Abstract
We interviewed 1038 HIV-positive inpatients in public hospitals in Miami, Florida, and Atlanta, Georgia, to examine patient factors associated with use of HIV care, use of antiretroviral therapy, and unprotected sexual intercourse. Multivariate analyses and multiple logistic regression models showed that use of crack cocaine and heavy drinking were associated with never having had an HIV-care provider, high-risk sexual behavior, and not receiving antiretroviral therapy. Inpatient interventions that link and retain HIV-positive persons in primary care services could prevent HIV transmission and unnecessary hospitalizations.
Approximately one third of HIV-infected persons wait to seek care until their disease has progressed enough that they need acute treatment.1,2 These persons obtain care in emergency departments and hospital inpatient wards, and they tend not to be retained in HIV outpatient care. Patients hospitalized for HIV-related complications are more likely to have advanced disease3 and high viral loads, putting them at increased risk of transmitting HIV to their sexual and drug-using partners.4 Thus, hospitals provide a potentially valuable setting for connecting HIV-infected patients to care and prevention services. To examine patient factors associated with engagement in high-risk sexual behaviors and utilization of HIV care, we conducted interviews with hospitalized HIV-infected patients in 2 large inner-city public hospitals.
METHODS
We conducted interviews with 1038 HIV-infected patients admitted to Jackson Memorial Hospital (Miami, FL) and Grady Memorial Hospital (Atlanta, GA) for HIV-related complications or associated illnesses during 2006 and 2007. Interviews were part of the screening process for Project HOPE (Hospitalized HIV-Infected Patients: A Population of Concern in the Era of HAART), a randomized controlled intervention trial designed to test a brief prevention intervention for HIV-positive crack cocaine users. We interviewed patients who were deemed medically and mentally stable by the attending physician and who provided verbal informed consent.
For our study, our dependent measures were (1) whether respondents had ever seen an HIV primary care provider, (2) whether respondents were currently using highly active antiretroviral therapy (HAART), and (3) whether respondents had unprotected sexual intercourse within the previous 6 months with a partner who was HIV negative or whose HIV status was unknown. We conducted univariate and bivariate analyses, and then we developed multiple logistic regression models to identify factors associated with the dependent measures.
RESULTS
The study population was mostly male (62%), 40 years or older (71%), and African American (82%); 40% did not graduate high school, 56% reported annual incomes of less than $5000, 19% reported living on the streets or in a shelter, 34% reported crack cocaine use, and 32% reported heavy alcohol use. The majority (68%) had received their HIV diagnosis more than 5 years ago. A substantial minority (20%) had never seen an HIV primary care provider, 40% had not seen an HIV primary care provider in the previous 6 months, 42% were taking antiretroviral therapy, and 10% reported high-risk sexual activity (Table 1).
TABLE 1.
Patient Factors Associated With HIV Care, HIV Medication, and Unprotected Sex Among HIV-Positive Inpatients (N = 1038): Miami, FL, and Atlanta, GA, 2006–2007
| Never Had an HIV Care Provider |
Currently Taking Medicine Specifically for HIV |
Unprotected Sex With HIV-Negative or Unknown-Status Partnera |
||||
| Percentage | P | Percentage | P | Percentage | P | |
| Total | 19.7 | … | 42.1 | … | 10.0 | … |
| Age,b y | .973 | <.001 | <.001 | |||
| < 40 | 19.7 | 34.2 | 14.8 | |||
| ≥40 | 19.6 | 45.4 | 8.0 | |||
| Gender | .050 | .964 | .001 | |||
| Men | 21.4 | 42.3 | 8.1 | |||
| Women | 16.4 | 42.2 | 13.1 | |||
| Race | .091 | .015 | .428 | |||
| Other | 15.3 | 50.0 | 11.6 | |||
| Black | 20.7 | 40.4 | 9.7 | |||
| Crack use in previous 6 mo | <.001 | <.001 | .002 | |||
| No | 15.9 | 47.7 | 8.0 | |||
| Yes | 26.9 | 31.6 | 14.0 | |||
| Heavy alcohol use in previous 6 mo | .003 | <.001 | .002 | |||
| No | 17.1 | 48.3 | 8.0 | |||
| Yes | 25.0 | 29.2 | 14.3 | |||
| Time since HIV diagnosis, y | <.001 | .012 | .093 | |||
| < 5 | 34.4 | 36.3 | 12.5 | |||
| 5–12 | 12.2 | 44.2 | 10.1 | |||
| > 12 | 11.6 | 47.3 | 7.4 | |||
| Annual income, $ | <.001 | .246 | .721 | |||
| ≥ 5000 | 14.1 | 44.0 | 10.5 | |||
| < 5000 | 24.0 | 40.4 | 9.8 | |||
| Education | .080 | .045 | .103 | |||
| Less than high school diploma | 22.3 | 38.3 | 11.9 | |||
| High school diploma or more | 17.9 | 44.6 | 8.8 | |||
| Living on the street or in a shelter | <.001 | <.001 | .983 | |||
| No | 16.9 | 45.1 | 10.0 | |||
| Yes | 31.0 | 30.0 | 10.0 | |||
| Has responsibility for children younger than 18 y | .502 | .789 | .902 | |||
| No | 20.1 | 41.9 | 10.0 | |||
| Yes | 17.9 | 43.1 | 10.2 | |||
| Incarcerated in the previous 6 mo | <.001 | .003 | .229 | |||
| No | 17.7 | 43.9 | 9.6 | |||
| Yes | 32.1 | 30.7 | 12.8 | |||
| Received HIV primary care in previous 6 mo | … | <.001 | .173 | |||
| No | … | 17.5 | 11.5 | |||
| Yes | … | 58.7 | 8.9 | |||
| Currently taking HIV medicine | <.001 | … | .001 | |||
| No | 28.3 | … | 12.7 | |||
| Yes | 7.8 | … | 6.4 | |||
| Ever injected drugs | .716 | .919 | .218 | |||
| No | 19.5 | 42.1 | 10.5 | |||
| Yes | 20.7 | 42.5 | 7.5 | |||
| Used marijuana in previous 6 mo | .031 | <.001 | .899 | |||
| No | 18.1 | 45.3 | 9.9 | |||
| Yes | 24.4 | 32.5 | 10.2 | |||
| Had sex in previous 6 mo | .578 | <.001 | … | |||
| No | 19.2 | 47.2 | … | |||
| Yes | 20.6 | 34.5 | … | |||
| Unprotected sex with HIV-negative or unknown-status partner in previous 6 mo | .050 | .001 | … | |||
| No | 18.9 | 43.8 | … | |||
| Yes | 26.9 | 26.9 | … | |||
| Diagnosed with a sexually transmitted disease in previous 12 mo | .414 | .386 | .272 | |||
| No | 19.2 | 42.7 | 9.4 | |||
| Yes | 22.5 | 38.2 | 12.7 | |||
| Ever had drug treatment | .267 | .036 | .001 | |||
| No | 20.6 | 44.4 | 7.9 | |||
| Yes | 17.7 | 37.5 | 14.4 | |||
Note. Ellipses indicate that the data is not applicable.
In the previous 6 months.
Mean age was 44.0 years (SD = 9.2).
There were significant results in each of the 3 regression models (Table 2). Crack use, heavy alcohol use, low income, and unstable housing were among the factors associated with the dependent measures.
TABLE 2.
Odds of Never Having Seen an HIV Care Provider, Currently Taking Medicine Specifically for HIV, and Unprotected Sex with HIV-Negative or Unknown-Status Partner Among HIV-Positive Inpatients (N = 1038): Miami, FL, and Atlanta, GA, 2006–2007
| Never Had an HIV Care Provider, AOR (95% CI) | Currently Taking Medicine Specifically for HIV, AOR (95% CI) | Unprotected Sex With HIV-Negative or Unknown-Status Partner,a AOR (95% CI) | |
| Age (continuous)b | 0.994 (0.976, 1.013) | 1.030 (1.015, 1.045) | 0.973 (0.951, 0.997) |
| Maleb | 1.487 (1.037, 2.132) | 0.986 (0.749, 1.299) | 0.556 (0.362, 0.852) |
| Blackb | 1.332 (0.84, 2.111) | 0.700 (0.498, 0.985) | 0.618 (0.364, 1.051) |
| Crack use in previous 6 mo | 1.573 (1.082, 2.286) | 0.688 (0.509, 0.930) | 1.660 (1.067, 2.582) |
| Heavy alcohol use in previous 6 mo | 1.488 (1.045, 2.119) | 0.520 (0.387, 0.699) | 1.571 (1.014, 2.435) |
| Time since HIV diagnosis, y | |||
| < 5 | 1.000 | 1.000 | |
| 5–12 | 0.304 (0.206, 0.449) | 1.268 (0.921, 1.745) | … |
| > 12 | 0.209 (0.135, 0.322) | 1.621 (1.166, 2.252) | … |
| Living on the street in a shelter | 1.827 (1.217, 2.741) | 0.545 (0.377, 0.787) | … |
| Annual income less than $5000 | 1.814 (1.258, 2.616) | … | … |
| Unprotected sex with HIV-negative or unknown-status partner | … | 0.578 (0.359, 0.931) | … |
| Currently taking HIV medicine | … | … | 0.565 (0.353, 0.905) |
Note. AOR = adjusted odds ratio; CI = confidence interval. Ellipses indicate nonsignificance.
In the previous 6 months.
Forced into model.
DISCUSSION
These data suggest that hospitalized HIV-positive people are frequently not linked to or retained in HIV care and exhibit high-risk behaviors that may enhance transmission of HIV to others. Patients reporting these high-risk sexual behaviors were less likely to be currently receiving HAART; thus, they were more likely to have high viral loads, and they may have been at higher risk of transmitting HIV to their sexual and drug-using partners.4
In addition to HIV, this patient population has a myriad of psychosocial problems, including low socioeconomic status, substance abuse, mental health problems, unstable housing, a high rate of sexually transmitted infections, and health complications related to their HIV disease.5–8 Because these individuals have multiple needs, it is critical to expand intervention services in the hospital setting, where more services can be delivered. These data also highlight the need to strengthen efforts to ensure that HIV-infected persons are retained in primary care soon after their HIV diagnosis, to prevent future hospitalizations.
We found that crack cocaine use and heavy alcohol use were associated with decreased use of HIV care and higher rates of risky sexual behaviors, results that are consistent with other studies.9–16 It has been suggested that the cycle of crack cocaine use followed by drug-seeking activities makes it difficult to adhere to antiretroviral medication regimens or instructions given by an HIV primary care provider.7,17 We also found that having unstable housing and having an annual income of less than $5000 were related to never having seen an HIV primary care provider and not currently receiving HAART. Homelessness and poverty have been shown to be common barriers to utilization of HIV care.18,19 However, structural interventions such as case management and the provision of housing can improve the everyday lives of this population,20–22 and our findings emphasize the need for interventions such as these.
Our study was limited by the exclusion of patients who only spoke Spanish, although this population was small at both hospitals.23 Also, these data were self-reported, which may mean that stigmatized behaviors were underreported. Alternatively, some patients may have overreported stigmatized behaviors so they would qualify for enrollment in the intervention study. Finally, our sample was typical of a US inner-city population, so generalizations to hospital populations in rural areas or in other countries should be made with caution.
Our findings suggest that HIV-positive persons whose main contact with the health care system occurs during hospitalization may benefit from hospital-based interventions, such as brief case management, that are designed to link them to and retain them in care and prevention services. These data also point to the need for novel interventions to ensure that people are retained in care early in the course of their HIV disease so they can benefit from the life-prolonging medications offered in the HAART era.
Acknowledgments
This study was funded by the National Institutes of Health/National Institute on Drug Abuse (grant R01 DA017612) and was supported in part by the Emory Center for AIDS Research (grant 2P30AI050409), and the University of Miami Developmental Center for AIDS Research (grant P30AI073961).
Authors would also like to acknowledge other members of the HOPE study team: Virginia Locascio, Cheryl Riles, Richard Walker, Sandra Edwards, Faye Yeomans, Mary Yohannan, Ossie Williams, Elizabeth Scharf, Jessica Kaplan, and Alexandra Marquez.
Note. All authors declare that they have no conflicts of interest nor received financial or material support.
Human Participant Protection
All research was reviewed and approved by the University of Miami institutional review board, the Western institutional review board, and the Emory University institutional review board, as well as the research oversight committees of Jackson Memorial Hospital and Grady Memorial Hospital.
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