Trends and predictors of linkage to HIV outpatient care following diagnosis in the era of expanded testing in England, Wales and Northern Ireland: Results of a national cohort study.

Abstract

We explore trends in linkage to HIV care following diagnosis and investigate the impact of diagnosis setting on linkage in the era of expanded testing. All adults (aged≥15years) diagnosed with HIV between 2005 and 2014 in England, Wales and Northern Ireland (EW&NI) were followed up until the end of 2017. People who died within 1month of diagnosis were excluded (n=1009). Trends in linkage to outpatient care (time to first CD4 count) were examined by sub-population and diagnosis setting. Logistic regression identified predictors of delayed linkage of >1month, >3months and >1year post-diagnosis (2012-2014). Overall, 97% (60250/62079) of people linked to care; linkage ≤1month was 75% (44291/59312), ≤3months was 88% (52460) and ≤1year was 95% (56319). Median time to link declined from 15days [interquartile range (IQR): 4-43] in 2005 to 6 (IQR: 0-20) days in 2014 (similar across sub-populations/diagnosis settings). In multivariable analysis, delayed linkage to care was associated with acquiring HIV through injecting drug use, heterosexual contact or other routes compared with sex between men (>1month/3months/1year), being diagnosed in earlier years (>1month/3months/1year) and having a first CD4 ≥ 200 cells/μL (>3months/1year). Diagnosis outside of sexual health clinics, antenatal services and infectious disease units predicted delays of >1month. By 3months, only diagnosis in 'other' settings (prisons, drug services, community and other medical settings) was significant. Linkage to care following HIV diagnosis is relatively timely in EW&NI. However, non-traditional testing venues should have well-defined referral pathways established to facilitate access to care and treatment.