Dutch research identifies relationship between HIV clinic characteristics and retention of patients in care

Dutch research published in the online edition of AIDS has provided insights into the relationship between the characteristics of HIV clinics and the retention of patients in care. All 26 specialist HIV care providers in the Netherlands had good rates of retention in care, but a number of characteristics were associated with the likelihood of patients starting treatment and achieving virological suppression.

Overall the authors were encouraged by their findings but think some have important implications for the internal procedures of HIV care providers.

Improvements in antiretroviral treatment mean that many HIV-positive patients now have an excellent prognosis. But to benefit fully from HIV therapy it is essential that patients are fully engaged in care. A number of key stages in the HIV care continuum, or cascade, have been identified: diagnosis; linkage to care; retention in care; initiation of antiretroviral treatment; viral suppression.


retention in care

A patient’s regular and ongoing engagement with medical care at a health care facility. 

virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

retrospective study

A type of longitudinal study in which information is collected on what has previously happened to people - for example, by reviewing their medical notes or by interviewing them about past events. 

linkage to care

Refers to an individual’s entry into specialist HIV care after being diagnosed with HIV. 


Confounding exists if the true association between one factor (Factor A) and an outcome is obscured because there is a second factor (Factor B) which is associated with both Factor A and the outcome. Confounding is often a problem in observational studies when the characteristics of people in one group differ from the characteristics of people in another group. When confounding factors are known they can be measured and controlled for (see ‘multivariable analysis’), but some confounding factors are likely to be unknown or unmeasured. This can lead to biased results. Confounding is not usually a problem in randomised controlled trials. 

Attrition at each of these stages has been recorded, especially in the United States. Research has focused on the characteristics of patients who do not fully engage in care. Barriers include mental health issues, drug and alcohol abuse, HIV-associated stigma, unstable housing, lack of health insurance and poor support networks.

Less is known about the relationship between the characteristics of HIV clinics and the retention of their patients in care. Investigators from the Netherlands therefore designed a retrospective study involving all 26 accredited HIV clinics in the country to see if specific clinic characteristics were associated with three key stages in the HIV care cascade: retention in care; starting HIV therapy; viral suppression.

Data were collected between October 2012 and January 2013. The clinics provided information on all adult patients who received care between 2007 and 2013.

Clinics also provided information on the size of their patient cohort; the specialisms of staff involved in the HIV care team; internal policy and organisation; outpatient care (specialist HIV clinic vs. internal medicine outpatient clinic); internal auditing of outcomes in previous three years; accreditation.

A total of 7120 patients received care during the study period. The majority were of Dutch origin and men-who-have-sex with men (MSM). Overall levels of engagement with each of the three stages of care were very good: 97% of patients were currently in care; 73% had started HIV therapy; and 59% had an undetectable viral load.

But outcomes varied between clinics. Rates of current engagement in care were between 92%-100%; rates of treatment initiation ranged from 53%-92% and the proportion of patients with viral suppression was between 81%-100%.

No clinic characteristics were associated with levels of current engagement in care.

Factors associated with the likelihood of patients starting HIV therapy were quality accreditation (OR = 1.62; 95% CI, 1.18-2.23), internal audit (OR = 1.36; 95% CI, 1.02-1.81) and larger patient cohort size (over 600 patients, OR = 1.80; 95% CI, 1.14-2.84; 300-600 patients, OR = 2.00; 95% CI, 1.25-3.21 vs. below 300 patients).

The authors acknowledge that the relationship between cohort size and treatment initiation could be the result of residual confounding. However, they comment, “our data support the hypothesis that treating more patients with a specific condition increases expertise, as demonstrated by previous studies in HIV-infected patients.”

Viral suppression was negatively associated with the presence of a social worker in the care team (OR = 0.62; 95% CI, 0.43-0.91).

“We hypothesize that centres with a relatively complicated patient population are more likely to have a social worker in the team,” comment the authors.

Patients of non-Dutch origin were less likely to be engaged at all three steps of the treatment cascade examined in the study.

“We conclude that ensuring access to HIV care, appointing expert health facilities and care providers, and routine monitoring of HIV-infected patients promotes retention in care,” write the investigators. “Quality assessment through accreditation and the measurement of performance benefits the delivery of HIV care.”


Engelhard EAN et al. Impact of HIV care facility characteristics on the cascade of care in HIV-infected patients in the Netherlands. AIDS, online edition. DOI: 10.1097/QAD.0000000000000938 (2015).