AIDS and Behavior

, Volume 17, Issue 1, pp 174–180

Antiretroviral Adherence Among Rural Compared to Urban Veterans with HIV Infection in the United States

  • Michael E. Ohl
  • Eli Perencevich
  • D. Keith McInnes
  • Nancy Kim
  • David Rimland
  • Kathleen Akgun
  • David A. Fiellin
  • Melissa Skanderson
  • Karen Wang
  • Amy Justice
Original Paper

Abstract

Rural-dwelling persons with HIV infection face barriers to maintaining high levels of antiretroviral adherence. We compared adherence among 1,782 rural and 18,519 urban veterans initiating antiretroviral therapy in the Veterans Affairs (VA) healthcare system in the United States between 1998 and 2007. Residence was determined using rural urban commuting area codes and adherence using pharmacy-based refill measures. The median proportion of days covered (PDC) by combination antiretroviral therapy in the first year of treatment ranged from 0.72 among urban residents to 0.79 among rural-small town/remote residents (p < 0.0001). In multivariable logistic regression, predictors of high adherence (PDC greater than 0.90) were residence in a rural-small town/remote setting (odds ratio 1.24, 95 % CI 1.09–1.56, relative to urban), increasing age, white race, absence of an alcohol or substance use disorder, and absence of hepatitis C infection. Results may differ outside VA healthcare, where there may be fewer resources to support adherence among rural-dwelling persons with HIV.

Keywords

HIV Rural health Medication adherence Veterans 

Resumen

Las personas con la infección del HIV que habitan en áreas rurales se enfrentan para mantener los altos niveles de adherencia antirretroviral. Comparamos la adherencia entre 1,782 veteranos rurales y 18,519 veteranos urbanos que iniciaron la Terapia Antirretroviral con el Sistema de Salud para Veteranos “Veterans Affairs” (VA) en Los Estados Unidos entre los años 1998 y 2007. El tipo de residencia fue determinado de acuerdo a los códigos del Rural Urban Commuting Area y la adherencia usando las medidas en las que se basan las farmacias para medir los resurtidos de medicamentos. El porcentaje medio de los días cubiertos (PDC) y la combinación con la Terapia de Antirretroviral en el primer año de tratamiento estuvo en el rango de 0.72 entre los residentes urbanos y 0.79 entre los residentes rurales y residentes de pueblos remotos y pequeños (p < 0,0001). En la regresión logística multivariable, predictores de alta adherencia (PDC mayor de 0.90) fueron los residentes de áreas rurales remotas y pueblos pequeños (Posible Radio 95 % CI 1.09–1.56, con relación a los del área urbana), el aumento de la edad, la raza blanca, ausencia de trastornos de alcohol o el uso de sustancias y la ausencia de la infección de la Hepatitis C. Los resultados pueden diferir fuera de el sistema de salud (VA), donde pueden existir menos recursos para apoyar la adherencia entre las personas con VIH que viven en áreas rurales.

References

  1. 1.
    Bhaskaran K, Hamouda O, Sannes M, et al. Changes in the risk of death after HIV seroconversion compared with mortality in the general population. JAMA. 2008;300(1):51–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Nieuwkerk PT, Gisolf EH, Reijers MH, et al. Long-term quality of life outcomes in three antiretroviral treatment strategies for HIV-1 infection. AIDS. 2001;15(15):1985–91.PubMedCrossRefGoogle Scholar
  3. 3.
    Antiretroviral Therapy Cohort Collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet. 2008;372(9635):293–9.CrossRefGoogle Scholar
  4. 4.
    Cases of HIV infection and AIDS in urban and rural areas of the United States, 2006. Centers for Disease Control and Prevention. 2-3-2012.Google Scholar
  5. 5.
    Lahey T, Lin M, Marsh B, et al. Increased mortality in rural patients with HIV in New England. AIDS Res Hum Retroviruses. 2007;23(5):693–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Ohl M, Tate J, Duggal M, et al. Rural residence is associated with delayed care entry and increased mortality among veterans with human immunodeficiency virus infection. Med Care. 2010;48(12):1064–70.PubMedCrossRefGoogle Scholar
  7. 7.
    Heckman TG, Somlai AM, Peters J, et al. Barriers to care among persons living with HIV/AIDS in urban and rural areas. AIDS Care. 1998;10(3):365–75.PubMedCrossRefGoogle Scholar
  8. 8.
    Reif S, Golin CE, Smith SR. Barriers to accessing HIV/AIDS care in North Carolina: rural and urban differences. AIDS Care. 2005;17(5):558–65.PubMedCrossRefGoogle Scholar
  9. 9.
    Heckman TG, Somlai AM, Kalichman SC, Franzoi SL, Kelly JA. Psychosocial differences between urban and rural people living with HIV/AIDS. J Rural Health. 1998;14(2):138–45.PubMedCrossRefGoogle Scholar
  10. 10.
    Heckman BD, Catz SL, Heckman TG, Miller JG, Kalichman SC. Adherence to antiretroviral therapy in rural persons living with HIV disease in the United States. AIDS Care. 2004;16(2):219–30.PubMedCrossRefGoogle Scholar
  11. 11.
    Ohl M, Lund B, Belperio PS, Goetz MB, Rimland D, Richardson K, Justice A, Perencevich E, Vaughan-Sarrazin M. Rural residence and adoption of a novel HIV therapy in a national, equal-access healthcare system. AIDS Behav. 2011 Dec 29. [Epub ahead of print].Google Scholar
  12. 12.
    Public Health Strategic Healthcare Group. The state of care for veterans with HIV/AIDS. 1-1-2009. Department of Veterans Affairs.Google Scholar
  13. 13.
    Braithwaite RS, Kozal MJ, Chang CC, et al. Adherence, virological and immunological outcomes for HIV-infected veterans starting combination antiretroviral therapies. AIDS. 2007;21(12):1579–89.PubMedCrossRefGoogle Scholar
  14. 14.
    Grossberg R, Zhang Y, Gross R. A time-to-prescription-refill measure of antiretroviral adherence predicted changes in viral load in HIV. J Clin Epidemiol. 2004;57(10):1107–10.PubMedCrossRefGoogle Scholar
  15. 15.
    Fultz SL, Skanderson M, Mole LA, et al. Development and verification of a “virtual” cohort using the National VA Health Information System. Med Care. 2006;44(8 Suppl 2):S25–30.PubMedCrossRefGoogle Scholar
  16. 16.
    Cowper DC, Kubal JD, Maynard C, Hynes DM. A primer and comparative review of major US mortality databases. Ann Epidemiol. 2002;12(7):462–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Rural Urban Commuting Area Codes. WWAMI Rural Health Research Center. http://depts.washington.edu/uwruca/ruca-data.php. Accessed 12 January 2011.
  18. 18.
    Hart LG, Larson EH, Lishner DM. Rural definitions for health policy and research. Am J Public Health. 2005;95(7):1149–55.PubMedCrossRefGoogle Scholar
  19. 19.
    Steiner JF, Koepsell TD, Fihn SD, Inui TS. A general method of compliance assessment using centralized pharmacy records. Description and validation. Med Care. 1988;26(8):814–23.PubMedCrossRefGoogle Scholar
  20. 20.
    Justice AC, Lasky E, McGinnis KA, et al. Medical disease and alcohol use among veterans with human immunodeficiency infection: a comparison of disease measurement strategies. Med Care. 2006;44(8 Suppl 2):S52–60.PubMedCrossRefGoogle Scholar
  21. 21.
    Kressin NR, Chang BH, Hendricks A, Kazis LE. Agreement between administrative data and patients’ self-reports of race/ethnicity. Am J Public Health. 2003;93(10):1734–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Gross R, Zhang Y, Grossberg R. Medication refill logistics and refill adherence in HIV. Pharmacoepidemiol Drug Saf. 2005;14(11):789–93.PubMedCrossRefGoogle Scholar
  23. 23.
    Nelson RE, Hicken B, West A, Rupper R. The effect of increased travel reimbursement rates on health care utilization in the VA. J Rural Health. 2012;28(2):192–201.PubMedCrossRefGoogle Scholar
  24. 24.
    Justice AC, Dombrowski E, Conigliaro J, et al. Veterans Aging Cohort Study (VACS): overview and description. Med Care. 2006;44(8 Suppl 2):S13–24.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York (outside the USA) 2012

Authors and Affiliations

  • Michael E. Ohl
    • 1
    • 2
    • 3
  • Eli Perencevich
    • 1
    • 2
    • 3
  • D. Keith McInnes
    • 4
    • 5
  • Nancy Kim
    • 6
  • David Rimland
    • 7
  • Kathleen Akgun
    • 6
  • David A. Fiellin
    • 6
  • Melissa Skanderson
    • 6
  • Karen Wang
    • 6
  • Amy Justice
    • 6
  1. 1.VA Office of Rural Health (ORH)Veterans Rural Health Resource Center-Central Region, Iowa City VA Medical CenterIowa CityUSA
  2. 2.Center for Comprehensive Access and Delivery Research and Evaluation (CADRE)Iowa City VA Medical CenterIowa CityUSA
  3. 3.Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityUSA
  4. 4.Center for Health Quality Outcomes and Economic ResearchENRM VA Medical CenterBedfordUSA
  5. 5.Department of Health Care PolicyBoston University School of Public HealthBostonUSA
  6. 6.Yale University Schools of Medicine and Public Health, VA Connecticut Healthcare SystemNew HavenUSA
  7. 7.Atlanta VAMC and Emory University School of MedicineAtlantaUSA

Personalised recommendations