Background: Despite development of safe and effective human immunodeficiency virus (HIV) treatment, about 40,000 new transmissions of HIV occur in the United States each year. About 61% of new infections are transmitted by individuals with known diagnoses but are not retained in medical care. These patients often lack access to traditional care systems. This project sought to identify out-of-care individuals, presenting to the emergency department (ED), and re-engage them to care by starting comprehensive HIV management in the ED.
Methods: The HIV fellow was consulted for any patient with a past diagnosis of HIV. Patients were considered out-of-care if they met any of the following criteria: had not see a primary care doctor in the previous six months, not currently taking or prescribed antiretroviral therapy, or high viral load. Fellows developed a HIV care plan for each patient including relevant lab work, medications, and follow-up instructions. They also documented patients’ self-reported barriers to care. A chart review was performed to determine successful re-engagement, defined as one follow up visit. We also examined barriers associated with persistent failure to re-engage.
Results: Patients meeting out-of-care status were included in the study (N=129). 49% of out-of-care individuals (n=63) re-engaged in HIV care. The top four barriers reported were substance abuse (27.9%), homelessness (36.6%), no cell phone (14%), and mental health (15.4%). Compared to those who successfully re-engaged to care, reported rates of homelessness for those who failed to re-engage were 14.4% (95%CI-12.7 to 41.4) higher. Rates of mental health problems were 2.4% (95%CI -18.2 to 22.9) higher. Rates of substance abuse were 3.9% (95%CI -24.4 to 32.2) higher. These differences were not statistically significant at an alpha of 0.05.
Conclusion: Almost half of patients seen as part of our comprehensive HIV program successfully re-engaged in HIV care. This study shows that a ED-based HIV re-engagement program has great potential to decrease the number of out-of-care individuals with HIV and reduce long term sequelae of HIV. Substance abuse, homelessness, and mental health disorders were associated with failure to re-engage. We should be mindful of these barriers and have appropriate resources available to help mitigate against them when designing ED-based re-engagement programs.