Comparable Sustained Virologic Suppression Between Community- and Academic-based HIV Care Settings

Purpose: The human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome epidemic in the United States is evolving because of factors such as aging and geographic diffusion. Provider shortages are also driving the restructuring of HIV care delivery away from specialized settings, and family medicine providers may play a larger role in the future. We attempted to compare the effectiveness of HIV treatment delivered at community versus hospital care settings. Methods: The outcome of interest was sustained virologic suppression defined as 2 consecutive HIV-1 RNA measurements <400 copies/mL within 1 year after antiretroviral initiation. We used data from the multistate HIV Research Network cohort to compare sustained virologic suppression outcomes among 15,047 HIV-infected adults followed from 2000 to 2008 at 5 community-and 8 academic hospital-based ambulatory care sites. Community-based sites were mostly staffed by family medicine and general internal medicine physicians with HIV expertise, whereas hospital sites were primarily staffed by infectious disease subspecialists. Multivariate mixed effects logistic regression controlling for potential confounding variables was applied to account for clustering effects of study sites. Results: In an unadjusted analysis the rate of sustained virologic suppression was significantly higher among subjects treated in community-based care settings: 1,646 of 2,314 (71.1%) versus 8,416 of 12,733 (66.1%) (P < .01). In the adjusted multivariate model with potential confounding variables, the rate was higher, although not statistically significant, in the community-based settings (adjusted odds ratio, 1.26; 95% confidence interval, 0.73-2.16). Conclusion: Antiretroviral therapy can be delivered effectively through community-based treatment settings. This finding is potentially important for new program development, shifting HIV care into community-based settings as the landscape of accountable care, health reform, and HIV funding and resources evolves.