North Carolina researchers are launching a three-year, $1.18 million study into one of HIV care's most persistent failures: patients who are hospitalized, identified as needing treatment, and then never make it to consistent outpatient care once they leave.

The problem is widespread. Fewer than half of Americans living with HIV are consistently retained in outpatient care, even though modern antiretroviral therapy has made the virus manageable as a chronic condition. People not engaged in regular care are more likely to be hospitalized in the first place, creating a cycle that existing interventions have repeatedly failed to break.

The federally funded study, known as LINC-NC, takes a different approach by going bigger than past research. Rather than examining a single hospital or health system, the team will combine electronic health records from three of North Carolina's largest health systems with state HIV surveillance data, covering 34 hospitals that collectively care for 80% of hospitalized HIV patients in the state. The dataset spans 2018 through 2024 and reaches more than 600 inpatient and outpatient sites across all 100 NC counties. To link patient records across systems without sharing sensitive identifying information, researchers will use privacy-preserving matching techniques that address a longstanding barrier to this kind of cross-system research.

The grant is funded through the National Institute of Mental Health, reflecting how closely mental health conditions are tied to falling out of HIV care. Unstable housing, substance use, distrust of the healthcare system, and insurance gaps compound the problem, making it difficult to identify which factors matter most and at which hospitals.

North Carolina is a particularly useful place to study this. The state reports roughly 1,500 to 1,700 new HIV diagnoses each year and ranks among the top 10 states nationally. Black North Carolinians bear a disproportionate share of new cases and experience worse retention in care, according to the state's most recent epidemiological data. The research team, which includes collaborators from three academic institutions and the NC Division of Public Health, will also conduct interviews with patients, hospital staff, and community organizations to understand the human side of why connections to care break down.

The timing adds another layer of significance. North Carolina expanded Medicaid in December 2023, extending coverage to an estimated 600,000 adults, a population that likely includes many HIV patients who previously lacked insurance and fell out of care as a result. That shift means the landscape the researchers are studying is actively changing as the work begins.

The study is expected to wrap up in three years. Researchers say the findings will be used to identify which hospital-level practices and policies are most effective at keeping patients connected to care after discharge.