Rural residence is associated with delayed care entry and increased mortality among veterans with human immunodeficiency virus infection

Context: Rural persons with human immunodeficiency virus (HIV) face many barriers to care, but little is known about rural-urban variation in HIV outcomes. Objective: To determine the association between rural residence and HIV outcomes. Design, Setting, and Patients: Retrospective cohort study of mortality among persons initiating HIV care in Veterans Administration (VA) during 1998-2006, with mortality follow-up through 2008. Rural residence was determined using Rural Urban Commuting Area codes. We identified 8489 persons initiating HIV care in VA with no evidence of combination antiretroviral therapy (cART) use at care entry, of whom 705 (8.3%) were rural. Outcome Measure: All-cause mortality. Results: At care entry, rural persons were less likely than urban persons to have drug use problems (10.6% vs. 19.5%, P < 0.001) or hepatitis C (34.3% vs. 41.2%, P = 0.001), but had more advanced HIV infection (median CD4: 186 vs. 246, P < 0.001). By 2 years after care entry, 5874 persons had initiated cART (528 rural [74.9%] and 5346 urban [68.7%], P = 0.001), and there were 1022 deaths (108 rural [15.3%] and 914 urban [11.7%], P = 0.004). The mortality hazard ratio for rural persons compared with urban was 1.34 (95% confidence interval: 1.05-1.69). The hazard ratio decreased to 1.18 (95% confidence interval: 0.93-1.50) after adjustment for HIV severity (CD4 and AIDS-defining illnesses) at care entry, and was 1.17 (95% confidence interval: 0.92-1.50) in a model adjusting for age, HIV severity at care entry, substance use, hepatitis B or C diagnoses, and cART initiation. Conclusions: Later entry into care drives increased mortality for rural compared with urban veterans with HIV. Future studies should explore the person, care system, and community-level determinants of late care entry for rural persons with HIV.