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An Exploratory Study to Assess Individual and Structural Level Barriers Associated With Poor Retention and Re-engagement in Care Among Persons Living With HIV/AIDS

Colasanti, Jonathan MD, MSPH; Stahl, Natalie MD; Farber, Eugene W. PhD; del Rio, Carlos MD; Armstrong, Wendy S. MD

JAIDS Journal of Acquired Immune Deficiency Syndromes: February 1st, 2017 - Volume 74 - Issue - p S113–S120
doi: 10.1097/QAI.0000000000001242
Supplement Article

Background: Retention in care is the most challenging step along the HIV care continuum. Many patients who engage in care and achieve viral suppression have care interruptions, characterized by moving in and out of care (“churn”). Poor retention has clinical consequences and contributes to new HIV transmissions, but how to predict or prevent it remains elusive. This study sought to understand the relationship between individual- and structural-level barriers, and poor retention for persons living with HIV/AIDS in Atlanta, GA.

Methods: We administered a survey, through interviews, with HIV-infected patients continuously retained in care for 6 years (“continuously retained,” n = 32) and patients with recent gaps in care (“unretained” n = 27). We assessed individual-level protective factors for successful engagement (self-efficacy, resilience, perceived social support, and disclosure), risk factors for poor engagement (substance use, mental illness, and stigma), and structural/systemic-level barriers (financial and housing instability, transportation, food insecurity, communication barriers, and incarceration history). Chi-square and Mann–Whitney U tests were used to compare the 2 populations.

Results: Both continuously retained and unretained populations had high rates of prior viral suppression but few unretained patients were virologically suppressed upon return to care (11%). Younger age, crack cocaine use, food insecurity, financial instability, housing instability, and phone number changes in the past year were significantly more likely to be present in the unretained population.

Conclusions: Our findings suggest the need for targeted risk assessment tools to predict the highest-risk patients for poor retention whereby public health interventions can be directed to those individuals.

*Department of Medicine (Infectious Diseases), Emory University School of Medicine, Atlanta, GA;

Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA;

Center for AIDS Research at Emory University, Atlanta, GA;

§Infectious Diseases Program, Grady Health System, Atlanta, GA;

Emory University School of Medicine, Atlanta, GA; and

Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA.

Correspondence to: Jonathan Colasanti, MD, MSPH, 341 Ponce de Leon Avenue North East, Atlanta, GA 30308 (e-mail:

Supported in part by the NIH/NIAID Emory CFAR (P30 AI050409) and the NIH/NIDA (RO1 DA032098).

The authors have no conflicts of interest to disclose.

J.C. and N.S. are cofirst authors.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.