A Multistate Analysis of Longitudinal Care Outcomes Among People Newly Linked to Human Immunodeficiency Virus Care in...

Advancing the HIV response in Missouri, an Ending the HIV Epidemic priority state, requires stronger characterization of treatment gaps. Routine cross-sectional reporting may fail to capture important gaps in care that longitudinal methods can reveal.

We characterized clinic engagement and viral suppression among people with Human Immunodeficiency Virus (HIV) aged ≥18 years who were newly linked to clinic in St Louis, Missouri, between 1 January 2015 and 15 March 2020. Using multistate analytic methods that capture change over time, we estimated the prevalence of individuals in 9 mutually exclusive and exhaustive states over 3 years following linkage to clinic. Care states were based on engagement (disengagement ≥90 days late for a scheduled appointment) and viral load status (suppression defined as viral load <200 copies/mL ≤200 days).

Overall 1110 patients were newly linked to clinic during the observation period, contributing 2255.4 person-years of follow-up. One year following linkage, 54.8% (95% CI, 51.6%-57.9%) were continuously retained, 15.2% (95% CI, 13.0%-17.7%) were reengaged, and 29.3% (95% CI, 26.6%-32.2%) were disengaged. In addition, 93.0% (95% CI, 90.6%-95.1%) of continuously retained individuals were virally suppressed at 1 year as compared with 81.6% (95% CI, 75.2%-87.7%) of reengaged individuals. Younger individuals and those from historically marginalized communities were more likely to disengage, reengage, and become viremic.

Multistate methods revealed a pattern of disengagement from clinic and reengagement, accompanied by elevated risk of viremia during disengagement. Shifting retention efforts from preventing isolated missed visits toward supporting sustained, long-term engagement in care is a key priority.