Missed Clinic Visits Linked to Tripled Risk of Death in U.S. HIV Group

April 2015

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What the Results Mean for You

This study of almost 3700 people with HIV across the United States found strong evidence that missing HIV care appointments may be linked to a higher risk of death. The researchers measured appointment keeping in three ways. Missing visits during the first 24 months of antiretroviral therapy by each of those ways doubled or tripled the risk of death from a point starting 24 months after therapy began.

Once a person tests positive for HIV and begins care, keeping appointments regularly is the next crucial step to returning to health. Another study reviewed on page 45 of this issue of HIV Treatment Alerts found that missing appointments lowered chances of starting antiretrovirals and reaching an undetectable viral load.8 And the next study reviewed in this issue found that about three quarters of people who made two or more clinic visits at least 3 months apart had an undetectable viral load.9 People who keep their HIV care appointments have the best chance of getting all the benefits of care -- starting antiretroviral therapy, reaching an undetectable viral load, gaining CD4 cells, and getting help avoiding or controlling the serious diseases that threaten people with HIV infection.

The definitions of appointment keeping developed by the Institute of Medicine and the US Department of Health and Human Services (DHHS) (Table 1) both predicted death in this study group. But the researchers found that some people counted as being in care by these definitions did miss one or more visits. Simply counting missed visits -- those not cancelled beforehand by the patient or provider -- was the strongest predictor of death after the first 24 months of antiretroviral therapy.


HIV care experts in the United States developed guidelines to help HIV providers get HIV-positive people into care, stay in care, and take their antiretrovirals as scheduled.10 If you have trouble keeping medical appointments -- for any reason -- you should talk to your provider to plan ways to improve appointment keeping. Your provider may put you in touch with a case worker who can help you address problems that make appointment keeping tough.11 Some medical offices have community-based "patient navigators" who help HIV-positive people manage many complicated aspects of health care.12

Some problems that cause people to miss medical visits may be easy to solve. Other problems may have deep roots that are hard to get at. But people with HIV should find help addressing these problems. And your HIV provider or other professionals in the HIV care office can get you the help you need.


  1. Mugavero MJ, Westfall AO, Cole SR, et al. Beyond core indicators of retention in HIV care: missed clinic visits are independently associated with all-cause mortality. Clin Infect Dis. 2014;59:1471-1479.
  2. Centers for Disease Control and Prevention. HIV in the United States: the stages of care.
  3. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493-505.
  4. Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral treatment of adult HIV infection: 2012 recommendations of the International Antiviral Society-USA panel. JAMA. 2012;308:387-402.
  5. Das M, Chu PL, Santos GM, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS One. 2010;5:e11068.
  6. US Department of Health and Human Services. HIV core indicators.
  7. Institute of Medicine. Monitoring HIV care in the United States: indicators and data systems. March 15, 2012.
  8. Kahana SY, Fernandez MI, Wilson PA, et al. Rates and correlates of antiretroviral use and virologic suppression among perinatally and behaviorally HIV-infected youth linked to care in the United States. J Acquir Immune Defic Syndr. 2015; 68:169-177.
  9. Cohen SM, Hu X, Sweeney P, Johnson AS, Hall HI. HIV viral suppression among persons with varying levels of engagement in HIV medical care, 19 US jurisdictions. J Acquir Immune Defic Syndr. 2014;67:519-527.
  10. Thompson MA, Mugavero MJ, Amico KR, et al. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care Panel. Ann Intern Med. 2012;156:817-833.
  11. Gardner LI, Metsch LR, Anderson-Mahoney P, et al; Antiretroviral Treatment and Access Study Group. Efficacy of a brief case management intervention to link recently diagnosed HIV-infected persons to care. AIDS. 2005;19:423-431.
  12. Bradford JB, Coleman S, Cunningham W. HIV system navigation: an emerging model to improve HIV care access. AIDS Patient Care STDS. 2007;21(Suppl 1):S49-S58.
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This article was provided by The Center for AIDS Information & Advocacy. It is a part of the publication HIV Treatment ALERTS!. Visit CFA's website to find out more about their activities and publications.


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