Health Policy$ense

HIV diagnosis and care – Does setting matter?

Does the particular setting and location of HIV diagnosis and care affect HIV outcomes? Two recent studies by LDI Senior Fellow Baligh R. Yehia, MD, Assistant Professor of Medicine and Director of the Penn Medicine Program for LGBT Health, and his colleagues, seek to answer this question.  

Location of HIV Diagnosis and Linkage to Medical Care
In a study published in the Journal of Acquired Immune Deficiency Syndrome, Dr. Yehia and colleagues look at whether the site of HIV diagnosis affects access to treatment and care.  Linkage to HIV care is imperative to maintaining the health of HIV-infected patients and reducing the number of new HIV infections. Today, only about 50% of persons diagnosed with HIV regularly engage in HIV care.

The authors analyzed 1,359 adults newly diagnosed with HIV in Philadelphia in 2010-2011, and classified their diagnosis site (medical clinic, inpatient setting, counseling and testing center (CTC), or correctional facility). Approximately 80% of the patients were linked to care, but the site-specific figures varied widely. Linkage to care by diagnosis site ranged from 86% of those diagnosed in medical clinics to only 44% of those diagnosed in correctional facilities. 

After adjusting for other factors, Dr. Yehia and colleagues conclude that receiving an HIV diagnosis in inpatient settings, CTCs, and correctional facilities results in a 23%, 46%, and 75% decrease in the probability of linkage to care compared with medical clinics, respectively. Additionally, the hazard of not linking to care is greater for black patients and persons with intravenous drug use as their HIV risk factor. They write that:

In contrast to inpatient and correctional facilities, persons diagnosed in medical care clinics had higher linkage rates. Integration of HIV testing and medical services may facilitate linkage to care by decreasing appointment wait times, leveraging patients’ familiarity with the clinic environment and staff, and providing ancillary support services (e.g., case management, social work). 

Location of Care Site and HIV Outcomes
In AIDS Patient Care and STDs, Dr. Yehia and colleagues explore whether the site of HIV care, at either a hospital or community-based center, influences HIV outcomes.

The authors conducted a retrospective cohort study of 12,637 HIV-infected adults in care at 25 Ryan White Program-funded clinics in the Philadelphia area between 2008 and 2011. Of these 25 clinics, 12 were classified as hospital-based. The authors examined the relationship between care setting and HIV outcomes. The study measured outcomes by completion of the final three steps of the HIV care continuum: (1) retention in care; (2) use of antiretroviral therapy; and (3) viral suppression. 

The authors find that women, non-Hispanic blacks, those with private insurance, and individuals with higher household incomes more commonly attend hospital-based clinics. Adjusting for patient and clinic factors, care setting was not associated with HIV outcomes. Therefore, although demographics differ among patients visiting hospital- and community-based clinics, completion of the final three steps of the HIV care continuum do not vary between hospital and community-based clinics. The authors conclude that this lack of variance may reflect advances in HIV therapy and the wide availability of HIV care resources.

Taken together, these two studies show that for patients engaged in care the location of HIV care does not affect HIV outcomes, while the location of HIV diagnosis does affect the probability of linkage to HIV care. Further research and resources should be dedicated to facilitating linkage to care for HIV-infected individuals newly diagnosed in correctional facilities, counseling and testing centers, and inpatient settings.

Daniel Calder, MPH is the Program Coordinator for the Penn Medicine Program for Lesbian, Gay, Bisexual, and Transgender Health.