From diagnosis to engagement in HIV care: assessment and predictors of linkage and retention in care among patients diagnosed by emergency department based testing in an urban public hospital.

The continuum of HIV care begins with HIV diagnosis, linkage to care, and then retention in care, which is essential to receive HAART and to reinforce adherence. Missed clinic visits have been shown to predict an AIDS-defining CD4 count and a detectable viral load as well as increased mortality. Attending clinic visits has been associated with a decrease in risky behaviors associated with transmission. Retention in care is a large problem in our population. In 2006, the majority of persons living with HIV/AIDS in New Orleans were not retained in care (58%). The purpose of this study is to determine factors that influence linkage and retention in HIV specialty care in an urban, predominantly uninsured, African American population diagnosed via emergency department-based testing in New Orleans, Louisiana. 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. 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). Linkage to care was 64% ever and 60% at 1 year in our study, which is lower than the national average of 75%. 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. 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%. This study