High Churn Rate in US South Impacts HIV Viral Suppression

Some 15.3% of patients with human immunodeficiency virus (HIV) showed a cycle of engaging and disengaging in care, or “churn,” over a median 3.3 years at a large urban clinic in Atlanta, Georgia. Researchers published their findings in Open Forum Infectious Diseases.

“The rate of churn in a southern US clinic was high, and those who experienced churn had increased transmissible viremia at reentry and disproportionately contributed to the community viral load and likely contributing to ongoing HIV transmission,” wrote corresponding author Srinivasa Nithin Gopalsamy, MD, of the Emory University Department of Medicine, and coauthors.

The retrospective cohort study included 1303 people with HIV who sought outpatient care at the Grady Infectious Disease Program clinic between 2012 and 2017. Researchers defined churn as a 12 month or longer gap between clinic visits or viral load measurements.

In addition to identifying an overall churn rate of 15.3% in the cohort, the study found that patients who experienced churn had worse HIV metrics at reengagement compared with before the care gap. The transmissible viremia rate increased from 28.6% to 66.2%, while the rate of viral suppression decreased from 62.3% to 28.3%.

Among patients who experienced churn and had transmissible viremia at reengagement, the median time to subsequent viral suppression was longer (153.5 days) than patients who did not experience churn (84 days). Additionally, patients returning to care contributed disproportionately to community viral load.

“Using 2017 as a representative year of this analysis, churn patients accounted for 7.3% of the community viral load while comprising only 3.7% of the clinic population, resulting in a ratio of 1.96,” researchers wrote.

Churn was not linked with a significantly increased risk of subsequent churn or loss to follow-up, however, compared with patients newly establishing care.

“Ultimately, the HIV epidemic reflects a series of regional microepidemics, and each area has unique drivers of HIV transmission,” researchers concluded. “In the southern United States, mitigating churn is necessary to reduce HIV incidence and move closer to ending the HIV epidemic.”

Reference:
Gopalsamy SN, Shah NS, Marconi VC, et al. The impact of churn on HIV outcomes in a Southern United States clinical cohort. Open Forum Infect Dis. 2022;9(7):ofac338. doi:10.1093/ofid/ofac338