One-quarter of 200 people with an HIV intake interview in Dallas or San Antonio missed their first HIV care visit. This chart review found that people who did not attend their first scheduled visit within 90 days of intake were unlikely ever to engage in care, according to a study published in AIDS Patient Care and STDs.
Research shows that more than half of people diagnosed with HIV in the United States do not enter care, and only 35% diagnosed remain in care. Engagement and retention rates are lower in racial and ethnic minorities, people living in southern states and younger patients. Much work documents the negative clinical impacts of missed initial and follow-up visits.
Researchers in Texas conducted this study in 200 consecutive HIV patients -- 100 in Dallas and 100 in San Antonio -- who completed a case-management intake. They had three aims: (1) identify predictors of missing initial HIV visits, (2) determine the time to initial visit and (3) describe the association between initial visit attendance and retention in HIV care.
Age averaged 40 years in the study group, 86% were men, 37% Hispanic, 35% black and 29% white. Most (61%) were men who have sex with men, and 51% were unemployed, 48% reported current substance use and 39% had a mental health diagnosis.
While 52 participants (26%) missed their initial HIV visit, 22 (11%) never entered care during the study period. Multiple logistic regression identified three independent predictors of a missed initial visit: unemployment (odds ratio [OR] 2.33, 95% confidence interval [CI] 1.04 to 5.24, P = .04), fewer attended case-management visits (OR 3.08, 95% CI 1.43 to 6.66, P = .004) and younger age (OR 0.96, 95% CI 0.93 to 0.996, P = .03).
Half of study participants made their first HIV care visit within 36 days of case-management intake (95% CI 32 to 41). Adjusted analysis linked shorter time to first visit with recent hospitalization (hazard ratio [HR] 2.18, 95% CI 1.38 to 3.43, P ≤ .001), CD4 count 200 cells/mm3 or lower versus 500 or higher (HR 1.9, 95% CI 1.25 to 2.88, P = .003) and Dallas site versus San Antonio (HR 1.48, 95% CI 1.03 to 2.14, P = .04).
Of the 200 study participants, 157 (78.5%) made their first visit within 90 days, and 21 (10.5%) completed their first visit after 90 days. Patients who did not make their first visit within 90 days were unlikely to enter care at all.
Among 22 people who did not make a visit during the study period, the researchers found that 12 had transferred their care. Among 155 patients with no evidence of transferring their care, those who attended their first visit were more likely to remain in care (40% versus 14%, P < .01). Compared with people who missed their first visit, those who did not were less likely to have a six-month gap in care (10% versus 28%, P = .01) and missed fewer scheduled appointments (33% versus 50%, P = .04). Notably, missed-visit rates ranged from 35% to 47% among people who either missed or attended their first visit.
The researchers note that "lost to care" initiatives typically start six months after a missed visit. They believe their data "suggest that waiting until 6 months is not necessary and that efforts to contact and locate those who have missed visits should be implemented sooner."
They advise that "a missed initial medical visit should trigger early outreach interventions from the clinic and regardless of initial visit attendance, retention in care efforts should continue into the first year of (re)engagement in HIV care."
Mark Mascolini writes about HIV infection.