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BACKGROUND: In 2013 there were almost 20,000 persons living with HIV in Texas that had no evidence of HIV-related medical care in that year. Linkage and retention in care are critical to receiving antiretrovirals, achieving viral suppression, and ultimately improving health outcomes and reducing HIV transmission. Texas implemented a pilot project in Dallas to determine the best mechanism for identifying persons out of care and re-engaging them in HIV-related medical care.
METHODS: The pilot project utilized surveillance data and medical records to identify HIV-positive persons not engaged in care. Surveillance defined out of care as no HIV-related test or HIV prescription in the past 12 months, and never linked to care as no test or prescription within 6 months of diagnosis. Medical providers considered someone out of care if there was no medical appointment in the past 6 months, or 2 or more missed appointments. Each person selected was contacted through telephone calls and home visits, and then assisted with scheduling medical appointments and referrals to other services.
RESULTS: By the end of 2013, 424 persons were selected in Dallas County. There were 175 persons that were ineligible for linkage to care: 53% were already engaged in care, 27% had moved, 10% were incarcerated and 7% were deceased. Of the 249 eligible for linkage to care, 21% of those selected by surveillance and 55% of those selected by a medical provider were successfully linked to care. Overall, those selected by surveillance were more likely to have never been engaged in care previously, and be male, black and younger than those selected by a medical provider. Some groups experienced greater success in linkage to care, including those less than 6 months out of care (85%), 35-44 years old (45%), black (45%), female (48%), and heterosexual (43%). Once linked to medical care, persons with a suppressed viral load increased from 0% at re-entry to care to 45% by mid-year 2014 if were identified by surveillance, and increased from 15% to 48% if identified by a medical provider.
CONCLUSIONS: People living with HIV that are out of care can successfully be identified and re-engaged in care. There are advantages to both mechanisms of identifying persons out of care; medical providers are able to identify someone has fallen out of care earlier, while surveillance has access to more information and can identify both persons never linked to care and those that have fallen out of care.