Outreach Helps Reengage Out-of-Care HIV Patients in Care

Daniel M. Keller, PhD

August 01, 2012

August 1, 2012 (Washington, DC) — Tens of thousands of people diagnosed with HIV and ever linked to care in New York City were not retained in care in 2010. These out-of-care (OOC) people living with HIV (PLWH) are at risk for HIV-related morbidity and mortality, as well as of transmitting the virus to uninfected sexual partners. However, Chi-Chi Udeagu, MPH, director of the HIV Epidemiology and Field Services Program of the New York City Department of Health and Mental Hygiene in Queens, presented evidence here at AIDS 2012: XIX International AIDS Conference that those PLWH who accepted assistance from public health workers for linkage to care were more likely than those who refused assistance to reengage in HIV medical care.

Udeagu said 1 of the main reported reasons that people dropped out of care was that they felt well, so education at the time of diagnosis and initial evaluation about the importance of staying in care is needed.

An estimated 133,417 people were infected with HIV in New York City in 2010. Of them, 83% were diagnosed with HIV, 85% of the diagnosed were ever linked to HIV care, and 75% of the those linked to care were retained in care, with 90% of them presumed ever to have started on antiretroviral therapy (ART), which was only 48% of the estimated number of infected individuals. Of people started on ART, 81% had a viral load suppressed at or below 400 copies/mL. This final number amounts to only 39% of infected individuals, according to New York City Department of Health and Mental Hygiene figures.

The department therefore implemented a public health outreach program to OOC PLWH to assist them in reengaging in care, counseling them on prevention measures, and preventing transmission to partners. Additional goals were for public health workers to better understand why PLWH become OOC and to better develop and plan HIV prevention strategies.

The project reached out by letters, telephone calls, and home visits to people who were confirmed HIV-positive in the city HIV Surveillance Registry but who had no evidence of HIV medical care in at least the last 9 months. Most (73%) were born in the United States, 55% were male, 42% were aged 40 to 49 years, and 25% were injection drug users. The majority (67%) were non-Hispanic black, and 30% were Hispanic.

PLWH who were confirmed to be OOC were offered assistance with reengagement in care and partner services. Of 797 identified PLWH presumed to be OOC, 689 (86%) were traced. Thirty-three percent of them were in care, and others had moved, died, or were incarcerated, leaving 414 (60%) who were offered linkage to care. Of them, 79% (327) accepted an appointment, of whom 77% (252) kept the appointment. At a 9-month follow up, 237 (94%) had at least 1 CD4 or viral load determination. Almost half of them had 3 or more determinations.

Public health workers interviewed 161 individuals, both from among the people who accepted an appointment and from the people who were offered linkage to care but who refused an appointment, about their reasons for being OOC.

The main reason for being OOC, reported by 41% of the participants, was that they felt good. Other reasons were feeling depressed (11%), interference of day-to-day responsibilities (16%), and lack of health insurance (10%). Others said they did not like or trust health workers (16%), had adverse effects from ART (12%), or did not think they were HIV-positive (9%).

Udeagu reported that in contrast to the 94% of people who accepted assistance with linkage to care and then kept an appointment, only 29% of PLWH who refused assistance eventually had an appointment. However, they took a mean of 170 days between the initial outreach and the appointment compared with a mean of 58 days for PLWH who accepted assistance (P < .001).

She concluded that the outreach was effective in getting OOC individuals to reengage in care and recommended educating all HIV-positive individuals on the need for continuing care — even if they felt well — to maintain them in care. She also advised that HIV prevention strategies should include outreach to OOC PLWH as well as prevention measures so that HIV-positive individuals do not transmit the virus, including condom distribution and informing these patients of the need to adhere to ART.

Kevin Fenton, MD, PhD, director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at the US Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, commented to Medscape Medical News on the importance of patient education at the time of diagnosis.

"You do need to spend time educating and supporting and counseling that patient about the nature of their diagnosis, the importance of maintaining and being in care despite how well they feel, and doing basic education and linking those patients to care as quickly as possible," he said. "More proactive strategies to link people to care immediately after diagnosis can really help to mitigate the [problem of] out-of-care patients that was actually mentioned in this presentation."

Although feeling well is a major reason that PLWH drop out of care, Dr. Fenton said there are other common structural barriers to adhering to care. "We often hear...at CDC about some of the real-world challenges people have with maintaining appointments. It means taking a day off from work, finding the resources to go to the hospital or to your doctor, it may be the stigma and the fear that people may have of going to an HIV treatment center and disclosing their status," he noted. "The end of this epidemic is not only going to rely on addressing behavioral and the biomedical determinants, but as HIV becomes increasingly concentrated, especially in the poor and the socioeconomically marginalized in our society, we need to be thinking about those wrap-around services to support those who are living with HIV."

The study did not receive any commercial funding. Udeagu and Dr. Fenton, who was not involved in the study, have disclosed no relevant financial relationships.

AIDS 2012: XIX International AIDS Conference: Abstract MOPDC0306. Presented July 23, 2012.


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