Abstract
Dear Editor,
Rapid HIV testing was instituted on an opt-in basis beginning in February 2008 in the Emergency Department of Interim Louisiana Public Hospital (ILPH). The outpatient clinic affiliated with the hospital is the HIV Outpatient Program (HOP), which was the HIV clinic affiliated with the Charity Hospital system and is the largest single provider of HIV services in the region. Patients who tested positive in the first year of this testing program were included in this retrospective cohort study. After 2.5 years of follow-up, a detailed chart review of these patients was performed. Institutional Review Board (IRB) approval was obtained and statistical software (SPSS 18.0) was used for analysis.
Linked to care was defined as any clinical visit to an HIV provider, and timely linkage to care was defined as a clinical visit within 3 months. Retention in care was defined as two visits to an HIV provider separated by 3 months in a 1-year period. A patient was defined as having been linked to an outside clinic if there was documentation of a visit to an outside HIV provider in our hospital system.
Ninety-nine (99) patients were newly diagnosed with HIV through rapid HIV testing in the emergency department. Of those 99, 56 (57%) were linked to care at the HIV clinic affiliated with our hospital and seven were linked to other clinics, with a total of 63 (64%) linked to any care. Linkage to care at 1 year was lower at 60% (59). The demographics for the three groups; newly diagnosed, linked to care, and retained at 2 years, are provided in Table 1. Of the 54 patients linked to the affiliated HIV clinic within 1 year at our hospital, 42 (78% of linked, 42% of total) were linked within the first 3 months qualifying as having timely linkage to care. Female gender (p value 0.01), insurance (p value 0.03), and African American race (p value 0.04) were statistically associated with linkage to care. The linked patients were slightly older (41 vs. 36, p value 0.07) and had slightly increased CD4 counts (243 vs. 166, p value 0.06) that trended towards significance.
“Free care” is a program through the hospital that provides care to qualified indigent patients in Louisiana.
Of the newly diagnosed, 36 patients (36%) were retained at 1 year, and 32 (32%) were retained at 2 years. Defining the denominator as linked patients, 36 patients (64%) were retained at 1 year, and 32 (57%) in the second year. Older age, lower CD4 count at baseline, increased number of visits to a HIV provider in the first 6 months, and increased number of medical encounters in the first 6 months were statistically associated with retention in care in the second year (Table 2). Gender and race did not play a role. Any co-morbidity and an appointment with an HIV provider within 6 months of a diagnosis trended towards a significance (p value 0.06).
SD, standard deviation.
Linkage to care was 64% ever and 60% at 1 year in our study, which is lower than the national average of 75%. 7 Although some studies have used measures such as CD4 counts or viral loads, that could potentially overestimate their linkage rates, our study used the strict criteria of a documented visit with an HIV provider to define linkage. 8 Using a lab definition measure, our linkage rate would have been higher, 72%. In this same population, among patients who had previously been diagnosed with HIV and were relinked to care, a similar rate of linkage was seen, 62%. 9 This study showed that female gender, insurance, and African American race were associated with increased linkage to care. A large cross-sectional study found similar findings with regards to delayed linkage among male and uninsured patients. 10 Our finding of African American race being associated with increased linkage to care was not seen in that study.
Retention in care was low, only 36% at 1 year and 32% at 2 years for these newly diagnosed patients (68% not retained). Nationally estimates are that 45–55% of all HIV patients fail to receive care during any year. 7 The Louisiana Office of Public Health estimates that among chronically infected patients in the Ryan White program, 62–71% remained in continuous care for the years 2006–2010. 11 This data, which is in contrast with the 32–36% retention in our study, may reflect differences in retention rates between patients with newly diagnosed HIV and those with an established infection, as well as patients that seek care in an emergency department as opposed to outpatient testing sites. A similarly low retention rate was seen in a population of patients retested in the emergency department with previously diagnosed HIV and relinked to care, with only 38% retained at 2 years of follow-up. 9 This may indicate that an emergency department-based population is distinct and more difficult to retain.
In this study, older age, lower CD4 counts at baseline, increased visits to an HIV provider in the first 6 months, and increased medical encounters in the first 6 months were statistically associated with retention in care at 2 years. Other studies have also found decreased retention in care with higher CD4 counts and younger patients. 12 –14 In our study there were no differences in retention by race. This outcome has been inconsistent in previous studies, with a study of a predominantly insured population and a separate study of veterans finding that race (African American) was associated with poor retention, 12,13 but a study of predominantly uninsured patients finding that it was not. 14 As race has now been demonstrated not to be associated with poorer retention in this study of a predominately uninsured population, it may be that economic factors are confounding the role of race in studies that have shown an association.
Our finding that increased medical encounters in the first 6 months with an HIV provider or any medical provider was statistically associated with increased retention in care has not been previously reported. Patients who had many visits may be more likely to be retained, or patients who were more ill may have had more appointments; the potential for confounding exists. Increasing the number of visits in the first 6 months by decreasing follow-up intervals may be a way to increase engagement without major changes to clinic structure and flow.
Patients who were diagnosed via emergency department testing had similar rates of linkage to care, but lower rates of retention in care than national estimates. This population may present a distinct group that is difficult to retain, and effective interventions to increase their linkage and retention are imperative to improving their health outcomes.