The Therapeutic Implications of Timely Linkage and Early Retention in HIV Care

Abstract

Following HIV diagnosis, linkage to outpatient treatment, antiretroviral initiation, and longitudinal retention in care represent the foundation for successful treatment. While prior studies have evaluated these processes in isolation, a systematic evaluation of successive steps in the same cohort of patients has not yet been performed. To ensure optimal long-term outcomes, a better understanding of the interplay of these processes is needed. Therefore, a retrospective cohort study of patients initiating outpatient care at the University of Alabama at Birmingham 1917 HIV/AIDS Clinic between January 2000 and December 2005 was undertaken. Multivariable models determined factors associated with: late diagnosis/linkage to care (initial CD4 < 350 cells/mm3), timely antiretroviral initiation, and retention across the first two years of care. Delayed linkage was observed in two-thirds of the overall sample (n = 567) and was associated with older age (odds ratio [OR] 1.31 per 10 years; 95% confidence interval [CI] = 1.06-1.62) and African American race (OR = 2.45; 95% CI = 1.60-3.74). Attending all clinic visits (hazard ratio [HR] = 6.45; 95% CI = 4.47-9.31) and lower initial CD4 counts led to earlier antiretroviral initiation. Worse retention in the first 2 years was associated with younger age (OR = 0.68 per 10 years; 95% CI = 0.56-0.83), higher baseline CD4 count, and substance abuse (OR = 1.78; 95% CI = 1.16-2.73). Interventions to improve timely HIV diagnosis and linkage to care should focus on older patients and African Americans while efforts to improve retention should address younger patients, those with higher baseline CD4 counts, and substance abuse. Missed clinic visits represent an important obstacle to the timely initiation of antiretroviral therapy. These data inform development of interventions to improve linkage and retention in HIV care, an emerging area of growing importance.

An Epidemic in Evolution: The Need for New Models of HIV Care in the Chronic Disease Era

“…54 For HIV-infected patients in particular, improved access has been associated with better engagement in care and health-related quality of life, 55,56 more cost-effective health services utilization, 57 and timelier initiation of antiretroviral therapy. 58 Collaborative care also offers the potential to "up-skill" non-HIV-expert providers through individual, patient-based education: for example, providers may learn how to better address antiretroviral adherence, recognize HIV treatment failure, and manage serious infection-and therapy-related complications. Finally, community-based care may be appealing to patients who prefer not to access HIV-identified facilities due to fears regarding stigma.…”

From Access to Engagement: Measuring Retention in Outpatient HIV Clinical Care

“…Delayed linkage and poor retention in outpatient HIV care have been associated with delayed receipt of antiretroviral medications, higher rates of viral load failure, and increased morbidity and mortality. [5][6][7][8][9][10][11][12][13][14][15][16][17] Beyond the effects on individual health, engagement in HIV care has important consequences for the public health as it plays a pivotal role in HIV transmission and secondary HIV infections. Studies have demonstrated reduced risk transmission behavior among HIVinfected patients engaged in clinical care, 18,19 and viral load suppression, which is achieved more commonly among those with better retention, 6,9 also reduces risk of transmission.…”

“…Recent studies, the majority of which have been retrospective and observational in design, have used a number of differing approaches to measure retention in care. [5][6][7][8][9][10][11][12][13][14][15][16][17] To date, there has not been a published summary of these measures to serve as a guide and provide a common nomenclature for HIV retention measures. A recent review of retention in care noted, ''a clear framework for how patient retention is defined and how it should be measured remains outstanding.''…”

Assessing Timely Presentation to Care Among People Diagnosed with HIV During Hospital Admission: A Population-Based Study in Ontario, Canada

“…age, sex or gender, income, immigration status) [6][7][8][9][10][11][12], psychosocial factors (e.g. mental health status, substance use, homelessness) [13][14][15], and geographic factors (e.g.…”