Moving toward a novel and comprehensive behavioral composite of engagement in HIV care

Suboptimal engagement in HIV care increases the risk of HIV-related morbidity and mortality; however, a comprehensive and practical measure of engagement in care does not exist. The objective of our study was to identify and develop a composite of engagement in HIV care. From May to August 2013, we conducted a cross-sectional study of HIV-positive individuals who consented to participate in an online survey. Engagement in care was assessed by the following self-reported variables: (1) having attended an HIV health-care provider appointment in the past six months, (2) reporting a scheduled future HIV health-care provider appointment, (3) knowing their last CD4+ cell count, (4) knowing their antiretroviral (ARV) medication names, (5) reporting ARV adherence >= 80% on the visual analog scale (VAS) and rating scale, (6) reporting adherence >= 90% on the VAS and rating scale, and (7) not having missed all ARVs for at least four days in a row in the past three months. To create the composite of engagement in care, the presence or absence of these variables were summed and categorized (7 = "high engagement," 5-6 = "moderate engagement," and 0-4 = "low engagement"). We examined the correlation between this composite and self-reported HIV viral load (VL; detectable versus undetectable) in a logistic regression model. We surveyed 1259 HIV-positive individuals: 85% reporting an undetectable VL and 67% reporting excellent adherence. Approximately 89%, 88%, and 67% of those with high, moderate, and low engagement, respectively, had an undetectable VL. Having moderate engagement was associated with 3.5-fold higher odds, and high engagement was associated with 4.0-fold higher odds of virologic undetectability compared to low engagement (overall p-value < 0.0001). Our data indicate that this novel and comprehensive composite of engagement may be a useful tool in clinical and research settings given its high correlation with virologic outcomes. Future research should validate this composite in other populations and examine it prospectively.