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AIDS. 2017 Mar 13;31(5):653-660. doi: 10.1097/QAD.0000000000001373.

Association between engagement in-care and mortality in HIV-positive persons.

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aResearch Department of Infection and Population Health, University College London bNational Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at University College London cBarts Health NHS Trust dDepartment of Applied Health Research, University College London eRoyal Free London NHS Foundation Trust, London, UK.



To assess associations between engagement in-care and future mortality.


UK-based observational cohort study.


HIV-positive participants with more than one visit after 1 January 2000 were identified. Each person-month was classified as being in or out-of-care based on the dates of the expected and observed next care visits. Cox models investigated associations between mortality and the cumulative proportion of months spent in-care (% IC, lagged by 1 year), and cumulative %IC prior to antiretroviral therapy (ART) in those attending clinic for more than 1 year, with adjustment for age, CD4/viral load, year, sex, infection mode, ethnicity, and receipt/type of ART.


The 44 432 individuals (27.8% women; 50.5% homosexual, 28.9% black African; median age 36 years) were followed for a median of 5.5 years, over which time 2279 (5.1%) people died. Higher %IC was associated with lower mortality both before [relative hazard 0.91 (95% confidence interval 0.88-0.95)/10% higher, P = 0.0001] and after [0.90 (0.87-0.93), P = 0.0001] adjustment. Adjustment for future CD4 changes revealed that the association was explained by poorer CD4 cell counts in those with lower %IC. In total 8730 participants under follow-up for more than 1 year initiated ART of whom 237 (2.7%) died. Higher values of %IC prior to ART initiation were associated with a reduced risk of mortality before [0.29 (0.17-0.47)/10%, P = 0.0001] and after [0.36 (0.21-0.61)/10%, P = 0.0002] adjustment; the association was again explained by poorer post-ART CD4/ viral load in those with lower pre-ART %IC.


Higher levels of engagement in-care are associated with reduced mortality at all stages of infection, including in those who initiate ART.

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