OBJECTIVE: Clinical interventions that lengthen life after HIV infection and significantly reduce transmission could have greater impact if more HIV-diagnosed people received HIV care. We tested a surveillance-based approach to investigating reasons for delayed entry to care. METHODS: Health department staff in three states and two cities contacted eligible adults diagnosed with HIV four to 24 months previously who had no reported CD4+ lymphocyte (CD4) or viral load (VL) tests. The staff conducted interviews, performed CD4 and VL testing, and provided referrals to HIV medical care. Reported CD4 and VL tests were prospectively monitored to determine if respondents had entered care after the interview. RESULTS: Surveillance-based follow-up uncovered problems with reporting CD4 and VL tests, resulting in surveillance improvements. However, reporting problems led to misspent effort locating people who were already in care. Follow-up proved difficult because contact information in surveillance case records was often outdated or incorrect. Of those reached, 37% were in care and 29% refused participation. Information from 132 people interviewed generated ideas for service improvements, such as emphasizing the benefits of early initiation of HIV care, providing coverage eligibility information soon after diagnosis, and leveraging other medical appointments to provide assistance with linkage to HIV care. CONCLUSIONS: Surveillance-based follow-up of HIV-diagnosed individuals not linked to care provided information to improve both surveillance and linkage services, but was inefficient because of difficulties identifying, locating, and recruiting eligible people. Inefficiencies attributable to missing, incomplete, or inaccurate surveillance records are likely to diminish as data quality is improved through ongoing use.

The HIV counseling, testing, and referral (CTR) encounter represents an important opportunity to actively facilitate entry into medical care for those who test positive for HIV, but its potential is not always realized. Ways to improve facilitation of linkage to care through the CTR encounter haven't been explored among HIV-infected persons who have not entered care. We conducted 42 structured and qualitative interviews among HIV-infected persons, diagnosed 5-19 months previously, in Indiana, Philadelphia and Washington State, who had not received HIV medical care. Respondents related individual and system-level barriers, as well as recommendations for improving the effectiveness of CTR as a facilitator of linkage to HIV medical care through more active referrals, and for strengthening the bridge between CTR and linkage to care services. Our findings suggest that standards for active case referral by CTR staff and integration of CTR and linkage to care services are needed.