Abstract
Dear Editor,
Disclosure of HIV serostatus to a support network has previously been associated with behavior changes that reduce HIV transmission and improve adherence to anti-retroviral medication. 2,3 The decision to disclose one's serostatus is complex and governed by factors that range from expectations of increased social support to fear of rejection and discrimination. 4 Previous research has demonstrated that an individual's perception of HIV-related stigma predicts his or her likelihood of disclosure. 5
Retention in medical care has been associated with a decrease in mortality and improved HIV biomarkers. 6 In contrast, inadequate retention in HIV care has been associated with poor adherence to antiretroviral therapy, increased resistance, and lower survival rates. 7
We conducted a retrospective cohort study using the medical records of thirty-six patients newly diagnosed in the first 6 months of 2008 and linked to care at the Medical Center of Louisiana New Orleans HIV Outpatient Program (HOP)—an urban safety net clinic. Disclosure status was recorded on a questionnaire at initiation of care and defined as informing at least one support person of their new diagnosis. A support person was defined by the intake nurse as “a family member or friend who will assist with your medical care.” This intake form was only used during the first 6 months of 2008, and our cohort includes the patients diagnosed in the emergency room without a previous diagnosis and subsequently linked to care. The medical chart of each patient was then reviewed to corroborate the answer to the questionnaire with the physician notes. Patients were followed for 2.5 years. The Health Resources and Services Administration (HRSA) has defined retention in HIV care as having ≥2 outpatient visits with an HIV provider at least 3 months apart during a 12-month period. Visit constancy is a measure that correlates with the HRSA definition but extends to time periods beyond one year. In our study, we calculated visit constancy to be the proportion of 6-month intervals with at least one visit to an HIV-provider over a five-interval period, with retention in care defined as ≥80%. 8 IRB approval was obtained prior to data collection. Statistical software (SPSS) was used for analysis, Chi-squared for nominal variables, and Anova for continuous variables.
Twenty-seven of the 36 patients (75%) disclosed their serostatus to a support person at initiation of care. There were no significant differences in age, gender, race, insurance status, or CD4 count at time of diagnosis between those who disclosed their serostatus and those who did not disclose their serostatus. The majority of subjects were African-American and uninsured. Table 1 compares the demographic data. Most commonly patients described more than one support person (52%). Support networks included family members, friends, and sexual partners. There was no difference in likelihood of retention in terms of which person(s) comprised the support network. Patients who disclosed their HIV serostatus were significantly more likely to be retained at year two by HRSA definition with an odds ratio of 16 (1.7–148, p value 0.015). Patients who disclosed their status were more likely to have a visit constancy factor of 80% or higher with an odds ratio of 7 (1.2–40, p value 0.03). Markers of improved health outcomes such as undetectable viral load and increased CD4 counts trended towards a positive relationship but were not statistically significant. Table 2 provides the detailed results of this study.
In this study, disclosure of HIV serostatus at diagnosis to a support person was significantly associated with retention in care. One previous study demonstrated increased retention in care over a 6-month period for African-American and Latino patients who disclosed their HIV status. 9 HIV disclosure has led to greater social support mechanisms, including transportation to clinic, reminders of appointments, financial assistance for medication, and encouragement to follow medical advice. 10 It has also been associated with improvement in mental health by reducing levels of stress and depression. 11 Nondisclosure has been observed in people with higher levels of HIV-related stigma. 12 HIV-related stigma has been associated with poorer psychological status, decreased physical function, and delays in entering care after a positive diagnosis. 13
The retrospective nature of this study restricted our ability to understand why patients did not disclose their HIV serostatus, nor were we able to examine if they disclosed later in their treatment course. A limitation of retention in care studies is the possibility that patients have left New Orleans and re-engaged at other HIV treatment centers. We examined the paper charts for notation by the HIV provider of a transfer of care and found none. Furthermore, there exists an equal chance of relocation regardless of disclosure status. Other variables such as access to transportation, stable housing, or active drug use could affect retention in care, but there is no reason to suspect they affected our patients disproportionally.
Based on the results of our study, disclosure to support persons must be considered an important factor in increasing retention in care. Strength based interventions should incorporate and encourage serostatus disclosure as a means of increasing social support, decreasing stress and improving retention in care.