Predictors of Linkage to Care for Newly Diagnosed HIV-Positive Adults

INTRODUCTION Linkage to care following a human immunodeficiency virus (HIV) diagnosis is critical. In the U.S. only 69% of patients are successfully linked to care, which results in delayed receipt of antiretroviral therapy leading to immune system dysfunction and risk of transmission to others. METHODS We evaluated predictors of failure to link to care at a large urban healthcare center in Philadelphia in order to identify potential intervention targets. We conducted a cohort study between May 2007 and November 2011 at hospital-affiliated outpatient clinics, emergency departments (EDs), and inpatient units. RESULTS Of 87 patients with a new HIV diagnosis, 63 (72%) were linked to care: 23 (96%) from the outpatient setting and 40 (63%) from the hospital setting (ED or inpatient) (p<0.01). Those who were tested in the hospital-based settings were more likely to be black (p=0.01), homeless (p=0.03), and use alcohol or drugs (p=0.03) than those tested in the outpatient clinics. Patients tested in the ED or inpatient units had a 10.9 fold (p=0.03) higher odds of failure to link compared to those diagnosed in an outpatient clinic. When testing site was controlled, unemployment (OR 12.2;p<0.01) and substance use (OR 6.4;p<0.01) were associated with failure to link. CONCLUSION Our findings demonstrate the comparative success of linkage to care in outpatient medical clinics versus hospital-based settings. This study both reinforces the importance of routine opt-out HIV testing in outpatient practices, and demonstrates the need to better understand barriers to linkage.