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Approximately 1.1 million people living with HIV live in the United States, and the incidence is highest in Southeastern United States. Electronic patient portal prevalence is increasing and can improve engagement in primary medical care. Retention in care and viral suppression—measures of engagement in HIV care—are associated with decreased HIV transmission, morbidity, and mortality.
We aimed to determine if patient portal access among people living with HIV was associated with retention and viral suppression.
We conducted an observational cohort study among people living with HIV in care at the Vanderbilt Comprehensive Care Clinic (Nashville, Tennessee) from 2011-2016. Individual access was defined as patient portal account registration at any point in the year prior. Retention was defined as ≥2 kept appointments or HIV lab measurements ≥3 months apart within a 12-month period. Viral suppression was defined as the last viral load in the calendar year <200 copies/mL. We calculated adjusted prevalence ratios (aPRs) and 95% CIs using modified Poisson regression with generalized estimating equations to estimate the association of portal access with retention and viral suppression.
We included 4237 people living with HIV contributing 16,951 person-years of follow-up (median 5, IQR 3-5 person-years). The median age was 43 (IQR 33-50) years. Of the 4237 people living with HIV, 78.1% (n=4237) were male, 40.8% (n=1727) were Black non-Hispanic, and 56.5% (n=2395) had access. Access was independently associated with retention (aPR 1.13, 95% CI 1.10-1.17) and viral suppression (aPR 1.18, 95% CI 1.14-1.22).
In this population, patient portal access was associated with retention and viral suppression. Future prospective studies should assess the impact of increasing portal access among people living with HIV on these HIV outcomes.
An estimated 1.1 million people living with HIV live in the United States, and the incidence is highest in Southeastern United States [
Electronic patient portals are web-based tools that allow patients and their families to interact with a health care system [
Studies have demonstrated that electronic patient portals have increased patient engagement in care for various patient care populations and age groups [
We conducted a retrospective, observational cohort study among people living with HIV aged 18 years who had at least one HIV health care provider visit at the Vanderbilt Comprehensive Care Clinic from January 1, 2011, to December 31, 2015. The beginning of the study period was the first full year that clinic patients had access to the Vanderbilt electronic patient portal. Follow-up began on the date of the first HIV clinic visit during the study period and continued until the year prior to death or the end of the study period on December 31, 2016, allowing ≥1 year of follow-up for all people living with HIV included. We did not include data after 2016 due to a change in the Vanderbilt electronic patient portal application in 2017.
The Vanderbilt University Medical Center deployed a robust electronic patient portal,
Clinical patient data were abstracted from the electronic health record which included information collected during routine clinical care. Our exposure of interest was electronic patient portal access, defined as whether a patient was registered for a
The outcomes of interest were retention and viral suppression. Retention was defined as having ≥2 maintained in-person HIV clinic appointments, HIV-1 RNA viral load measurements, or CD4+ counts which occurred ≥3 months apart within a 12-month period based on the Health and Resources Services Administration HIV/AIDS Bureau definition of retention in care [
Covariates chosen based on a thorough review of the literature as well as in consultation with clinicians and epidemiologists who work directly with people living with HIV included birth sex, race/ethnicity, year of cohort entry, reported HIV transmission risk factor, insurance type, age, CD4+ cell count, and HIV-1 RNA viral load at the first clinic appointment attended. These covariates were chosen based on their connection to patient portal access and HIV care outcomes. Race/ethnicity was self-reported and categorized as White non-Hispanic, Black non-Hispanic, Hispanic, and other. Year of cohort entry was modeled continuously and defined as the year the patient entered the study. We categorized reported HIV transmission risk factors as male-male sexual contact (men who have sex with men; MSM), heterosexual contact, injection drug use (IDU), or other/unknown. If a patient had more than one type of transmission risk, IDU took precedence over MSM, which took precedence over heterosexual contact, in order of the risk of HIV transmission [
We reported demographic characteristics stratified by the existence of a patient portal account during follow-up, as we wanted to compare those who never accessed the patient portal to those who did. We reported categorical variables by frequency and proportion and used Pearson chi-squared test for comparisons. Continuous variables were reported as median and IQR, and Wilcoxon rank sum tests were used for comparisons [
We estimated adjusted prevalence ratios (aPRs) and 95% CIs for retention and viral suppression using a modified Poisson regression [
Analyses were approved by the Vanderbilt University Institutional Review Board (approval number 170089) and conducted in accordance with the ethical standards set by the Declaration of Helsinki.
The study population included 4237 people living with HIV followed for a total of 16,951 person-years. Of the 16,951 person-years, 74.8% (n=12,679) were categorized as retained in care and 71.4% (n=12,103) as virally suppressed. Median follow-up time per patient was 5 (IQR 3-5) person-years. The median age was 43 (IQR 33-50) years. Of the 4237 people living with HIV, 78.1% (n=3311) were male, 40.8% (n=1727) were Black non-Hispanic, and 41.2% (n=1747) reported MSM as an HIV transmission risk factor. The median baseline CD4+ count was 478 (IQR 288-692) cells/µL and median baseline HIV-1 RNA viral load was 100 (IQR 50-25,119) copies/mL (
Of the 4237 people living with HIV included, 56.5% (n=2395) had patient portal access at any point during follow-up. People living with HIV who had a
Baseline demographic characteristics of the study population stratified by patient portal account status.
Characteristic | No account during follow-up (n=1842) | Account existed during follow-up (n=2395) | All participants (N=4237) | |||||||
Baseline age (years), median (IQR) | 44 (34-51) | 42 (31-49) | 43 (33-50) | <.001 | ||||||
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<.001 | |||||||||
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Male | 1261 (68.5) | 2050 (85.6) | 3311 (78.1) |
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Female | 581 (31.5) | 345 (14.4) | 926 (21.9) |
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<.001 | |||||||||
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Black non-Hispanic | 1003 (54.5) | 724 (30.2) | 1727 (40.8) |
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Hispanic | 138 (7.5) | 102 (4.3) | 240 (5.7) |
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White non-Hispanic | 407 (22.1) | 1134 (47.3) | 1541 (36.4) |
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Other/unknown | 294 (16) | 435 (18.2) | 729 (17.2) |
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<.001 | |||||||||
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MSMb | 497 (27) | 1250 (52.2) | 1747 (41.2) |
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Heterosexual | 622 (33.8) | 332 (13.9) | 954 (22.5) |
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IDUc | 80 (4.3) | 35 (1.5) | 115 (2.7) |
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Other/unknown | 66 (3.6) | 50 (2.1) | 116 (2.7) |
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Missing data | 577 (31.3) | 728 (30.4) | 1305 (30.8) |
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Baseline CD4+ count (cells/µL), median (IQR) | 444 (258-676) | 500 (309-702) | 478 (288-692) | <.001 | ||||||
Baseline HIV-1 RNA viral load (copies/mL), median (IQR) | 158.5 (50.1-19,952.6) | 63.1 (50.1-25,118.9) | 100.0 (50.1-25,118.9) | .30 | ||||||
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.007 | |||||||||
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2011 | 1126 (61.1) | 1452 (60.6) | 2578 (60.8) |
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2012 | 155 (8.4) | 234 (9.8) | 389 (9.2) |
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2013 | 175 (9.5) | 211 (8.8) | 386 (9.1) |
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2014 | 198 (10.7) | 236 (9.9) | 434 (10.2) |
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2015 | 146 (7.9) | 235 (9.8) | 381 (9) |
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2016 | 42 (2.3) | 27 (1.1) | 69 (1.6) |
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aWilcoxon rank sum test was used for continuous variables and Pearson chi-square test was used for categorical variables to compare those with an account to those without an account.
bMSM: men who have sex with men.
cIDU: injection drug use.
In the multiple imputed, adjusted, and modified Poisson regression analysis, patient portal access was independently associated with better retention (aPR 1.13, 95% CI 1.10-1.17;
Adjusted prevalence ratios for the association of patient portal account existence and HIV outcomes of retention in care and viral suppression. All models adjusted for variables included in the table as well as the year of cohort entry.
Characteristic | Retention in care model, aPRa (95% CI) | Viral suppression model, aPR (95% CI) | |||
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No account | REFb | REF | ||
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Account exists | 1.13 (1.10-1.17)* | 1.18 (1.14-1.22)* | ||
Baseline age (per 10 years) | 1.09 (1.04-1.13)* | 1.09 (1.04-1.13)* | |||
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Male | REF | REF | ||
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Female | 1.04 (1.00-1.08) | 0.99 (0.95-1.04) | ||
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Black non-Hispanic | 0.99 (0.95-1.02) | 0.95 (0.92-0.99)* | ||
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Hispanic | 1.04 (0.98-1.11) | 1.03 (0.96-1.10) | ||
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White non-Hispanic | REF | REF | ||
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Other/unknown | 0.93 (0.90-0.97)* | 0.94 (0.90-0.97)* | ||
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MSMc | 1.13 (1.03-1.23)* | 1.11 (1.00-1.23) | ||
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Heterosexual | 1.15 (1.05-1.26)* | 1.15 (1.03-1.27)* | ||
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IDUd | REF | REF | ||
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Other/unknown | 0.96 (0.88-1.05) | 0.95 (0.86-1.06) | ||
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Private | REF | REF | ||
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Public | 1.03 (0.99-1.07) | 0.97 (0.94-1.01) | ||
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Ryan White | 0.99 (0.95-1.02) | 0.94 (0.90-0.98)* | ||
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100 | 0.99 (0.91-1.07) | 0.99 (0.91-1.07) | ||
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200 | 0.99 (0.97-1.02) | 0.99 (0.97-1.02) | ||
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350 | REF | REF | ||
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500 | 1.01 (0.99-1.02) | 1.00 (0.99-1.02) | ||
Baseline HIV-1 RNA viral load (log10-transformed; copies/mL) | 1.00 (0.98-1.01) | 0.94 (0.92-0.96)* |
aaPR: adjusted prevalence ratio.
bREF: reference.
cMSM: men who have sex with men.
dIDU: injection drug use.
*
In the multiple imputed, adjusted, and modified Poisson regression analysis, patient portal access was independently associated with improved viral suppression (aPR 1.18, 95% CI 1.14-1.22;
We conducted a sensitivity analysis in which patients with missing data were excluded. This led to a complete case population of 1643 patients (38.8% of total cohort, N=4237) contributing 5589 person-years (33% of total person-years, N=16,951). The results were similar, but less precise, when the 2 full models from the primary analysis were used for retention and viral suppression (
Adjusted prevalence ratios for the association of patient portal account existence and the HIV outcomes of retention in care and viral suppression—complete case analysis. All models adjusted for variables included in the table as well as the year of cohort entry.
Characteristic | Retention in care model, aPRa (95% CI) | Viral suppression model, aPR (95% CI) | |
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No account | REFb | REF |
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Account exists | 1.13 (1.07-1.19)* | 1.16 (1.10-1.23)* |
Baseline age (per 10 years) | 1.08 (1.06-1.10)* | 1.08 (1.06-1.11)* | |
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Male | REF | REF |
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Female | 1.05 (0.98-1.13) | 1.01 (0.93-1.09) |
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Black non-Hispanic | 0.96 (0.97-1.01) | 0.92 (0.87-0.98)* |
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Hispanic | 1.00 (0.91-1.10) | 0.97 (0.87-1.08) |
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White non-Hispanic | REF | REF |
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Other/unknown | 0.95 (0.88-1.01) | 0.96 (0.90-1.03) |
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MSMc | 1.06 (0.93-1.21) | 1.05 (0.92-1.20) |
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Heterosexual | 1.12 (0.98-1.28) | 1.12 (0.97-1.29) |
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IDUd | REF | REF |
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Other/unknown | 1.01 (0.85-1.20) | 1.01 (0.85-1.21) |
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Private | REF | REF |
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Public | 0.97 (0.91-1.04) | 0.94 (0.88-1.01) |
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Ryan White | 1.00 (0.95-1.05) | 0.96 (0.90-1.01) |
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100 | 1.00 (0.98-1.03) | 0.99 (0.98-1.05) |
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200 | 1.00 (0.99-1.02) | 0.99 (0.99-1.02) |
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350 | REF | REF |
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500 | 1.00 (0.99-1.01) | 1.01 (0.99-1.02) |
Baseline HIV-1 RNA viral load (log10-transformed; copies/mL) | 1.00 (0.98-1.02) | 0.96 (0.94-0.98)* |
aaPR: adjusted prevalence ratio.
bREF: reference.
cMSM: men who have sex with men.
dIDU: injection drug use.
*
Electronic patient portal access via Vanderbilt’s
In our cohort, compared to patients without patient portal access, those with access were more likely to be younger, male, White non-Hispanic, and report MSM as their HIV transmission risk factor. They also had a higher CD4+ count at their first clinic visit compared to patients without patient portal access. Our results are consistent with previous studies in populations including people living with HIV and people without HIV, which showed that a higher proportion of those with access to patient portals tend to be younger and White, although the age difference in our study was only 2 years [
In addition to patient portal access, increasing age and reported HIV risk factor were independently associated with retention and viral suppression. People living with HIV in an older age group compared to those in a younger age group and people living with HIV who reported heterosexual activity or MSM compared to IDU as an HIV transmission risk factor were more likely to achieve retention and viral suppression. These findings are consistent with a systematic review of retention studies [
Factors that were independently associated with worse retention and viral suppression included race/ethnicity, insurance type, and HIV-1 RNA viral load at the first Vanderbilt Comprehensive Care Clinic visit. People living with HIV who are Black non-Hispanic (compared to those who are White non-Hispanic), have Ryan White coverage (compared to private insurance), or had a higher HIV-1 RNA viral load at their first clinic visit had worse retention and viral suppression. These findings are consistent with previous cohort studies assessing viral suppression trends over time, in which Black non-Hispanic race/ethnicity was associated with worse viral suppression and having Ryan White insurance was associated with worse HIV outcomes [
In the setting of the current COVID-19 pandemic, engaging care through electronic means such as patient portals and telehealth have increased [
Our study is subject to several limitations. First, we had data on patient portal access but not on the frequency of or reasons for electronic patient portal use. It is possible to have patient portal access but never use the portal. However, regardless of use, patient portal access was associated with improved retention and viral suppression, demonstrating that providing access to patient portals is likely to improve HIV outcomes. Similarly, studies have stressed the importance of electronic health literacy in patient portal effectiveness and care outcomes. In our study, a patient may have had access to the electronic patient portal and used it but also had difficulty understanding the platform or information due to technological or health literacy barriers [
We examined the association of an under-studied exposure with HIV care outcomes and found that electronic patient poral access was independently associated with retention and viral suppression in our cohort of people living with HIV. Studies have demonstrated that electronic patient portals offer a unique opportunity to improve outcomes that are a part of the HIV Care Continuum, such as retention and viral suppression [
Retention and viral suppression are necessary for reducing HIV transmission and mortality, as well as increasing the quality of life for people living with HIV. We found that electronic patient portal access was associated with improved retention and viral suppression. This suggests that increased access to electronic patient portals among people living with HIV may be an effective method to promote better HIV Care Continuum outcomes. Large prospective studies assessing the impact of patient portal access on retention and viral suppression are needed to confirm these findings.
adjusted prevalence ratio
injection drug use
men who have sex with men
For their contributions to this study, we thank the patients, physicians, and staff of the Vanderbilt Comprehensive Care Clinic and the Tennessee Center for AIDS Research Epidemiology and Outcomes Working Group.
This work was supported by the National Institutes of Health (R01 MH113438 to PI-Pettit) and the Tennessee Center for AIDS Research (P30 AI110527). This work was also supported by the Clinical Translational Science Award (UL1TR000445) and Clinical Translational Science Award (TL1TR002244) from the National Center for Advancing Translational Sciences. Its contents are solely the responsibility of the authors and do not necessarily represent official views of the National Center for Advancing Translational Sciences or the National Institutes of Health.
PFR received funding from Gilead and Johnson & Johnson (paid to the individual) and from the National Institutes of Health/National Institute of Allergy and Infectious Diseases (paid to institution).