Background
Poor retention in HIV care has been associated with adverse clinical outcomes. We sought to understand barriers to care and factors related to being out of care (OOC) in the DC Cohort, a longitudinal cohort of PWH in Washington, DC, using data from clinical care sites and linked data from the DC Department of Health (DC Health).
Methods
We evaluated the status of DC Cohort participants from 1/1/11 to 12/31/23. Participants were considered OOC if they did not have an HIV care encounter or lab in the 18 months prior. We used DC Health HIV Surveillance lab data and manual clinical chart review to determine whether participants initially deemed OOC had died, transferred to another site, had evidence of care elsewhere in DC, or were truly OOC. Logistic regression models were used to describe the OOC population and evaluate associations between participant characteristics and being OOC.
Results
We evaluated 12,563 DC Cohort participants. Overall, 1,418 (11%) died, 41 (0.3%) withdrew, 1,893 (15%) transferred care, 517 (4.1%) statuses could not be determined, and 2,101 (24%) were considered OOC. Linked DC Health data showed 1,353 (64%) of the OOC participants had evidence of care elsewhere at least 6 months after their last Cohort contact. Of those with known labs, 82% were virally suppressed and 63% had CD4 ³ 500 cells/mL. This left 748 participants OOC and 6,557 participants in care. Among those OOC, 64% were non-Hispanic Black, 79% male, and the mean age was 52. OOC participants were more likely to be non-Hispanic White, (aOR (95% CI): 1.7 (1.4, 2.2)), 10 years older (aOR: 1.2 (1.1, 1.3)), not virally suppressed (aOR: 3.5 (2.8, 4.5)), not have AIDS (aOR: 1.7 (1.4, 2.1)), be unemployed (aOR: 1.6 (1.2, 2.1)), and receive care at a Ryan White clinic (aOR: 1.5 (1.2, 1.9)). Being female (aOR: 0.7 (0.5, 0.8)), perinatally infected (aOR: 0.3 (0.1, 0.6)), having a CD4 ³ 500 cells/mL (aOR: 0.5 (0.4, 0.8)), public insurance (aOR: 0.4 (0.4, 0.6)), hypertension (aOR: 0.6 (0.5, 0.7)), and hyperlipidemia (aOR: 0.4 (0.3, 0.4)) were associated with a lower likelihood of being OOC.
Conclusions
By linking clinical and surveillance data we were able to more accurately assess PWH’s care status in the Cohort. While 24% of participants were thought to be OOC, 64% of those were found to have transferred and most had evidence of VS after transfer. Individual and structural level factors were associated with being OOC and interventions aimed at addressing these factors may help improve sustained engagement in care.