Overall, our data suggest that the quality of HIV care received by patients at these VA sites is high. Fulfilling of individual QI indicators (e.g., antiretroviral use and PCP prophylaxis) was comparable with that recently reported for large integrated healthcare systems 10, 16
and better than levels reported for Ryan White-funded clinics for several QIs 9, 29
. Gaps in quality of HIV care received persist, however, for patients with recent unhealthy alcohol and illicit drug use, as well as for HIV-infected Veterans with Black race/ethnicity, female gender, homelessness, and depression. Our study quantifies the magnitude of effect of unhealthy alcohol and illicit drug use on the quality of HIV care received and suggests that targeted interventions to improve the quality of care among these patients may be indicated.
Patients with unhealthy alcohol use in the past year, on average, received 4.3% fewer indicated HIV care processes than patients without unhealthy alcohol use. To our knowledge, our study is the first to report the effects of current unhealthy alcohol use on the quality of HIV care received. The effect of alcohol use on quality of care for other chronic illnesses is mixed. Massachusetts Medicaid clients with substance use, including alcohol, were less likely to receive diabetes and asthma indicators 30
. In contrast, HCV-infected private insurance beneficiaries with alcohol use were more likely to receive seven HCV quality indicators compared with non-drinkers 31
and alcohol was not a predictor of receipt of care among National Health and Nutrition Examination Survey (NHANES) participants with severe hypertension 32
. Quality of acute myocardial infarction care was comparable for most quality indicators, but lower for receipt of beta blockers at discharge in those with vs. without alcohol-related diagnoses 33
. The mechanisms of observed disparities in quality of care for unhealthy alcohol users in the current study merit further investigation, but may include decreased patient engagement in HIV care (as evidenced by their decreased likelihood of attending ≥ 2 HIV clinic visits) and competing medical needs (as evidenced by increased HCV prevalence) that distract providers from addressing preventive care.
Patients with illicit drug use in the past year, on average, received 5.4% fewer indicated HIV care processes than patients without illicit drug use. This is consistent with prior studies demonstrating a lower proportion of QIs met for HIV-infected patients with hard drug use 10
and opioid dependence 9
. The percent of patients for whom individual QIs were met was mixed in the current study, with illicit drug users less likely to receive 6 of 9 QIs (including antiretroviral therapy) and more likely to receive 2 of 9 QIs (including PCP prophylaxis) compared with non-users. Similarly, Backus et al.
reported mixed directions in receipt of care processes for U.S. military Veterans, with illicit drug users more likely to receive 4 of 10 QIs and more likely to receive 5 of 10 QIs10
. Illicit drug users were less likely to receive potent antiretroviral therapy and there was non-significant trend toward greater receipt of PCP prophylaxis. The reasons for this divergence in receipt of medication-based QIs are unclear and merit further study. One hypothesis is that providers may be less likely to offer cART to drug users due to concerns about suboptimal adherence precipitating resistance, which is less important for PCP and MAC prophylaxis 34
. Evidence suggests there is no difference in antiretroviral resistance rates between HIV-infected drug users and non-users 35
The differences observed in quality of care for patients with and without substance abuse generates the hypothesis that interventions that increase engagement of HIV-infected patients with substance abuse may improve the quality of HIV care received. For example, substance use treatment in HIV-infected individuals is associated with improved ART adherence 36
, decreased emergency department visits and hospitalizations 37
, and increased receipt of primary care 38
, but substance use treatment is often underutilized.39–42
. In a recent study, opioid-dependent, HIV-infected patients receiving office-based buprenorphine/naloxone from their HIV providers experienced a 6% increase in average quality of care received over 12 months follow-up. Patients receiving buprenorphine had more visits with their HIV provider during follow-up and were more likely to improve QOC compared with those receiving other treatment 9
. Similarly, both patients with unhealthy alcohol use and those with recent illicit drug use in the current study were less likely to have at least 2 visits per year. Other non-addiction-specific interventions that increase adherence to HIV clinic visits may increase opportunities for receipt of indicated care processes, as well.
In our study, other groups besides substance users experienced important gaps in the quality of their HIV care. Black patients received fewer QIs than white patients, consistent with prior data suggesting decreased cART utilization in Black HIV-infected patients 10, 43–44
. VACS participants who reported a history of ever having been homeless received lower quality of care, on average, as well, consistent with prior studies suggesting substantial barriers to care for homeless individuals 45–46
. Depressed participants also received fewer QIs compared with non-depressed participants. Prior studies demonstrate suboptimal HIV outcomes for depressed patients 47
which can improve with depression treatment, particularly for those with substance abuse 36
. The VA has recently developed new QIs and multidisciplinary care team interventions for depression care in HIV-infected Veterans 48–49
. Males received more QIs than females, a finding opposite of that observed in the U.S. population 50
. Relatively few HIV-infected females were included in our dataset, and female veterans likely represent a more vulnerable group compared with females in the general U.S. population 51–53
. Further studies that address reasons for and interventions to address disparities in the quality of HIV care received by patients of Black race/ethnicity, and those who are female, homeless or depressed are urgently needed. Since Black race/ethnicity, homelessness, and depression were also associated with increased substance use in our data, our multivariable findings may underestimate the negative association between substance use and quality of HIV care, as suggested by attenuation of effect size when these were included in the multivariable model (). HIV clinics in the VHA are well-positioned to serve as models for improving ongoing engagement in care for all patients with unhealthy alcohol and illicit drug use.
Patients with diabetes experienced increased quality of HIV care compared to those without. This may represent the overlap in the management of HIV and other chronic conditions. Influenza and pneumococcal vaccinations, for example, are indicated for both HIV-infection and diabetes; providers may benefit from increased awareness of the need for these in a patient with both conditions. Also, patients with both HIV and diabetes may require more frequent visits, increasing the opportunity to receive indicated care processes. Further research is required to assess the role of multiple comorbid chronic illnesses, which are highly prevalent in HIV-infected populations, on receipt of HIV quality of care indicators.
Our study findings should be interpreted with respect to several potential limitations. First, our sample of predominantly male U.S. military Veterans may have limited generalizability to other HIV-infected populations. VACS participants, however, received overall QI levels comparable to another large HIV-infected VHA sample and an analysis of quality of care in 13,064 HIV-infected Kaiser Permanente beneficiaries 10, 16
. Second, we were unable to measure some QIs due to limitations of medical record data collection and validation (e.g., high risk sexual behavior screening). Inclusion of these QIs in electronic medical record collection would facilitate assessment of such QIs for both clinical and research purposes. Third, we were unable to account for QIs delivered by non-VA providers. This is unlikely to bias results of most QIs (e.g., most HIV-infected Veterans fill prescription for cART at VA pharmacies), but may be important for QIs commonly delivered in non-VA settings (e.g., influenza vaccinations). Fourth, there is the possibility that missed or canceled clinic visits could result in not receiving QIs. While there is not a uniform indicator for missing or canceled clinic visits in the dataset, we are reassured by a sensitivity analysis that we conducted, limited to only participants with at least 2 visits, which did not change our findings. Finally, we did not collect data on provider or facility-level characteristics that might contribute to quality of HIV care received.
In summary, despite overall high levels of quality of care for HIV-infected patients in VHA care, gaps persist for those with unhealthy alcohol and illicit drug use and other vulnerable subgroups. As chronic illness management becomes an increasingly dominant aspect of HIV care, ongoing measurement of care processes and strategies to improve the quality of HIV care received become paramount. Our findings advance the National HIV/AIDS Strategy goal of improving care for persons living with HIV 5
by identifying populations that may particularly benefit from targeted quality improvement efforts. Effective interventions are likely multifaceted, team-based interventions that better integrate mental health and addiction treatment with HIV primary care 9, 49, 54