Jeffery Johnson Burack and Sisneros Silver Mallory, Alta Bates Summit Medical Foundation

Ensuring timely access to care for persons living with HIV is a public health imperative in industrialized countries. Highly active antiretroviral therapy (HAART) has proved to be highly effective in delaying AIDS onset and has led to substantial reductions in AIDS incidence and mortality. However, despite the widespread availability of HAART in the United States, including through the AIDS Drug Assistance Program, Medicare and Medicaid, over 44,000 new AIDS cases were reported in 2002. Initiating medical care late in the course of HIV infection is associated with greater morbidity and mortality, and with poorer response to HAART. Persons with unrecognized or untreated HIV infection are at higher risk of transmitting it to others. Race, poverty, language, concerns about stigmatization, and lack of awareness of risk may be factors associated with late presentation for HIV treatment. Identification of patient characteristics associated with late presentation for care is therefore crucial to developing targeted interventions aimed at mobilizing early entrance into HIV care, improving health outcomes and quality of life, and reducing disparities in HIV disease burden.

We propose to investigate characteristics associated with delays in seeking HIV care and in initiation of HIV treatment among patients of the East Bay AIDS Center and the Alameda County Medical Center's HIV Services Division. In collaboration with colleagues at the Center for AIDS Prevention Studies, we will design, develop and field a survey on risk factors for late resentation, demographics, and beliefs, attitudes and concerns related to HIV treatment and care. The survey will be preceded by interviews and focus groups to identify key themes and patterns in our East Bay community related to HIV testing and care. This qualitative data will provide a comprehensive narrative of the issues related to delays in seeking and accessing HIV care, and will inform survey design. The resulting survey will be followed by chart review to retrieve CD4 lymphocyte count, HIV-1 viral burden, clinical stage at first presentation, and subsequent treatment course, including timing of initiation of HAART.

Specifically, we propose a cross-sectional survey of persons presenting for initiation of HIV medical care in which our principal objectives will be:

  1. To identify risk factors associated with low CD4 cell count at first presentation for clinical consultation.
  2. To estimate the time intervals between acquisition of infection, awareness of risk or illness, HIV testing, presentation for medical treatment, and initiation of HAART in our cohort.
  3. To determine which factors (socio-demographic, self-awareness, perception of HIV risk, perceived obstacles to care, etc.) contribute to prolonging these intervals.
  4. To provide case study profiles of individuals at high risk for late presentation for HIV treatment among a diverse, urban HIV-positive population in California.

We hope to generate a model of how social and contextual factors mediate the impact of HIV, and through that model to find ways to allow our patients and community to maximally benefit from the enormous advances in HIV prevention and treatment. Completing this project will build the internal resources and experience of EBAC and ACMC personnel, open new opportunities for collaboration, and better enable us to design, secure funding for, and carry out future innovative HIV/AIDS-related sociobehavioral research.