# Presentation: 222181

## Delay from Testing HIV Positive until First HIV Care for Drug Users: Adverse Consequences and Possible Solutions

**Barbara J Turner  MD, MSEd***
**John Fleishman PhD****

- *Division of General Internal Medicine
- Dept of Medicine, University of Pennsylvania
- **Agency for Healthcare Research and Quality, Rockville, MD

## Background

**First CD4 count within 12 months after HIV diagnosis **

**Source**
**CDC, 2005**

## Delays

## Prior Research on Delay

- 203 consecutive outpatients at initial HIV primary care presentation (cohort from early 90s)
- Mean 8.1 years from acquiring HIV to first HIV primary care
- Mean 2.5 years from awareness of infection until HIV primary care
- Longer delay for heterosexual sex as risk factor
- Take advantage of patient contacts with health care to decrease time until care received

**Samet J et al. AIDS. 2001;15(1):77-85 **

**MMWR Morb Mortal Wkly Rep. 2003;52(25):581-6. **

## Delay in First Receipt of HIV Care

- HIV Cost and Services Utilization Study (HCSUS) – nationally representative sample of HIV-infected persons in care from mid-90s
- Nearly 1/3 of the sample delayed >3 months after testing HIV+ until first HIV care and 20% delayed >6 months
- Among those who delayed >3 months, the average delay was 1.5 years; among those who delayed >6 months, the average delay was >2 years

**Turner BJ et al, Arch Intern Med. 2000; 160:2614-22**

## Characteristics Associated  with >3 Month Delay

- African American or Latino – adjusted odds ratio 	(AOR) 1.53 [CI 1.14-2.00]
- HIV symptoms – AOR 0.45 [CI 0.34-0.89]
- Medicaid insured -- AOR 0.52 [CI 0.30-0.92]
- Usual source of medical care at the time of diagnosis -- AOR 0.60 [CI 0.47-0.77]
- High trust in medical provider -- 			AOR 0.78 [CI 0.72-0.99]
- HIV risk factor -- injection drug use 		AOR 1.37 [CI 0.90-2.08]

## Adjusted Association of Testing Site with Delay in Care

- Physicians Office  	AOR	1.00 (reference)
- Hospital 			AOR 1.03 [CI 0.69-1.52]
- Anonymous testing center AOR 1.25 [CI 0.97-1.61]
- Non-Medical site*	AOR 1.15 [CI 0.57-2.02]
- Other sites 		AOR 0.62 [CI 0.39-0.99]
- (Non-medical site: Prison, military, blood donation center)

## Objectives

- To evaluate the association of types of recent illicit drug use and delay from diagnosis until first receipt of HIV care
- To examine the association of recent illicit drug use with unprotected sex behavior

## HCSUS: the First Nationally RepresentativeSample of People with HIV/AIDS in Care

**HCSUS: the First Nationally Representative****Sample of People with HIV/AIDS in Care**

## Interview Procedure

- National sample of HIV+ persons in care in 1996 (population definition period)
- Baseline and two follow-up (FU) interviews
**Baseline: Jan. 1996  - April 1997**
**First FU:  Dec. 1996 - July 1997**
**Second FU:  Aug 1997 - Jan 1998**
**Third FU:  July 1998 – Dec. 1998  **
- Overall response rate for baseline long-form interviews = 71% (N= 2,864)
- First three interviews completed by 2,267 persons

## Study Population

- Sample 1: 1,540 HIV+ persons diagnosed by 1993, allowing up to three years until first receipt of care
**All study cohort in HIV care by first interview in 1996**
**1,330**** persons (86%) responding to questions about recent illicit drug use**
- Sample 2: 1,421 HIV+ persons responding to a separate interview about sexual risk taking
**1,351**** (95%) with complete data on illicit drug use**

## Study Variables

- Delay: first HIV+ test until first HIV care (days)
- Illicit drug use in past year (2nd interview)
**Type**
**Using larger amounts to get the same effect?**
**Emotional or psychological problems from using?**
_**Categories**_** **(adapted from Phin J. in Adams  KM et al. Polydrug Use: Results of a National Collaborative Study, 1978)
**No illicit drug use**
**Low:**** ****Marijuana or analgesics only (Phin score of 1)**
**Moderate****:**** Cocaine, heroin, sedatives, amphetamines, inhalants, or hallucinogens (Phin score of 2 or 3); no dependence**
**High:**** ****Multiple drugs (Phin score of **_**>**_** 4); dependence**
- Sexual risk: Any unprotected sex in past 6 months

## Analysis

- Weighted analyses (Stata)
- Multivariate logistic regression
**Controlling for gender, race/ethnicity, age, and having a usual source of medical care when first testing HIV+**
- Sensitivity analyses
**Substitute drug with highest Phin score**
**Control for heavy alcohol use (>3 drinks on occasion in last month)**
**Control for injection drug use as a risk factor**

## Results: >3 Month Delay (N=1330)

**16%**

**50%**

**20%**

**14%**

**Illicit Drug Use Category**

## Adjusted Odds of >3 Month Delay

**0.5 ****	****          1            1.5             2.0            2.5**

**List **

**High **

**Low**

**Adjusted Odds Ratio**

**Reference -  None**

**Moderate**

**2.70**

**Illicit Drug Use Category**

## Among Persons Delaying >3 Months: Mean Days Until First HIV Care

**Days**

**Illicit Drug Use Category**

## Unprotected Sex Within Past 6 Months (N=1,351)

**15%**

**58%**

**17%**

**11%**

**Illicit Drug Use Category**

## Adjusted Odds of Unprotected Sex Within Past 6 Months

**0.8      1            1.5             2.0            2.5           3.0**

**List **

**High **

**Low**

**Adjusted Odds Ratio**

**Reference -  None**

**Moderate**

**3.55**

**4.37**

**Illicit Drug Use Category**

## Additional Analyses

- Delay >3 months
- Usual source of medical care 			(AOR 0.59, CI 0.47-0.74)
- Heavy alcohol use (4+ drinks on one occasion)  	     (AOR 1.56, CI 0.93-2.62)
- HIV risk - injection drug use
- 		(AOR 1.32, CI 1.03-1.68)
- Cocaine or heroin use in past year 			(AOR 1.66, CI 1.12-2.45)
- Unprotected sex
- Significantly higher for all levels of drug use (AORs 1.67 to 2.70)

## Limitations

- Not clear if applies to current situation
- Biased toward shorter delay because these patients were in HIV care at the time of survey
- Illicit drug use category definitions - loose
- Not adjusted for mental health disorders
- Not considering substance abuse treatment
- No specific information on unprotected sex in interval between testing positive and first HIV care

## Slide 21

## Opportunities to Reduce Delayfrom HIV+ Test to HIV Care

- Linkage to longitudinal drug treatment and a usual source of medical care
**Among >40,000 HIV- and HIV+ drug users, both types of care independently reduced odds of hospitalization** (Laine C et al, JAMA 2001)
- Case management (Gardner L et al. AIDS. 2005)
- Testing in a supportive setting
- Immediate referral and specifics about an accessible HIV provider
- Insurance barriers (now you need an ID)

## Conclusions

- Delay from testing to care is common and lengthy
- >3 months for 27% of moderate and 40% of severe drug use groups
- Among those who delay >3 months, mean 1.5 years for moderate and 1.3 for severe group
- Unprotected sex significantly more common in illicit drug users
- HIV care offers opportunities improving clinical outcomes and for harm reduction

## Slide 24