needs compared with men, represented 24% and 19% of persons in the United States (U.S.) with HIV infection diagnosed in 2015 and 2016, respectively.[4] In addition to routine visits for HIV clinical care, screening recommendations for women with HIV include mammograms for baseline breast cancer screening, which vary by professional organization, starting at ages 40 years,[5] 45 years,[6] and 50 years[3,7] or earlier if there is a family history of breast cancer or genetic risk identified. Recommendations also include cervical cancer screening starting at age 21 years and by age 30 years, with co-testing (Pap and human papilloma virus)[8] and annual testing for sexually transmitted infections (STIs)—syphilis, gonorrhea, and chlamydia.[9] Like the general population of adult women in the United States, women with HIV should also be screened regularly for other comorbidities, including cardiovascular disease, hypertension, diabetes, obesity, and depression, and managed appropriately.[3]

The extent to which women with HIV are receiving preventive screening services and engaged in routine, outpatient clinical care (including laboratory tests) has been understudied nationally, although a local Utah study showed suboptimal routine screening among women.[10] However, some data suggest several barriers to care for HIV-positive women, including social, structural, psychosocial, cultural, and economic barriers, especially for disproportionately affected black/African American women and Hispanic women/Latinas.[11] National HIV strategies[12,13] that include increased roles for the Health Resources and Services Administration's (HRSA's) Ryan White HIV/AIDS Program (RWHAP) support direct health care treatment and support services for disproportionately affected populations, including women.[14] As such, clinical care and preventive services access opportunities for women may be expanding as part of ending the HIV epidemic.[13]

In this study, we examined preventive health screenings and VL and CD4 measurements among women living with HIV infection who had engaged in care at least once. Because women who are unable to access regular, outpatient care may encounter emergency department (ED) settings for HIV medical care, we also examined ED visits and hospitalizations among HIV-positive women. Our goal was to inform strategies and strengthen opportunities for preventative screenings and routine, culturally tailored care to help educate health care providers and public health practitioners, and ensure optimal health for HIV-positive women.

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