After linking newly diagnosed patients to care, retaining them in care is the next key goal. An intervention to improve retention in HIV care had little impact on patients with depression or anxiety, alcohol use or drug use in a 12-month 1838-person randomized trial. But among those higher-risk patients who received at least 60% of intended intervention phone calls, retention nearly matched that of lower-risk patients, according to the study.
Research by the Centers for Disease Control and Prevention (CDC) determined that 45% of people aware of their HIV infection are not retained in care in the United States. Depression, anxiety, and drug or alcohol use could pose obstacles to steady HIV care. An enhanced personal contact intervention proved effective in promoting retention over 12 months in a 1838-person randomized trial in six U.S. HIV clinics. CDC investigators and colleagues conducted this subanalysis to determine the impact of depression, anxiety, and drug or alcohol use on the effectiveness of this intervention.
With Retention Through Enhanced Personal Contact (REPC), a clinic-based professional encourages appointment-keeping with reminder calls, missed-visit calls, interim calls halfway between scheduled visits and brief face-to-face meetings in the clinic. Upon enrollment, all study participants completed an audio computer-assisted self-interview that uses standard tests to measure depression and anxiety symptoms, alcohol use and drug use.
The 1225 adults in the REPC intervention arm and the 613 participants in the standard-of-care arm were either new HIV patients or established patients who had missed visits in the past 12 months. The researchers defined retention in care as keeping at least one visit with the HIV primary care provider in each of three consecutive four-month intervals after study enrollment. They defined successful intervention calls as calls in which the professional actually spoke to the patient, not those in which the professional left a voicemail message.
About two-thirds of participants in the intervention arm and the standard-of-care arm were men, about two-thirds black and about three-quarters taking antiretroviral therapy. Only about 15% of participants in each study arm had private insurance. About 30% of participants in each study group were younger than 40 years old, about one-third were 40 to 49 and the rest were older. Minorities of participants reported illicit drug use (19%) or heavy drinking (15%), and 14% had severe depression or anxiety. Overall, 654 study participants (36%) fell into the higher-risk category because of poor mental health or substance use and 1184 (64%) fell into the lower-risk category.
The intervention improved retention in nondrinkers, light drinkers and moderate drinkers, but not in heavy drinkers in either unadjusted or multivariable analysis. The intervention also improved retention in people who did not use illicit drugs, but not in those who used illicit drugs. And the intervention had no impact on participants with severe anxiety or depression.
Among the 1225 study participants in the intervention arm, a significantly lower proportion of higher-risk patients than lower-risk patients was successfully contacted by phone (40.6% versus 50.7%, P < .0001). More higher-risk patients than lower-risk patients fell into the lowest tertile for phone contact success (40% versus 27%).
Overall, higher-risk participants had consistently lower retention rates than lower-risk participants. But for both higher- and lower-risk participants, the 12-month retention percentage rose in tandem with successful phone contact percentage. Among higher-risk patients with at least 60% phone contact success, the intervention improved retention almost as much as in lower-risk patients with at least 60% phone contact success, and this small between-group difference was not statistically significant.
The researchers determined that 26% of higher-risk patients in the intervention arm received at least 60% of phone calls from their clinic contact and responded with good retention in care. These findings, the investigators write, "give us confidence that there are some patients at high risk of disengaging from care who will respond to an enhanced contact-type intervention." But the 74% of participants who did not receive enough phone calls to respond to the intervention "represent a big challenge for a clinic to determine how to improve their clinic attendance."