HIV patients who miss appointments have increased risk of death

HIV-positive patients who miss hospital appointments in the first year after their diagnosis have an increased risk of death, US researchers report in the January 15^th edition of Clinical Infectious Diseases. Even after controlling for CD4 cell count and use of antiretroviral therapy, patients who missed appointments still had an increased risk of death.

The investigators do not believe that missing occasional appointments in the first year of HIV care in itself contributed to mortality. Rather they suggest that missing appointments could act as a warning sign that an individual could have characteristics associated with a poorer outcome.

In 2006 a policy of routine, opt-out HIV testing was recommended for all adults using healthcare facilities in the US. The policy was introduced because of concerns that as many as 25% of the individuals with HIV in the US are undiagnosed.

If successful, this testing policy could result in a significant increase in the number of patients accessing HIV care. Earlier research has shown that a significant proportion of patients recently diagnosed with HIV do not attend follow-up appointments and that this can mean that there are delays in providing treatment and care.

Investigators from the University of Birmingham, Alabama, wished to explore the relationship between missed hospital appointments during the first year after diagnosis with HIV and longer-term survival. They hypothesised that patients who missed appointments had higher mortality.

They therefore performed a retrospective study involving 543 patients who were diagnosed at the clinic between 2000 and 2005.

These patients had a mean age of 38 years. The majority (54%) of patients were black. Most of the patients (52%) acquired HIV through sex with another man. Mean baseline viral load was 25,000 copies/ml and 38% of patients had a baseline CD4 cell count below 200 cells/mm³, with 67% of these patients being prescribed antiretroviral therapy in the first year. Over a third of patients had no health insurance and 15% had public insurance.

The investigators looked at records of clinic attendance during the first year after diagnosis and compared subsequent mortality between patients who missed appointments and those who did not. They also recorded the details of the patients’ age, sex, race, HIV risk group, mental health status, use of drugs and alcohol, CD4 cell count, viral load, use of HIV treatment and health insurance status.

In the first year after diagnosis with HIV, 60% of patients failed to attend an outpatient appointment. They found that 32 patients (10%) who missed an appointment died compared to ten patients (5%) who kept all their appointments.

Factors associated with missed appointments were younger age (odds ration [OR], 0.81 per ten years, 95% confidence interval [CI], 0.66-0.99), black race (OR, 2.74, 95% CI, 1.77-4.23), and having public health insurance (OR, 2.09, 95% CI, 1.10-3.96).

The investigators' statistical analysis revealed a significant relationship between missing appointments in the first year and an increased risk of death (p = 0.02). Mortality was 2.3 per 100 person years amongst patients who missed an appointment in the first year after diagnosis compared to 1 per 100 person years amongst patients who did not.

Other factors associated with an increased risk of death were older age and a CD4 cell count below 200 cells/mm³. Even when the investigators performed further analysis that controlled for the use of antiretroviral treatment and CD4 cell count, they still found that missing appointments in the first year after diagnosis was associated with an increased risk of death.

“Missed primary HIV care visits in the year after establishing initial outpatient treatment was associated with subsequent mortality, even when controlling for baseline CD4 cell count and receipt of antiretroviral therapy within the first year”, comment the investigators.

The mortality rate amongst patients who missed appointments was double that of patients who attended all their appointments, and the investigators suggest “extrapolation of our findings to the national level of the general population results in considerable mortality”.

They speculate that patients who are less likely to be retained in subsequent HIV care and who have poorer adherence to HIV treatment can be predicted by looking at patients who miss appointments in the first year. “Accordingly, missed visits in patients establishing initial outpatient treatment may serve as a marker in identifying individuals at risk of poor future treatment outcomes.”