AIDS:
13 November 2010 - Volume 24 - Issue 17 - p 2665–2678
doi: 10.1097/QAD.0b013e32833f4b1b
Clinical Science
Entry and retention in medical care among HIV-diagnosed persons: a meta-analysis
Marks, Gary; Gardner, Lytt I; Craw, Jason; Crepaz, Nicole
Author Information
Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
Received 7 May, 2010
Revised 2 August, 2010
Accepted 11 August, 2010
Correspondence to Gary Marks, PhD, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, MS: E-45, Atlanta, GA 30333, USA. Tel: +1 404 639 5261; fax: +1 404 639 6127; e-mail: gmarks@cdc.gov
Abstract
Objective: A ‘test and treat’ strategy to reduce HIV transmission hinges on linking and retaining HIV patients in care to achieve the full benefit of antiretroviral therapy. We integrated empirical findings and estimated the percentage of HIV-positive persons in the United States who entered HIV medical care soon after their diagnosis; and were retained in care during specified assessment intervals.
Methods: We comprehensively searched databases and bibliographic lists to identify studies that collected data from May 1995 through 2009. Separate meta-analyses were conducted for entry into care and retention in care (having multiple HIV medical visits during specified assessment intervals) stratified by methodological variables. All analyses used random-effects models.
Results: Overall, 69% [95% confidence interval (CI) 66–71%, N = 53 323, 28 findings] of HIV-diagnosed persons in the United States entered HIV medical care averaged across time intervals in the studies. Seventy-two percent (95% CI 67–77%, N = 6586, 12 findings) entered care within 4 months of diagnosis. Seventy-six percent (95% CI 66–84%, N = 561, 15 findings) entered care after testing HIV-positive in emergency/urgent care departments and 67% (95% CI 64–70%, N = 52 762, 13 findings) entered care when testing was done in community locations. With respect to retention in care, 59% (95% CI 53–65%, N = 75 655, 28 findings) had multiple HIV medical care visits averaged across assessment intervals of 6 months to 3–5 years. Retention was lower during longer assessment intervals.
Conclusion: Entry and retention in HIV medical care in the United States are moderately high. Improvement in both outcomes will increase the success of a test and treat strategy.
Introduction
HIV investigators [1–5] recently have been discussing a ‘test and treat’ strategy for reducing transmission of HIV infection at the population level. The idea is to increase the number of people who become aware that they are HIV-positive through expanded testing efforts, assist these people in entering medical care, and initiate HAART at earlier stages of disease, for example, when CD4 cell counts are above 350/μl. Patients on HAART who see their medical providers regularly are more likely to have suppressed viral load than those who see their providers irregularly [6]. Those with suppressed viral load are less infectious and, thus, less likely to transmit HIV infection through risk behaviors [7,8].
We could better gauge the potential success of a test and treat strategy if we knew the proportion of HIV-diagnosed persons who enter care soon after their diagnosis and the proportion of HIV patients who are seen regularly for HIV medical care. Knowing these proportions can help guide resource allocation and programmatic efforts to improve these outcomes, and establish benchmarks for monitoring progress.
Several studies have examined entry and retention in care among HIV-diagnosed persons, but there is no single source for estimating these outcomes. Disparate conclusions can be reached if the results of one study or a small subset of studies are considered in isolation of the others. Quantitatively combining the findings from multiple studies through meta-analytic techniques can generate an integrated conclusion.
We performed meta-analyses of US studies conducted in the era of HAART to estimate the proportion of HIV-diagnosed persons who enter HIV medical care soon after their diagnosis (e.g., within 4 months of diagnosis); and the proportion of HIV-diagnosed persons who are retained in care, conceptualized in the analysis as having multiple HIV medical visits during specified assessment intervals (e.g., three or more visits in prior 12 months). Additionally, we examined each of these outcomes according to several methodological variables that may affect estimates of these outcomes (e.g., assessment interval for entry or retention in care, recruitment settings, sampling methods, source of outcome measures, and number of participants in the study).
Methods
Study selection
We searched three electronic databases (PUBMED, EMBASE, and CINAHL) for reports published between 1996 and 2009, including papers published electronically ‘ahead of print’ using multiple search terms (keywords and MESH terms). The combined terms ‘HIV’ and ‘care’ were cross-referenced with terms reflecting two domains: medical care (medical, primary, outpatient, ambulatory); and entry or retention in care (sporadic, regular, discontinue, utilize, utilization, connect, establish, engage, entry, enter, entrants, link, linkage, initiate, delay, retention, retain, routine, access, stable, stability, present, patterns, unmet needs). We also checked reference lists of reports identified in our search. Authors were contacted for additional or clarifying information when needed.
Studies were included in the analysis if they met the following criteria: conducted in the United States; started data collection no earlier than May of 1995 (beginning of HAART availability); and reported data on entry into HIV medical care or retention in HIV care from surveillance, observational, or epidemiological investigations. Data from the control arm of intervention trials to improve entry or retention in care among HIV-diagnosed persons were also included. For the entry into care outcome, we included studies that reported data on the proportion of HIV-diagnosed persons who entered HIV medical care within specified time intervals after diagnosis (e.g., had an HIV medical care visit within 4, 6, and 12 months of diagnosis). For the retention in care outcome, we included studies that provided data on the proportion of HIV patients, regardless of the length of time since diagnosis, who had multiple visits for HIV medical care during specified assessment intervals (e.g., three or more visits in past 12 months; visits in consecutive quarters or consecutive 6-month periods). Studies of retention in care were omitted if they did not have a specified time interval for assessing the outcome or if they had restrictive eligibility criteria (e.g., only patients who had received case management or ancillary services at a clinic were monitored for medical care attendance; only newly enrolled patients who had an initial clinic visit were selected for analysis and observed to see who returned for a second visit within 6 months). Only three studies were omitted based on these criteria [9–11].
Data extraction
Three reviewers independently abstracted the following data from eligible studies: the raw data for calculating the entry and retention outcomes, the time interval for assessing entry or retention in care, the manner in which retention in care was operationalized, the method used to obtain the outcomes [e.g., self-report, clinic medical records, state databases such as the HIV/AIDS Reporting System (HARS)], setting of HIV testing (for studies of entry to care), study participants, sampling/recruitment methods, location(s) of study, and date of data collection. There was an average of 91% agreement among reviewers in abstracting data from the articles. Disagreements were reconciled through discussion.
Methodological approach
The following rules guided data abstraction for the analyses:
1. A study could contribute data on both entry and retention in care if data were presented separately for these two outcomes.
2. If an article reported findings from more than one independent sample (e.g., data from different cities or states), each sample contributed data to the analysis.
3. Data from studies testing interventions to enhance entry or retention were not included unless findings were reported separately for a control arm that did not receive the intervention.
4. If multiple publications reported data from the same study, we used the findings from the publication that had the largest analytic sample or the most recent publication to avoid overlap.
Analytic methods
Separate meta-analyses were conducted for entry into care and retention in care. Standard meta-analytic approaches were used [12]. For each study in the analysis, a proportion was calculated by dividing the number of participants (n) with the outcome by the total number of participants in the study (N). In aggregating the findings, we multiplied each proportion by its corresponding weight (inverse variance), summed the weighted proportions across findings, and then divided by the sum of the weights. To meet the normal distribution assumption, we first converted the individual proportions to logits because there was substantial variation in findings across studies and the logit distribution is approximately normal [12]. All analyses were conducted on the logit scale and the final results were converted back to proportions for interpretation and displayed as percentages in the tables.
We examined the heterogeneity of the findings using the Q statistic, for which a significant result indicates the existence of heterogeneity, and the I2 statistic, which quantifies the percentage of variation across studies due to heterogeneity. I2 values around 25, 50, and 75% typically correspond to low, medium, and high heterogeneity, respectively. Because there was significant heterogeneity, the aggregated findings are based on a random-effects model. This model yields a more conservative estimate of variance and generates more accurate inferences about a population of studies beyond those included in the review [13].
Stratified analyses examined entry and retention in care according to several methodological variables displayed in Tables 1 and 2 [14–16].QB tests were conducted to test whether point estimates differed across subgroups of a specific variable (test of heterogeneity) with the estimated random-effects variance component added to the standard error within each subgroup [12]. Some of the stratified variables were highly collinear, precluding multivariate comparisons.
 Table 1 Image Tools |  Table 2 Image Tools |
In sensitivity analyses, we compared the aggregated result from the meta-analysis with results obtained after iterations using k-1 findings (k = number of independent findings). That is, we removed a finding and calculated the overall proportion. Then, we replaced that finding, removed another, and repeated the process. Additionally, two studies[17,18] had much longer time intervals (3 and 5 years) for assessing retention in care than the other studies. We repeated the analyses after omitting these two studies.
Publication bias was examined through inspection of funnel plots of logit scores and standard errors. There was no evidence of publication bias for either outcome. All analyses were conducted using the Comprehensive Meta-Analysis software version 2 (Biostat, Englewood, New Jersey, USA) [19].
Results
Entry into care
Twenty-six US studies contributed 28 independent findings on entry into care (Fig. 1) with a total of 53 323 HIV-diagnosed persons. Table 3[14–17,20–41] provides descriptive summaries and findings of those studies. Data were collected from 1995 to 2009 in multiple regions of the United States. Twelve findings were based on data collected before 2003 (early HAART era) and 16 findings were from data collected in 2003 or later.
 Fig. 1 Image Tools |  Table 3 Image Tools |
The overall aggregated result indicated that 69% [95% confidence interval (CI) 66–71%, k = 28] of HIV-diagnosed persons in the United States entered HIV medical care averaged across the assessment intervals examined in the studies. There was significant heterogeneity of results across the 28 findings (Q27 = 336, P < 0.0001, I2 = 93.0%). In k-1 analysis, the aggregated result ranged from 67.7 to 69.7% after deleting one finding at a time. The narrow range attests to the limited effect of removing single findings from the analysis.
Table 1 displays the findings of the stratified analyses. The percentage of HIV-diagnosed persons who entered care was higher in studies that collected data in 2003 and later than in studies that collected data before 2003 (72 versus 65%, QB = 3.87, P = 0.05). Entry into care did not differ significantly by interval of time since diagnosis. Entry within 4, 6, and 12 months of diagnosis was 72, 72, and 64%, respectively. Many of the ‘4-month findings’ (eight of 12) and ‘6-month findings’ (four of seven) but none of the ‘12-month findings’ were based on persons who tested HIV-positive at emergency/urgent care departments. A higher percentage entered care when HIV testing was done in emergency/urgent care departments (76%) than when testing was done in other community venues (67%, QB = 3.16, P = 0.07). The setting in which HIV testing took place was also highly collinear with two methodological variables in Table 1 (method for obtaining participants and sample size). All of the studies in emergency/urgent care departments were conducted on consecutive persons who tested HIV-positive and all of those studies, except two, had small sample sizes (n < 100).
Retention in care
Twenty-eight US studies contributed 28 findings on retention in care (Fig. 1), with a total of 75 655 HIV-diagnosed persons. Table 4 [6,14–18,42–63] presents the findings and summaries of those studies. All but four [14–17] were unique from the studies of entry into care. The data were collected from 1996 to 2006, again in multiple regions of the United States. Only four studies collected data in 2003 or later.
 Table 4 Image Tools |  Table 4 Image Tools |
The overall aggregated result from the 28 findings indicated that 59% (95% CI 53–65%) of HIV-diagnosed persons, regardless of the length of time since diagnosis, had multiple HIV medical care visits averaged across the assessment intervals. There was significant heterogeneity of results across individual findings (Q27 = 6327, P < 0.0001, I2 = 99.6%). In k-1 analysis, the estimates ranged from 57.5 to 60.7% after removing one study at a time. The estimate increased slightly (62%, 95% CI 57–66%) after omitting the two studies [17,18] that had long assessment intervals (3 and 5 years).
Table 2 displays the stratified findings. The percentage of HIV-diagnosed persons retained in care was higher in studies conducted before 2003 (62%, k = 24) than in studies conducted in 2003 or more recently (42%, k = 4, QB = 8.40, P = 0.004). Retention in care differed by the length of the assessment interval (QB = 31.88, P < 0.001). Sixty-nine percent had two or more HIV medical care visits during a 6-month interval. Retention during a 12-month interval was 54% (based on findings that had a threshold of two or more medical visits during the interval) and 59% (based on findings that had a threshold of three or more medical visits during the interval). Retention was 61% during an interval of 18–24 months (medical visits in consecutive 6-month periods) and 26% during an interval of 3–5 years (medical visits in consecutive years).
The findings for the other stratified variables in Table 2 are presented in two ways: before the two 3–5-year retention findings were omitted; and after those two findings were excluded (in parentheses in Table 2). Our narrative below focuses on the results after exclusion. Retention was highest in persons with some prior history of HIV medical care (65%) and lowest when HIV-diagnosed persons were selected from state databases (55%). Retention was highest in studies that used patient self-reports as the outcome measure (72%) and lowest in studies that used state databases (55%). Retention in care did not differ appreciably between higher-risk samples (consisted of drug users, persons with mental health problems, recently released from prison, or persons unstably housed) versus more general samples, or between larger versus smaller samples.
Discussion
Our findings offer an encouraging picture of entry into HIV medical care among persons in the United States diagnosed with HIV infection during the HAART era. Overall, 69% entered HIV medical care averaged across time intervals and 72% entered care within 4 months of diagnosis. There was modest improvement from the first half of the HAART era (data collected before 2003) to the second half (2003 and later). This trend is consistent with previously published findings indicating that patients' CD4 cell counts at first visit for HIV care have improved from 1997 to 2007 [64].
Our analysis revealed that 76% of persons who tested HIV-positive at emergency/urgent care departments entered care. HIV medical care may be colocated within the same medical complex that houses the emergency department, thus facilitating linkage to care [22,26,27,34]. Conducting HIV testing in emergency departments is important because persons who are unaware of their HIV infection may present at those departments for other health issues. There has been concern about whether HIV testing can be successfully integrated in busy emergency departments. In a national survey of 102 university-affiliated medical emergency departments, only 58 of 102 offered rapid HIV testing and only 34 of the 58 (59%) had the capability to link someone testing positive to clinical care [65]. Lack of personnel to link HIV-positive patients to care was the second most frequent reason cited for not offering rapid HIV testing. Our findings suggest that, on average, when emergency departments conduct HIV testing, linkage to care is higher than in community settings.
Retention in care was higher in studies conducted before 2003 than in studies conducted more recently. This should not be interpreted to mean that retention has gotten worse. Only four studies were conducted in 2003 or later and the aggregated results of those studies may be unstable. Overall, 59% of HIV-diagnosed persons had multiple medical care visits averaged across assessment intervals. In stratified analyses, 69% had two or more medical care visits in a 6-month interval. This is a short time span for gauging retention. Retention was 54% in studies that had a threshold of two or more medical visits in 12 months and 59% in studies with a threshold of three or more in 12 months. The percentage was similar in studies that measured retention during an 18–24-month interval (61% had at least one HIV medical care visit in consecutive 6-month periods). None of the studies provided information regarding patient's treatment plan (e.g., provider's recommendation about how often a patient should return for care), which is likely to vary across patients. Although it is difficult to gauge the percentage of patients who were not retained in care according to their individualized plans, the findings of our meta-analysis can be viewed in the context of the US Department of Health and Human Services general recommendations about HIV care [66]. Those recommendations call for most ongoing HIV patients to have medical visits for monitoring CD4 cell count and viral load every 3–4 months. Some patients who are fully adherent to their antiretroviral therapy (ART) regimens and have sustained viral suppression and stable clinical status may be asked to return for care every 6 months [66]. If we use these general recommendations as a standard, then our aggregated findings suggest that up to 40% of HIV patients may be falling short of recommendations for retention in care. Studies with individual-level data on compliance with treatment plans are needed for a more precise estimate [67].
Our meta-analyses are not without limitations. First, the stratified analyses were bivariate comparisons unadjusted for other variables. Some of the variables were highly collinear and could not be entered together in a multivariate analysis. Caution is warranted in interpreting the subgroup comparisons. Second, there was substantial heterogeneity in the findings for entry into care as well as retention in care. The stratified analysis helped sort out some of the variation, but the aggregated estimates contain all of this heterogeneity and should be interpreted accordingly. Third, the studies of retention in care focused on patient attendance for regular (primary) medical care, but it is possible that some urgent care visits or other types of visits were inadvertently included. This would inflate estimates of attendance for regular care.
Other limitations are more specific to the studies themselves. Retention in care was highest when based on patient self-report (72%). Self-reports may be prone to error and also to social desirability biases that may inflate estimates of retention. State databases (e.g., HARS) generated the lowest estimates of retention in care even after omitting the two database studies that had assessment intervals of 3 and 5 years [17,18]. Studies that used state databases generally relied on the presence of a CD4 cell or viral load laboratory result in the database as an indicator of receipt of HIV medical care. Some patients, however, may have had medical care visits without having specimens drawn for testing. For other patients, laboratory results may not have been reported to state HARS or may have been misidentified. Finally, HIV patients may move out of a reporting area and receive care elsewhere. Consequently, state databases may underestimate retention in care.
Entry and retention outcomes may be improved through interventions. Studies have shown that linkage coordinators who work with newly HIV-diagnosed persons using a strength-based approach (i.e., identifying and utilizing the strengths of each individual) can significantly increase the number of persons who enter care in a timely manner [16,68]. Having such coordinators available at HIV testing sites (e.g., cross-training posttest counselors to perform linkage coordination) and at local health departments may increase linkage rates. Improving retention in care may be more challenging. Programs are needed in HIV clinics to address, at the patient-level, informational, motivational, and behavioral factors that may affect clinic attendance. Additionally, some patients may have unmet needs pertaining to housing, transportation, mental health, or drug use that require referral to case managers, social workers, or other professionals. Clinic-level factors are also important, including patient-friendly administrative and medical systems, positive provider–patient relationships, flexible clinic hours, and appointment reminder notices (e.g., phone calls, e-mails, text messages). Further, clinics may need to coordinate with public health department personnel who may be able to locate patients who have fallen out of care and motivate them to return [69].
Our meta-analyses concerned only two aspects of the test and treat strategy. The strategy includes several components: HIV testing to identify persons with unrecognized infection, linkage to care, retention in care, provision of ART, and adherence to treatment regimen to achieve viral suppression. Our findings provide baseline estimates for entry and retention in care and indicate that there is considerable room for improvement in these parameters.
Acknowledgements
The authors sincerely thank the following authors for providing additional data to assist their coding and analyses: Yvette Calderon, Jason Haukoos, Sung-Yeon Kang, Michael Lyons, Abigail Silva, and Douglas White. No compensation was given for any contributions made by these individuals.
G.M. has full access to all the data in the analysis and takes responsibility for the integrity of the data and the accuracy of the findings. G.M., L.I.G., and J.C. contributed to study concept and design and acquisition of data. G.M. and N.C. contributed to statistical analysis and interpretation of data. G.M. drafted the article. G.M., L.I.G., J.C., and N.C. contributed to critical revision of the article for important intellectual content.
All authors have read and approved the article for submission to AIDS.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention.
None of the findings from the analysis reported herein have been published in any article, abstract, or letter. The findings have not been presented at any professional meeting or conference.
No author has any potential conflicts of interest, including specific financial interests, relationships, or affiliations with external entities relevant to the subject of this article.
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This article has been cited 1 time(s).
AIDS
The role of the health system in HIV treatment-as-prevention
AIDS, 24(17): 2741-2742.
10.1097/QAD.0b013e3283408735
PDF (86) | CrossRef
The role of the health system in HIV treatment-as-prevention
AIDS, 24(17): 2741-2742.
10.1097/QAD.0b013e3283408735
PDF (86) | CrossRef
Keywords:
AIDS; entry; HIV; medical care; retention
© 2010 Lippincott Williams & Wilkins, Inc.
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