Risk factors for delayed initiation of medical care after diagnosis of human immunodeficiency virus

Background: The full benefit of timely diagnosis of human immunodeficiency virus (HIV) infection is realized only if there is timely initiation of medical care. We used routine surveillance data to measure time to initiation of care in New York City residents diagnosed as having HIV by positive Western blot test in 2003. Methods: The time between the first positive Western blot test and the first reported viral load and/or CD4 cell count or percentage was used to indicate the interval from initial diagnosis of HIV (non-AIDS) to first HIV-related medical care visit. Using Cox proportional hazards regression, we identified variables associated with delayed initiation of care and calculated their hazard ratios (HRs). Results: Of 1928 patients, 1228 (63.7%) initiated care within 3 months of diagnosis, 369 (19.1%) initiated care later than 3 months, and 331 (17.2%) never initiated care., Predictors of delayed care were as follows: diagnosis at a community testing site (HR, 1.9; 95% confidence interval [CI], 1.5-2.3), the city correctional system (HR, 1.6; 95% CI, 1.2-2.0), or Department of Health sexually transmitted diseases or tuberculosis clinics (HR, 1.3; 95% CI, 1.1-1.6) vs a site with colocated primary medical care; nonwhite race/ethnicity (HR, 1.8; 95% Cl, 1.5-2.0); injection drug use (HR, 1.3; 95% CI, 1.1-1.5); and location of birth outside the United States (HR, 1.1; 95% CI, 1.0-1.2). Conclusions: A total of 1597 persons (82.8%) diagnosed as having HIV in 2003 ever initiated care, most within 3 months of diagnosis. Initiation of care was most timely when diagnosis occurred at a testing site that offered colocated medical care. Improving referrals by nonmedical sites is critical. However, because most diagnoses occur in medical sites, improving linkage in these sites will have the greatest effect on timely initiation of care.