Initiation of Antiretroviral Therapy in the Hospital Is Associated With Linkage to HIV Care for Persons Living With HIV and Substance Use

Clin Infect Dis. 2020 Jun 22;ciaa838. doi: 10.1093/cid/ciaa838. Online ahead of print.

Abstract

Background: Studies have demonstrated benefits of ART initiation on the day of HIV testing or at first clinical visit, regardless of CD4 count. The hospital setting is under-studied for immediate ART initiation.

Methods: CTN0049, a linkage to care randomized clinical trial, enrolled 801 persons living with HIV (PLWH) and substance use disorder (SUD) from 11 hospitals across the U.S. This secondary analysis examined factors related to initiating (including re-initiating) ART in the hospital and its association with linkage to HIV care, frequency of outpatient care visits, retention in care and viral suppression.

Results: Of 801 participants, 15% (124/801) initiated ART in the hospital, with more than two-thirds of these participants (65%;80/124) initiating ART for the first time. Time to first HIV care visit among those who initiated ART in the hospital and those who did not was 29 and 54 days, respectively, (p=0.0145). Hospital initiation of ART was associated with increased frequency of HIV outpatient care visits at 6-month (aOR=1.39, 95% CI [1.02, 1.88]) and 12-month follow-up assessments (aOR=1.53, 95% CI [1.15, 2.04]). There was no association with ART initiation in the hospital and retention in HIV care and viral suppression over a 12-month period. Participants recruited in Southern hospitals (compared to non-Southern hospitals) were less likely to initiate ART in the hospital (p<0.001). History of participation in substance use treatment was associated with greater likelihood of hospital ART initiation (p=0.008).

Conclusions: Previous research demonstrated benefits of immediate ART initiation, yet this approach is not widely implemented, particularly in the hospital setting with PLWH and SUD. Findings suggest starting ART in the hospital is beneficial for increasing linkage to HIV care and frequency of visits for PLWH and SUD. Implementation research should address patient and provider barriers to early ART initiation in the hospital.

Keywords: ART initiation; HIV; hospital; substance use; substance use disorder; treatment linkage.