A Multistate Analysis of Longitudinal Care Outcomes Among People Newly Linked to Human Immunodeficiency Virus Care in Missouri
Open Forum Infectious Diseases
Authors: Aditi Ramakrishnan, Daniel Vo, Ernie-Paul Barrette, Rachel M Presti, William G Powderly, Anne Trolard, Corey Grejtak-Heaps, Elvin H Geng, Aaloke Mody & Lindsey M Filiatreau
In this study, the researchers examined longitudinal patterns of HIV care engagement, disengagement, reengagement, and viral suppression among people with HIV (PWH) newly linked to care in St. Louis, Missouri. Missouri is an Ending the HIV Epidemic (EHE) priority state where traditional cross-sectional measures indicate substantial gaps in HIV retention and viral suppression. The authors hypothesized that longitudinal analysis could provide a more nuanced understanding of how individuals move into and out of HIV care over time.
The study used electronic health record data from 1,110 adults newly linked to a Ryan White–funded HIV primary care clinic at Washington University in St. Louis between January 2015 and March 2020. Using multistate analytic methods, researchers classified participants into nine clinical states based on clinic engagement and viral load status and estimated transitions among these states over three years. Disengagement was defined as being more than 90 days late for a scheduled appointment, while viral suppression was defined as a viral load below 200 copies/mL.
At one year following linkage, 54.8% of participants remained continuously retained in care, while 15.2% had reengaged after disengagement and 29.3% were disengaged. Among continuously retained patients, 93.0% were virally suppressed compared with 81.6% of those who had reengaged. By two years, 66.2% had experienced at least one episode of disengagement. Among individuals who disengaged, 54.5% subsequently reengaged, although only 41.3% remained reengaged one year later. Younger and Black participants were more likely to experience disengagement, reengagement, and viremia.
Overall, the findings demonstrate that HIV care engagement is not a linear process but a cyclical pattern of retention, disengagement, and reengagement. The authors conclude that HIV programs should prioritize sustained, long-term engagement, including support following reengagement, rather than focusing primarily on isolated missed visits. They also emphasize the value of multistate methods and real-time longitudinal data for identifying vulnerable points in the HIV care continuum and targeting retention and reengagement interventions, particularly among historically marginalized populations.