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Time From Testing Positive for HIV to Presentation for Primary Care

Jeffrey H. Samet, MD, MA, MPH; Kenneth A. Freedberg, MD, MSc; Michael D. Stein, MD; Rachel Lewis, BA; Jacqueline Savetsky, MPH; Lisa Sullivan, PhD; Suzette M. Levenson, MPH; Ralph Hingson, ScD

Arch Intern Med. 1998;158:734-740.

Background  Human immunodeficiency virus (HIV)–infected individuals' initial presentation to medical care frequently occurs at a point of advanced immunosuppression.

Objectives  To investigate the time between HIV testing and presentation to primary care. Also to examine factors associated with delayed presentation.

Methods  One hundred eighty-nine consecutive outpatients without prior primary care for HIV infection were assessed at 2 urban hospitals: Boston City Hospital, Boston, Mass, and Rhode Island Hospital, Providence. Sociodemographics, alcohol and drug use, social support, sexual beliefs and practices, and HIV testing issues were examined in bivariate and multivariate analyses for association with delay in presentation to primary care after positive test results for HIV.

Results  Of 189 patients, 74 (39%) delayed seeking primary care for more than 1 year, 61 (32%) delayed for more than 2 years, and 35 (18%) for more than 5 years after an initial positive HIV serologic evaluation. The median CD4⁺ cell count of subjects was 0.28x10⁹/L (range, 0.001-1.71x10⁹/L). In multiple linear regression analysis the following characteristics were found to be associated with delayed presentation to primary care after HIV testing: history of injection drug use (P<.001); not having a living mother (P=.01); not having a spouse or partner (P=.08); not being aware of HIV risk before testing (P<.001); and being notified of HIV status by mail or telephone (P=.002). An interaction effect between sex and screening for alcohol abuse was significant (P=.03) and suggested longer delays for men with positive screening test results (CAGE [an alcoholism screening questionnaire containing 4 structured questions], 2+) compared with men without positive screening test results or women.

Conclusions  Patients with positive HIV test results often delay for more than a year before establishing primary medical care. Information readily available at the time of HIV testing concerning substance abuse, social support, and awareness of personal HIV risk status is useful in identifying patients who are at high risk of not linking with primary care. Patients who were notified of their HIV status by mail or telephone delayed considerably longer than those notified in person. Efforts to ensure primary care linkage at the time of notification of positive HIV serostatus are necessary to maximize benefits for both individual and public health and should be an explicit task of posttest counseling.

From the Section of General Internal Medicine, Departments of Medicine (Drs Samet and Freedberg, and Mss Lewis and Savetsky), Social and Behavioral Sciences (Drs Samet and Hingson and Ms Levenson), and Epidemiology and Biostatistics (Drs Freedberg and Sullivan), Boston University School of Medicine and Public Health, Boston, Mass; and the Department of Medicine, Brown University School of Medicine, Providence, RI (Dr Stein).

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