Using Laboratory Surveillance Data to Estimate Engagement in Care Among Persons Living with HIV in Los Angeles County, 2009

Abstract

Poor engagement in HIV care has been associated with delayed access to antiretroviral treatment and increased HIV transmission. Using viral load (VL) results from HIV laboratory surveillance data to conduct longitudinal and cross-sectional analyses, we examined linkage to care, retention in care, and their associated factors in 37,325 persons living with HIV (PLWH) in Los Angeles County (LAC). Linkage to care was considered timely if a VL test result was present ≤3 months of diagnosis. Successful retention in care was defined as having two or more VL test results ≥90 days apart during 2009. Of 6841 persons newly diagnosed with HIV in 2007-2009, 67% were linked to care within 3 months of diagnosis. Factors associated with delayed linkage to care included being African American, Latino, and Asian/Pacific Islander (adjusted hazard ratio [AHR]=0.81; 95% CI=0.75-0.87, AHR=0.83; 95% CI=0.77-0.89, AHR=0.82; 95% CI=0.71-0.94, respectively). Of the 37,325 PLWH, 52% were retained in care during 2009. Factors associated with lack of retention in care included injection drug use (adjusted prevalence ratio [APR]=0.88; 95% CI=0.84-0.93), incarceration at diagnosis (APR=0.56; 95% CI=0.51-0.61), being diagnosed in pre-highly active antiretroviral therapy (HAART) era (APR=0.94; 95% CI=0.92-0.96) or at a public facility (APR=0.97; 95% CI=0.95-1.00), age <45 years (APR=0.87; 95% CI=0.86-0.89), and having concurrent HIV/AIDS diagnoses (APR=0.94; 95% CI=0.92-0.96). This study demonstrates the value of using VL surveillance data to monitor engagement in care among PLWH, and its potential to improve linkage and retention efforts where disparities in care are observed.

Considering Care-Seeking Behaviors Reveals Important Differences Among HIV-Positive Women Not Engaged in Care: Implications for Intervention

“…Similar to previous studies, we found that regardless of care-seeking behaviors, women who are out of care were more likely to be uninsured. 14,[16][17][18][19] However, despite this finding, we found that, compared with women in care, both seekers and nonseekers were no more likely to perceive lack of health insurance as a barrier to care. Although prior studies have found drug use to be associated with poor engagement in care, 14,16,19,[21][22][23][24][25] we found that, compared with women in care, only non-seekers were more likely to report high-risk drug use and sexual behaviors.…”

“…We forced age and race/ethnicity into the multivariate models as these have been consistently associated with engagement in HIV care in previous studies. 6,17,[22][23][24][25] All analyses were conducted using SAS statistical software (SAS 9.2, SAS Institute, Inc., Cary, NC).…”

“…Consequently, they are at high risk for poor health outcomes and for transmitting HIV to others. [4][5][6][7][8][9][10] Although prior studies have identified numerous factors associated with poor engagement in care (e.g., lack of transportation [11][12][13] and health insurance, [14][15][16][17][18][19] caregiving responsibilities, 13,20 depression, 13,16,21 and substance use 14,16,19,[21][22][23][24][25], these studies have been limited in two important respects. First, many have viewed those who are not engaged in care as a single, homogenous group, failing to recognize potentially nuanced differences among women that may help to inform the development of targeted interventions.…”

Using HIV Surveillance Laboratory Data to Identify Out-of-Care Patients

“…HIV-associated laboratory tests that are reported to public health surveillance have been used as a proxy measure of care engagement of HIV? individuals [3][4][5].…”

Optimizing the Use of Surveillance Data for Monitoring the Care Status of Persons Recently Diagnosed With HIV in NYC

“…7 However, despite growing interest in the use of HIV surveillance data for measuring care-related outcomes among PLWH at both the national and local levels, there has been only limited comprehensive evaluation of the validity of surveillance data for such purposes. 4,[8][9][10] To date, most nationally representative estimates for HIV-related care measures have validated data from cohort studies against clinical data on HIV care visits. 11,12 In addition, several studies have raised concerns about the accuracy of laboratory data in reflecting linkage to care.…”