The Vermont Model for Rural HIV Care Delivery: Eleven Years of Outcome Data Comparing Urban and Rural Clinics

Context: Provision of human immunodeficiency virus (HIV) care in rural areas has encountered unique barriers. Purpose: To compare medical outcomes of care provided at 3 HIV specialty clinics in rural Vermont with that provided at an urban HIV specialty clinic. Methods: This was a retrospective cohort study. Findings: Over an 11-year period 363 new patients received care, including 223 in the urban clinic and 140 in the rural clinics. Patients in the 2 cohorts were demographically similar and had similar initial CD4 counts and viral loads. There was no difference between the urban and rural clinic patients receiving Pneumocystis carinii prophylaxis (83.5% vs 86%, P = .38) or antiretroviral therapy (96.8% vs 97.5%, P = .79). Both rural and urban cohorts had similar decreases in median viral load from 1996 to 2006 (3,876 copies/mL to < 50 copies/mL vs 8,331 copies/mL to < 50 copies/mL) and change in percent of patients suppressed to < 400 copies/mL (21.4%-69.3% vs 16%-71.4%, P = .11). Rural and urban cohorts had similar increases in median CD4 counts (275/mm3-350/mm3 vs 182 cells/mm3-379/mm3). A repeated measures regression analysis showed that neither fall in viral load (P = .91) nor rise in CD4 count (P = .64) were associated with urban versus rural site of care. Survival times, using a Cox proportional hazards model, were similar for urban and rural patients (hazard ratio for urban = 0.80 [95% CI, 0.39-1.61; P = .53]). Conclusions: This urban outreach model provides similar quality of care to persons receiving care in rural areas of Vermont as compared to those receiving care in the urban center.