Journal article
Rural Residence Is Associated With Delayed Care Entry and Increased Mortality Among Veterans With Human Immunodeficiency Virus Infection
Medical care, Vol.48(12), pp.1064-1070
12/2010
DOI: 10.1097/MLR.0b013e3181ef60c2
PMCID: PMC3138500
PMID: 20966783
Abstract
Context:
Rural persons with human immunodeficiency virus (HIV) face many barriers to care, but little is known about rural-urban variation in HIV outcomes.
Objective:
To determine the association between rural residence and HIV outcomes.
Design, Setting, and Patients:
Retrospective cohort study of mortality among persons initiating HIV care in Veterans Administration (VA) during 1998–2006, with mortality follow-up through 2008. Rural residence was determined using Rural Urban Commuting Area codes. We identified 8489 persons initiating HIV care in VA with no evidence of combination antiretroviral therapy (cART) use at care entry, of whom 705 (8.3%) were rural.
Outcome Measure:
All-cause mortality.
Results:
At care entry, rural persons were less likely than urban persons to have drug use problems (10.6% vs. 19.5%, P < 0.001) or hepatitis C (34.3% vs. 41.2%, P = 0.001), but had more advanced HIV infection (median CD4: 186 vs. 246, P < 0.001). By 2 years after care entry, 5874 persons had initiated cART (528 rural [74.9%] and 5346 urban [68.7%], P = 0.001), and there were 1022 deaths (108 rural [15.3%] and 914 urban [11.7%], P = 0.004). The mortality hazard ratio for rural persons compared with urban was 1.34 (95% confidence interval: 1.05–1.69). The hazard ratio decreased to 1.18 (95% confidence interval: 0.93–1.50) after adjustment for HIV severity (CD4 and AIDS-defining illnesses) at care entry, and was 1.17 (95% confidence interval: 0.92–1.50) in a model adjusting for age, HIV severity at care entry, substance use, hepatitis B or C diagnoses, and cART initiation.
Conclusions:
Later entry into care drives increased mortality for rural compared with urban veterans with HIV. Future studies should explore the person, care system, and community-level determinants of late care entry for rural persons with HIV.
Details
- Title: Subtitle
- Rural Residence Is Associated With Delayed Care Entry and Increased Mortality Among Veterans With Human Immunodeficiency Virus Infection
- Creators
- Michael Ohl - VA Office of Rural Health (ORH), Midwest Rural Health Resource Center, Iowa City VAMC, Iowa City, IAJanet Tate - Veterans Aging Cohort Study, VA Connecticut Healthcare System, West Haven, CTMona Duggal - Veterans Aging Cohort Study, VA Connecticut Healthcare System, West Haven, CTMelissa Skanderson - Veterans Aging Cohort Study, VA Connecticut Healthcare System, West Haven, CTMatthew Scotch - Center for Medical Informatics, Yale University, New Haven, CTPeter Kaboli - VA Office of Rural Health (ORH), Midwest Rural Health Resource Center, Iowa City VAMC, Iowa City, IAMary Vaughan-Sarrazin - VA Office of Rural Health (ORH), Midwest Rural Health Resource Center, Iowa City VAMC, Iowa City, IAAmy Justice - Veterans Aging Cohort Study, VA Connecticut Healthcare System, West Haven, CT
- Resource Type
- Journal article
- Publication Details
- Medical care, Vol.48(12), pp.1064-1070
- DOI
- 10.1097/MLR.0b013e3181ef60c2
- PMID
- 20966783
- PMCID
- PMC3138500
- NLM abbreviation
- Med Care
- ISSN
- 0025-7079
- eISSN
- 1537-1948
- Grant note
- U10 AA013566-10 || AA / National Institute on Alcohol Abuse and Alcoholism : NIAAA
- Language
- English
- Date published
- 12/2010
- Academic Unit
- Psychiatry; Health Management and Policy; Epidemiology; General Internal Medicine; Internal Medicine
- Record Identifier
- 9984063204102771
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