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Understanding delays in HIV care initiation in the Southeastern US
S. Napravnik1, E.S. Brouwer1, E.B. Quinlivan2, P.A. Leone1, E.M. Foust3, M. Cohen1, A.C. Sena2, C.L. Gay2, L. Hightow-Weidman2, K.B. Patterson2, B. Stalzer2, M. Case2, H. Swygard2, J.J. Eron2
1The University of North Carolina at Chapel Hill, Medicine and Epidemiology, Chapel Hill, United States, 2The University of North Carolina at Chapel Hill, Medicine, Chapel Hill, United States, 3NC Department of Health and Human Services, North Carolina Division of Public Health, Raleigh, United States
Background: Initiating HIV care early after infection is essential to maximizing patient clinical outcomes and decreasing HIV transmission in communities. Therefore we assessed delays in HIV testing and care initiation in North Carolina, US.
Methods: In-depth interviews were conducted with HIV-infected observational clinical cohort participants. Patients were asked about their HIV testing history and reasons for delaying HIV care.
Results: The study population (N=333) included 36% women, 72% African Americans, a median 36 years of age at HIV care initiation (IQR: 31, 41). Patients were HIV diagnosed at public health departments (36%), during hospitalization (25%), at hospital outpatient clinics (17%), private physician offices (15%), and other venues (including drug treatment centers and prisons) (6%). Reasons for seeking HIV testing included: feeling sick (56%); knowledge of HIV exposure (18%); wanting to know HIV status with no identified HIV exposure (15%); and other reasons (including pregnancy, work/insurance requirement) (11%). Fifty-one percent initiated HIV care < 1 year after diagnosis, 28% 1-3 years, and 21% ≥3 years. Median CD4 at HIV care initiation was 289 cells/mm3 (IQR: 63, 528); 43% initiated care at CD4< 200. Initiating HIV care at CD4< 200 was associated with diagnosis during hospitalization versus other sites (72% versus 29%, P< 0.001), and testing due to illness versus other reasons (65% versus 13%, P< 0.001). Patient reported reasons for delaying HIV care initiation included: barriers to accessing HIV care (including clinic appointment wait times, not sure where to go) (51%); denial and fear (32%); feeling healthy (9%); financial concerns (5%); and other life issues (including ongoing drug use) (4%).
Conclusions: Many HIV-infected patients seek testing and are diagnosed due to illness. Barriers to accessing care, fear and denial are common reasons for delayed HIV care initiation, indicating innovative programs for early diagnosis and linkage to care are urgently needed.
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