A Multistate Analysis of Longitudinal Care Outcomes Among People Newly Linked to Human Immunodeficiency Virus Care in Missouri.

Background: Advancing the HIV response in Missouri, an Ending the HIV Epidemic priority state, requires stronger characterization of treatment gaps. Routine cross-sectional reporting may fail to capture important gaps in care that longitudinal methods can reveal. Methods: We characterized clinic engagement and viral suppression among people with Human Immunodeficiency Virus (HIV) aged ≥18 years who were newly linked to clinic in St Louis, Missouri, between 1 January 2015 and 15 March 2020. Using multistate analytic methods that capture change over time, we estimated the prevalence of individuals in 9 mutually exclusive and exhaustive states over 3 years following linkage to clinic. Care states were based on engagement (disengagement ≥90 days late for a scheduled appointment) and viral load status (suppression defined as viral load <200 copies/mL ≤200 days). Results: Overall 1110 patients were newly linked to clinic during the observation period, contributing 2255.4 person-years of follow-up. One year following linkage, 54.8% (95% CI, 51.6%-57.9%) were continuously retained, 15.2% (95% CI, 13.0%-17.7%) were reengaged, and 29.3% (95% CI, 26.6%-32.2%) were disengaged. In addition, 93.0% (95% CI, 90.6%-95.1%) of continuously retained individuals were virally suppressed at 1 year as compared with 81.6% (95% CI, 75.2%-87.7%) of reengaged individuals. Younger individuals and those from historically marginalized communities were more likely to disengage, reengage, and become viremic. Conclusions: Multistate methods revealed a pattern of disengagement from clinic and reengagement, accompanied by elevated risk of viremia during disengagement. Shifting retention efforts from preventing isolated missed visits toward supporting sustained, long-term engagement in care is a key priority.