Case 2: HIV Testing as the Gateway to Care: A 24-Year-Old Man With A New Diagnosis of HIV Infection (Continued)

Initially hesitant because of concerns about his immigration status and disclosure, the patient ultimately agrees to start antiretroviral medications. He is taking no other medications and does not have any drug allergies, so the clinician recommends dolutegravir plus tenofovir/emtricitabine. Laboratory tests are performed that include blood counts and metabolic evaluations to assess renal and liver function as well as coinfections with other STIs and hepatitis B or C virus. Laboratory tests for HIV infection, along with confirmatory testing, include a CD4+ cell count, an HIV viral load test, and an HIV genotype test. The patient is provided with his first dose of HIV medication in the clinic while the immediate antiretroviral therapy team formulates a patient-centered follow-up plan. With his medical evaluation completed, the patient meets with a social worker and a patient navigator for a complete social evaluation; this team initiates the process of connecting the patient to insurance coverage and assistance programs and reviews other important social and mental health needs identified during screening that could interfere with his connection and adherence to HIV care.

The patient is navigated to care, and linkage is confirmed by his navigator with plans to follow up at 3, 6, and 12 months via telephone or text to confirm that this linkage is ongoing. Disease investigation specialists from the New York City Field Services Unit interview the patient and elicit a list of contacts to pursue partner notification. Genotype testing at the New York City Public Health Laboratory reveals a wild-type virus. His CD4+ cell count is 533/µL and his plasma HIV RNA level is 47,899 copies/mL. He is not coinfected with hepatitis B or C virus and does not have a bacterial STI. His complete blood cell count, renal test results, and hepatic screening results are all normal.

Data from the Public Health Laboratory are analyzed by HIV surveillance and the sequence indicates that the patient’s HIV infection is part of a small but growing cluster of infections with sequence homology. Linked to this cluster by sequence is an individual who was a named contact of 3 individuals diagnosed with HIV infection in the last year, including the patient described in this case. This individual demonstrated high-level viremia on the single available viral load test in the HIV registry, with a CD4+ cell count of 325/µL. Based on laboratory reports, this match, identified via registry, has not received any HIV care in more than 3 years. Other contacts identified by the patient did not match to the registry.

Given these data, this contact who is out of care is designated a high-priority case by staff at the Field Services Unit who are then deployed to engage this individual in care. He is contacted on the next business day and interviewed. He reports that he has not been connected to care because of concerns about his undocumented immigration status and about the high cost of care (he received a large bill after his first visit to the clinic). Given his trepidation about the cost of HIV care, he agrees to visit the STI clinic to be evaluated by the immediate antiretroviral therapy team. After meeting with the social worker and the medical practitioner, he decides to start antiretroviral therapy that day and to apply to the AIDS Drug Assistance Program to support his care.