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Original article
Delayed linkage to care in one-third of HIV-positive individuals in the Netherlands
  1. MG van Veen1,2,
  2. SCM Trienekens1,
  3. T Heijman2,
  4. HM Gotz3,
  5. S Zaheri4,
  6. G Ladbury1,5,
  7. J de Wit6,
  8. JSA Fennema2,
  9. F de Wolf4,
  10. MAB van der Sande1,7
  1. 1Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
  2. 2Public Health Service, Amsterdam, The Netherlands
  3. 3Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands
  4. 4HIV Monitoring Foundation (SHM), Amsterdam, The Netherlands
  5. 5EPIET, ECDC, Stockholm, Sweden
  6. 6Centre for Social Research in Health, University of New South Wales, Sydney, New South Wales, Australia
  7. 7Julius Center for Health Sciences and Primary Care, University of Utrecht, Utrecht, The Netherlands
  1. Correspondence to Dr MAB van der Sande, Epidemiology and Surveillance Unit, Centre for Infectious Disease Control, National Institute for Public Health and the Environment, PO Box 1—pb 75, 3720 BA Bilthoven, The Netherlands; marianne.van.der.sande{at}


Objectives To determine time to linkage to HIV care following diagnosis and to identify risk factors for delayed linkage.

Methods Patients newly diagnosed with HIV at sexually transmitted infections (STI) clinics in the Netherlands were followed until linkage to care. Data were collected at the time of diagnosis and at first consultation in care, including demographics, behavioural information, CD4+ counts and HIV viral load (VL) measurements. Delayed linkage to care was defined as >4 weeks between HIV diagnosis and first consultation.

Results 310 participants were included; the majority (90%) being men who have sex with men (MSM). For 259 participants (84%), a date of first consultation in care was known; median time to linkage was 9 days (range 0–435). Overall, 95 (31%) of the participants were not linked within 4 weeks of diagnosis; among them, 44 were linked late, and 51 were not linked at all by the end of study follow-up. Being young (<25 years), having non-Western ethnicity or lacking health insurance were independently associated with delayed linkage to care as well as being referred to care indirectly. Baseline CD4+ count, VL, perceived social support and stigma at diagnosis were not associated with delayed linkage. Risk behaviour and CD4+ counts declined between diagnosis and linkage to care.

Conclusions Although most newly diagnosed patients with HIV were linked to care within 4 weeks, delay was observed for one-third, with over half of them not yet linked at the end of follow-up. Vulnerable subpopulations (young, uninsured, ethnic minority) were at risk for delayed linkage. Testing those at risk is not sufficient, timely linkage to care needs to be better assured as well.


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