Retention in HIV care: what the clinician needs to know

Abstract

Poor retention in HIV disease care is a common, modifiable risk factor associated with poor outcomes, including higher rates of antiretroviral therapy failure, increased HIV transmission risk behaviors, and worse survival. Predictors of poor retention include younger age, female sex, racial or ethnic minority status, low socioeconomic status, no usual source of health care, less advanced HIV disease, fewer non-HIV-related comorbidities, and greater unmet psychosocial needs. Thus far, there have been few published randomized trials of interventions to improve retention. The fact that most clinics are understaffed and underresourced in a flat funding environment raises serious questions about the translation, dissemination, and sustainability of interventions found to be successful in the research setting. Efforts to improve retention in care should incorporate informational, motivational, and behavioral skills components. Practical steps can be taken by clinics to improve retention. This article summarizes a lecture by Thomas P. Giordano, MD, MPH, at the 13th Annual Clinical Conference for the Ryan White HIV/AIDS Program held in Washington, DC, in August 2010.

Figure 1

Cumulative probability of survival according to the number of quarters with an HIV care visit during the first year after receipt of an antiretroviral therapy prescription. Based on Veterans Affairs data for patients initiating antiretroviral therapy in the late 1990s. Adapted from Giordano et al.

Figure 2

Examples of measuring retention in care. Top, quarterly tracking of attended appointments (checked boxes) and missed appointments (X). Bottom, various measures of the tracking results for Patients A through D. HRSA indicates Health Resources and Services Administration; HAB, HIV/AIDS Bureau. Adapted from Mugavero et al.18