Send to

Choose Destination
HIV Med. 2018 Jul;19(6):386-394. doi: 10.1111/hiv.12604. Epub 2018 Apr 14.

The use of funnel plots with regression as a tool to visually compare HIV treatment outcomes between centres adjusting for patient characteristics and size: a UK Collaborative HIV Cohort study.

Author information

Southmead Hospital, North Bristol NHS Trust, Department of Immunology, Bristol, UK.
School of Mathematics, University of Bristol, Bristol, UK.
Research Department of Infection and Population Health, Institute for Global Health, University College London, London, UK.
National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections at University College London, London, UK.
HIV i-Base, London, UK.
Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions at University of Bristol, Bristol, UK.



A measure used for assessing the effectiveness of HIV care and comparing clinical centres is the proportion of people starting antiretroviral therapy (ART) with viral suppression (VS) after 1 year. We propose a method that adjusts for patients' demographic characteristics, and visually compares this measure between different sites accounting for centre size.


We analysed viral load measurements for UK Collaborative HIV Cohort (UK CHIC) patients starting ART between 2006 and 2013. We used logistic regression to estimate the proportion with VS after 1 year of ART adjusted for patient mix (in terms of age and a combined gender/ethnicity/acquisition mode variable) and calendar year. We compared outcomes between centres using funnel plots which account for centre size.


The overall proportion of the cohort with VS 1 year after starting ART was 90% and increased from 83% to 93% between 2006 and 2013. VS was lower in younger individuals. White men who have sex with men (MSM) had the highest (94%), and black African (81%) and white (82%) heterosexual women the lowest proportions achieving VS. Comparing the unadjusted funnel plot with the adjusted, there were movements of some centres from outside to inside the 95% contour limits, which was largely explained by the patient mix of these centres.


VS 1 year after ART start was associated with demographic characteristics and centre size; therefore, to compare the performances of centres, adjustment for these factors is required. Adjusted funnel plot is an effective tool which accounts for both the demographic characteristics and the centre size. Social factors, rather than treatment decisions within the control of the centres, may drive differences in outcomes.


HIV; antiviral therapy; funnel plot; quality of care; viral suppression

Supplemental Content

Full text links

Icon for Wiley Icon for PubMed Central
Loading ...
Support Center