Poverty Is Associated with Missing HIV Primary Care Appointments: How Can Social Workers Help?

Background and Purpose: Poor retention of patients in HIV care (“retention”) is associated with suboptimal patient-level HIV clinical outcomes (e.g., viral non-suppression) and population-level HIV prevention outcomes (increased HIV transmission).  Research shows that patients who miss 3 or more scheduled HIV primary care visits have 4 times the mortality risk of patients who never miss scheduled visits (Mugavero et al, 2014). However, do patients who miss three or more visits differ from those who miss fewer than three? This study identified factors associated with poor retention and the extent to which such factors can predict the actual number of missed HIV primary care visits.

Methods: We obtained de-identified, patient-level medical records data from a large, urban, HIV/AIDS clinic in southeastern United States. The sample included 1,159 adults (≥ 18 years old) living with HIV who received HIV primary care services at the clinic. A primary care addresses routine medical care and is scheduled in advance (emergency, walk-in visits or specialty care not included). The primary outcome was retention (specifically, lack of retention), measured by the number of missed HIV primary care visits (0, 1-2, or 3+ missed visits). A missed visit is one that was not cancelled at any point prior to the scheduled visit. Predictors included: sex, age, race, education level, Ryan White HIV/AIDS Program (RWHAP) support services (yes/no), primary healthcare payer type (RWHAP, public insurance, private insurance, none), and poverty (based on monthly income). Multivariable multinomial logistic regressions compared factors associated with missing 1-2 vs. 0 visits, 3+ vs. 0 visits, and 3+ vs. 1-2 visits.

Results: In the full multivariable model, socioeconomic and demographic characteristics remained significantly associated with missing either 1-2 or 3+ visits (versus 0 missed visits--100% retention), including poverty, lack of RWHAP support services, not having at least a high school degree, and younger age. Compared with uninsured patients, those with private insurance had half the risk of missing 1-2 versus 0 visits (risk ratio [RR]=0.48, 95% confidence interval [CI]=0.28-0.83). Only poverty remained predictive of missing 3+ versus 1-2 visits (RR=2.70, 95% CI =1.49-4.88).

Conclusions and Implications: Patients at risk for missing 3+ visits, and who may have been at higher mortality risk, were not so different from patients who missed 1-2 visits. This finding is particularly relevant in terms of its potential to inform clinical interventions to improve retention in care. Social workers are well-suited to helping patients attend their appointments by supporting them to access support services and health insurance/healthcare assistance and, therefore, fulfill a vital role in HIV care.

References

Mugavero MJ, Westfall AO, Cole SR, Geng EH, Crane HM, Kitahata MM, et al. Beyond core indicators of retention in HIV care: missed clinic visits are independently associated with all-cause mortality. Clin Infect Dis. 2014;59(10):1471-9.