Dissertations and Theses
Date of Degree
9-1-2024
Document Type
Dissertation
Degree Name
Doctor of Philosophy (Ph.D.)
Department
Epidemiology and Biostatistics
Advisor(s)
Heidi E. Jones
Committee Members
DENIS NASH
KAREN FLOREZ
URIEL FELSEN
Subject Categories
Clinical Epidemiology | Public Health
Keywords
HIV, Diabetes, Clinical Care Models, Infectious Disease Clinic, Integrated Clinical Care, New York City
Abstract
ABSTRACT
Control and Management of Type-II Diabetes Among People Living with HIV (PLWH) compared to HIV-Negative Patients and by Clinic Type in the Bronx, NYC
by
Aprielle Wills
Advisor: Heidi E Jones, MPH PHD
Background: The Centers for Disease Control (CDC) estimated that approximately 1.3 million people in the United States (U.S.) were living with an HIV diagnosis by the end of 2021. With advancements of antiretroviral therapy (ART) and improved access to care, HIV has become a chronic condition in the U.S. As PLWH age, they are experiencing higher rates of other chronic conditions, specifically type-II diabetes (type-II DM), which is approximately 4-times higher among PLWH than HIV-negative adults. Multiple risk factors related to traditional lifestyle factors, race/ethnicity, barriers to care, duration of HIV infection and poorly controlled hypertension and hyperlipidemia can contribute to the higher prevalence of type-II DM among PLWH and worsening type-II DM outcomes, such as chronic kidney disease.
The role of clinical care delivery may have an impact on the type-II DM outcomes of PLWH especially among PLWH who have historically experienced barriers to care and treatment. The American Diabetes Association (ADA) has established clinical care guidelines for effective monitoring of type-II DM that includes twice yearly monitoring of hemoglobin A1c (HbA1c), blood pressure management, hyperlipidemia management, and screening of chronic kidney disease through a combination of yearly urine (i.e., albumin creatine ratio, ACR) and blood (estimated glomerular filtration rate, eGFR) tests. In addition to monitoring type-II DM testing and management, evidence suggests that clinical care models, including provider type, can affect type-II diabetes outcomes, and may present an opportunity to evaluate and improve upon existing care delivery systems.
This dissertation focuses on addressing the gaps in literature on the role of clinical care models on the type-II DM outcomes of PLWH; examining type-II DM outcomes among PLWH compared to HIV-negative adults and examining potential differences in clinical care delivery on these outcomes.
Methods: The aims of this dissertation were to conduct a systematic literature review to compare the effect of different delivery models for HIV care on the management of type-II DM in high resource settings (Aim 1). Secondly (Aim 2), compare diabetes control (HbA1c
Results: We conducted a systematic review (registered with Prospero and according to PRIMSA guidelines) to evaluate the role of the clinical care delivery model on diabetes outcomes among PLWH receiving care in high income countries published from January 1, 2000, to January 5, 2024. We identified 4,443 unique studies and, of those, five studies met the inclusion criteria.
Four of the five studies were conducted in the U.S. and provider type was the predominant clinic-level comparison, while the other evaluated differences within a hospital vs. community-based setting. Overall, studies showed low rates of type-II DM screening among PLWH (range 40-50%), moderate Hba1c control (50-85%) and found that provider type had a minimal impact on type-II DM related outcomes.
In Aim 2, we matched a cohort of 357 PLWH and 1,697 controls by age, sex and race/ethnicity from those receiving care in integrated primary care settings in the Bronx, New York City (NYC). Patients included in this retrospective matched cohort were predominately middle-aged (mean 54.5±10.6 years) at cohort entry, female (54.1%), and Latino (44.3%) or Non-Hispanic Black (43.3%). We found that within the first year of study encounter. 48.1% (n=988) of patients had two or more HbA1c tests (i.e., HbA1c monitoring according to ADA guidelines) and of these (n=988) patients, 46.3% had HbA1c control (HbA1c
In Aim 3, we compared patients living with HIV who received care primarily at an infectious disease clinic versus primary care settings from the same clinical network in the Bronx. In this analysis, patients at cohort entry were mainly middle-aged (mean 54.5±9.8 years), men (50.6%), and Latino (46.7%) or Non-Hispanic Black (43.5%). The majority (76.1%) of PLWH in the study received their care at a dedicated infectious disease (ID) clinic and 23.9% at integrated primary care sites during the study period. Patients were more likely to receive two or more HbA1c tests (aOR 1.58 95% CI 1.19, 2.09) and have HbA1c control (aOR 1.40 95% CI 1.06, 1.86) at integrated primary care sites after controlling for a priori confounders of baseline hypertension and HbA1c control, duration of HIV infection (years since diagnosis), duration of type-II DM (years since diagnosis) viral load suppression (/ml); and hepatitis C (HCV) status) compared to those receiving care at the ID clinic.
Discussion: This dissertation has helped to identify differences in the monitoring of type-II DM outcomes, including differences in CKD screening patterns among PLWH compared to their HIV-negative peers in the Bronx, NY. This work has also helped identify potential differences in type-II DM outcomes by clinic type within a large clinical care
Recommended Citation
Wills, Aprielle, "CONTROL AND MANAGEMENT OF TYPE-II DIABETES AMONG PEOPLE LIVING WITH HIV (PLWH) COMPARED TO HIV-NEGATIVE PATIENTS AND BY CLINIC TYPE IN THE BRONX, NYC" (2024). CUNY Academic Works.
https://academicworks.cuny.edu/sph_etds/108