The impact of comorbidity and clinical complexity on retention in HIV care

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Significant advances in the medical management of HIV have heralded a new era of treatment which acknowledges psychosocial, as well as medical, comorbidity factors. However, policy guidelines, reporting requirements and directives are yet to be revised accordingly, with metrics for successful treatment continuing to be considered in medical terms alone. The importance of medical and/or psychosocial comorbidity in impacting well-being, quality of life, and optimal holistic HIV management has arguably been under-represented in reporting outcomes. At present, biomedical markers such as viral load are used to measure treatment ‘success’. Optimal holistic care should transcend viral load alone and include other measures such as overall functioning and health-related quality of life. Retention in care is a current metric within the HIV Care and Treatment Cascade, and the only one which allows for holistic monitoring or medical review by HIV specialists; however, at present, its full potential is not realised. Consistent definitions and means to measure retention are elusive, with differences within and between regions making comparisons difficult. However, retention remains an important component of the Cascade, as it affords the opportunity for optimal monitoring and timely intervention for biopsychosocial comorbidities which may ultimately impact disease progression and quality of life. In the context of three key theoretical models (the Biopsychosocial Model, the Syndemic Model, and the Andersen Behavioral Model of Health Service Use), the present study series aims to review current definitions of retention in HIV care and understand its specific antecedents through a series of four empirical studies. A systematic literature review considers the global literature on the subject, while a local qualitative analysis of both clinician and client perspectives provides context within the Australian public health landscape. A third study describing the development of an HIV client complexity rating scale, to assess for comorbidity, is outlined. These results are then used to assess the impact on retention in an Australian cohort of people living with HIV, in the fourth and final study. Results suggest a complex interplay of individual and contextual biological, psychological and social factors which impact retention in HIV care. Further, they suggest that particular interactions, or syndemics, beyond biomedical markers alone are implicated in poor retention in HIV care. The results are discussed in the context of appropriate theoretical models to understand the factors and the nature of the relationships between them. Implications for future research, as well as policy and reporting guidelines, are discussed.
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