and community-level predictors and mediators of suboptimal hiv primary care appointment ...

239 Pages·2013·3.14 MB·English

EXPLORING INDIVIDUAL- AND COMMUNITY-LEVEL PREDICTORS AND
MEDIATORS OF SUBOPTIMAL HIV PRIMARY CARE APPOINTMENT ADHERENCE:
THE IMPORTANCE OF PLACE

by
D. SCOTT BATEY

DAVID E. POLLIO, COMMITTEE CHAIR
CAROL DROLEN
MICHAEL J. MUGAVERO
JOSEPH E. SCHUMACHER
BRENDA SMITH

A DISSERTATION

Submitted in partial fulfillment of the requirements
for the degree of Doctor of Philosophy
in the School of Social Work
in the Graduate School of
The University of Alabama

TUSCALOOSA, ALABAMA

2013
Copyright David Scott Batey 2013
ALL RIGHTS RESERVED
ABSTRACT
The advent of highly active antiretroviral therapy (HAART) for the treatment of human
immunodeficiency virus (HIV) has provided prolonged viral suppression and an extended quality
of life for HIV-infected persons. Research focusing on factors associated with suboptimal HIV
medication adherence has been the principal antecedent to more contemporary research
suggesting that absolute adherence to HIV primary care appointments is vitally important to
achieve successful clinical management of the disease, as well, and missed visits have been
independently associated with HIV virologic failure when other factors are controlled.
Generally speaking, research examining the role of community correlates in shaping
behaviors is somewhat scant in the HIV treatment literature. Existing research suggests that
HIV-infected persons may experience unique patterns of negative health outcomes, such as
quality of life, access to and retention in treatment, and morbidity. It stands to reason that these
patterns may be the result of certain characteristics of many communities that are conducive to
poor health, in general, such as low high school graduation rates, high rates of un- and
underemployment, substandard housing, and extensive poverty.
This study, conducted in two distinct phases, involves secondary data analysis of
individual-level factors collected through a prospective cohort study (the 1917 Clinic Cohort)
that includes HIV positive individuals who receive primary and sub-specialty medical care at the
University of Alabama at Birmingham (UAB) 1917 Clinic. The second phase involves
investigation of community-level data (census tract- or county-level) for each participant’s
ii
residence address at the time of initial presentation to HIV primary medical care. The mediation
effect of community-level variables on the association between individual-level predictors and
linkage to and retention in care outcomes was then investigated. A non-probability, convenience
sample of HIV-infected adults initially presenting for HIV primary medical care at the UAB
1917 Clinic was selected from larger cohort studies, including the CFAR Network of Integrated
Clinical Systems (CNICS) and Project CONNECT, a local UAB 1917 Clinic new patient
orientation protocol which provides systematic linkage to HIV medical care. Study eligibility
included age 19 or over, an HIV diagnosis with a Project CONNECT interview during the study
period (7/01/09-6/30/11), normal cognitive functioning, ability to speak and communicate in
English, and self-reported residence within the State of Alabama.
The principal exposures for this study included three measures of linkage to care (a
general linkage to care measure, effective linkage to care, and efficient linkage to care) and five
measures of retention in care (appointment no show, visit adherence, visit constancy, gaps in
care, and the HRSA-HAB). All measures are widely used in the literature. Bivariate logistic
regression was used to determine relationships between individual- and community-level
independent variables and the study outcomes. To determine mediation, bivariate logistic
regression and Ordinary Least Squares (OLS) regression was used to identify associations
between individual- and community-level independent variables and measures of strain.
The study replicated existing findings in the literature that have established relationships
between individual- and community-level independent variables and linkage to and retention in
HIV primary medical care. Additionally, findings suggest that some concepts of community-
level strain—specifically, aggregate community measures of age structure, crime, and family
structure—may also predict principal outcomes. While a measure of composite strain was not
iii
found to mediate the relationship between independent variables and the study outcomes, two
aggregate strain measures (age structure and family structure) were found to mediate the
relationship between self-reported trouble remembering and HIV transmission risk, respectively,
and HIV primary medical care visit adherence.
The findings are highly relevant to social work practice, research, and policy in the
HIV/AIDS linkage to and retention in care field, and they suggest a number of future directions
to further investigate the role of the community—and community strain specifically—in
facilitating and/or preventing optimal HIV treatment.

iv
DEDICATION
Seven years is a very long time to work—days, nights, and weekends—on anything.
This seven-year journey included its ups and downs, tears in celebration and tears in despair.
The final product is a culmination of experiences that transpired directly through my work on the
dissertation, but also from those experiences that continued to occur as a part of everyday life.
For all of the patience, advice, support, and love, I dedicate this dissertation to my
partner, L. Bryan Hobson. If selfishness is a catalyst to seeing a personal goal to completion, it
was Bryan’s selflessness that allowed me to focus on this goal. Now in our 20th year together, I
owe him so much more than a dedication in a dissertation. You have been my pillar, and I look
forward to spending the rest of my days doing the same for you.
I also dedicate this work to my parents, B.J. and Virginia Batey. Your support gave me
the confidence to succeed early in life, and it continues to be unwavering as I, now more often,
need that extra push when I question my abilities. Without ever speaking the words, I learned
more about social and economic justice in our household than I could ever learn in a classroom;
your care and concern for your fellow man has played a pivotal role in this study and, in fact, in
whom I am today. My greatest regret is the loss of my dad as I entered my fourth year of this
journey; but, one of the last things he said to me was, “You must finish this dissertation. You
have invested too much.” As I put the finishing touches on this work, I miss my dad
tremendously, and I love both you and Mom very, very much.

v
LIST OF ABBREVATIONS AND SYMBOLS
ACTU AIDS Clinical Trial Unit, ACTU-4 is a measure of HIV medication
adherence

AIDS Acquired Immune Deficiency Syndrome
ART antiretroviral therapy
ARTAS Antiretroviral Treatment and Access Study
ARV antiretroviral
ASI Addiction Severity Index
ASSIST Alcohol, Smoking, and Substance Involvement Screening Test, a measure
of substance use

AUDIT-C Alcohol Use Disorders Identification Test-Hepatitis C, a measure of
alcohol use

AYP Adequate Yearly Progress, national scale of school performance
β standardized regression coefficient
CARE Comprehensive AIDS Resources Emergency, also known as the Ryan
White Act

CD4 cluster of differentiation 4; CD4 + T cells are white blood cells that are the
cornerstone of the immune system

CDC Centers for Disease Control and Prevention
CFAR Center for AIDS Research
vi
CI confidence interval
CNICS CFAR Network of Integrated Clinical Systems
CONNECT Client-Oriented New Patient Navigation to Encourage Connection to
Treatment, as in Project CONNECT

CTR counseling, testing, and referral, as in CDC’s standardized guidelines
DHHS U.S. Department of Health and Human Services
EHS education-health-services, as in types of employment
EMR electronic medical record
EuroQOL-5D European Quality of Life, quality of life instrument
FBI Federal Bureau of Investigation
FPL Federal Poverty Level
GST general strain theory
HAART highly active antiretroviral therapy
HIV human immunodefiency virus
HIVSI HIV Symptom Index, a measure of the frequency of HIV symptoms
HPTN HIV Prevention Trials Network
HRAP-R HIV Risk Assessment for Prevention-Revised, a measure of HIV risks
HRSA Health Resources and Services Administration
HRSA HAB HRSA HIV/AIDS Bureau, as in a commonly used measure of retention in
HIV primary medical care

IDU (or IVDU) intravenous drug use
IMB Information, Motivation, and Behavior, as in Fisher’s model
IRB Institutional Review Board
vii
KVP kept-visit proportion, one interpretation of the visit adherence retention in
HIV primary medical care measure

MEMS Medication Event Monitoring System
MSM men who have sex with men
MVP missed visit proportion, one interpretation of the visit adherence retention
in HIV primary medical care measure

N (or n) number
NAIC National Association of Insurance Commissioners
NASW National Association of Social Workers
NHAS National HIV/AIDS Strategy
NIAID National Institute of Allergy and Infectious Diseases
NIC Never in Care, as in the NIC Pilot Project
NIH National Institutes of Health
NMAC National Minority AIDS Council
OR odds ratio
p probability associated with the occurrence of the null hypothesis
PHQ Patient Health Questionnaire
PRO (or PBM) patient-reported outcome (or patient-based metrics)
RCT randomized controlled trial
SD standard deviation
SES socio-economic status
SOC standard of care
SSI Social Security Income
viii
STD sexually transmitted disease
UA The University of Alabama
UAB University of Alabama at Birmingham
vL viral load, the amount of virus copies per mL
ZIP Zone Improvement Plan, as in ZIP codes
ix