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PLoS One. 2016 Jan 11;11(1):e0146119. doi: 10.1371/journal.pone.0146119. eCollection 2016.

Geographic Variations in Retention in Care among HIV-Infected Adults in the United States.

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  • 1Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America.
  • 2Johns Hopkins University, Baltimore, Maryland, United States of America.
  • 3Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland, United States of America.
  • 4University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
  • 5British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.
  • 6University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America.
  • 7University of Washington School of Medicine, Seattle, Washington, United States of America.



To understand geographic variations in clinical retention, a central component of the HIV care continuum and key to improving individual- and population-level HIV outcomes.


We evaluated retention by US region in a retrospective observational study.


Adults receiving care from 2000-2010 in 12 clinical cohorts of the North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) contributed data. Individuals were assigned to Centers for Disease Control and Prevention (CDC)-defined regions by residential data (10 cohorts) and clinic location as proxy (2 cohorts). Retention was ≥2 primary HIV outpatient visits within a calendar year, >90 days apart. Trends and regional differences were analyzed using modified Poisson regression with clustering, adjusting for time in care, age, sex, race/ethnicity, and HIV risk, and stratified by baseline CD4+ count.


Among 78,993 adults with 444,212 person-years of follow-up, median time in care was 7 years (Interquartile Range: 4-9). Retention increased from 2000 to 2010: from 73% (5,000/6,875) to 85% (7,189/8,462) in the Northeast, 75% (1,778/2,356) to 87% (1,630/1,880) in the Midwest, 68% (8,451/12,417) to 80% (9,892/12,304) in the South, and 68% (5,147/7,520) to 72% (6,401/8,895) in the West. In adjusted analyses, retention improved over time in all regions (p<0.01, trend), although the average percent retained lagged in the West and South vs. the Northeast (p<0.01).


In our population, retention improved, though regional differences persisted even after adjusting for demographic and HIV risk factors. These data demonstrate regional differences in the US which may affect patient care, despite national care recommendations.

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