HIV patients who delay seeking care are much sicker when they begin care

Patients recently diagnosed with human immunodeficiency virus (HIV) are significantly more likely to seek medical treatment if they are followed even briefly by a case manager, according to findings of the national Antiretroviral Treatment Access Study (ARTAS).

Physician/researchers in Atlanta, Baltimore, Los Angeles and Miami evaluated individuals recently diagnosed with HIV and found that patients who worked with case managers were 40 percent more likely to visit an HIV clinician in the outpatient setting at least twice within the first year following diagnosis. The findings were published in the March 4 issue of the journal AIDS.

The ARTAS study, funded by the Centers for Disease Control and Prevention (CDC), randomized 316 recently diagnosed HIV patients to two groups. Half the patients were offered the standard of care, which includes counseling and a single "passive referral" to a medical care provider with no follow-up. The other group of patients was introduced to a case manager who met with them individually between three and five times after the initial diagnosis. The meetings were intended to build a relationship between patient and case manager, identify and address the needs of the patient and barriers to seeking treatment, and to encourage contact with an HIV clinic. If needed, the case manager accompanied the patient to a clinic. All contacts between case managers and patients occurred within 90 days after the beginning of the study.

Seventy-eight percent of patients in the case-management arm of the study visited an HIV clinician at least once within 6 months and at least twice within 12 months following diagnosis, compared to only 60 percent of patients in the standard-of-care arm of the study. Sixty-four percent of the case-management group visited an HIV clinician at least twice within 12 months, compared to 49 percent of the standard-of-care group.

The researchers estimated the cost for the case management intervention to be approximately $4,000 per additional person linked to care beyond the number expected under standard of care.

Previous research has shown that about one-third of individuals who know they are HIV-infected are not receiving care, and many delay beginning care for more than a year after diagnosis. Patients who delay seeking care are much sicker when they begin care and are more likely to infect others. The CDC has identified linking HIV patients to appropriate care, prevention services and treatment soon after receiving a positive diagnosis as a primary prevention objective.

"Previous studies have shown the benefits of case management on use of antiretroviral therapy by individuals already in care," said Carlos del Rio, MD, professor of medicine at Emory University School of Medicine, chief of medical services at Atlanta's Grady Memorial Hospital and principal investigator for the Atlanta study site. "This is the first trial to compare head to head the typical passive referral with a time-limited employment of case management."

In addition to Emory, the study included researchers from the Division of HIV/AIDS at the CDC, the University of Miami School of Medicine, the Health Research Association in Los Angeles, the Johns Hopkins Bloomberg School of Public Health and the Wright State University.