John W. Hogan, M.D. Howard University College of Medicine
After completing this session participants should be able to : Discuss factors related to delayed linkage to care after receiving a positive HIV test result. Discuss the importance of the multidisciplinary team approach to patient management. Discuss strategies on linking patients to care.
The "HIV treatment Cascade" refers to the graphic representation of how many people living with HIV/AIDS in the U.S.: get tested, get linked to care, stay in care, get on antiretroviral treatment, and ultimately get to a suppressed viral load. It provides a critical picture of how close we are -- or are not -- in the U.S. to achieving the "end of AIDS“.
Number (in ‘000s) Prevalence Diagnosed Treated 1,106,400- 1,200,000 874,056- 960,000 437,028- 489,600 ~80% Diagnosed ~40% Treated Smith MK, et al. PLoS One. 2012;9:e1001260. Gardner EM, et al. Clin Infect Dis. 2011;52:793-800. Burns DN, et al. Clin Infect Dis. 2010;51:725-731. ~20% of All HIV-Infected Are HIV RNA <50 copies/mL 209,773- 376,992 Viral Suppression
On July 13, 2010, the White House released the National HIV/AIDS Strategy (NHAS). This ambitious plan is the nation’s first-ever comprehensive coordinated HIV/AIDS roadmap with clear and measurable targets to be achieved by 2015.
Goals of the National HIV/AIDS Strategy By 2015, increase from 79% to 90% the percentage of people living with HIV who know their serostatus (from 948,000 to 1,080,000 people). By 2015, increase the proportion of newly diagnosed patients linked to clinical care within three months of their HIV diagnosis from 65% to 85% (from 26,824 to 35,078 people). Improve access to prevention and care services for all Americans.
Linkage To Care: The large majority of people newly diagnosed with HIV in 2010 (89%) were linked to care within 12 months of their initial diagnosis. 76% were linked to care within three months of their diagnosis. The share of people entering care has increased since 2006, yet there are still people with HIV who are not getting the care and treatment they need. Fact Sheet-The HIV/AIDS Epidemic in Washington, D.C.; The Henry J. Kaiser Family Foundation
The time between the first positive Western blot test and the first reported viral load and/or CD4 cell count or percentage was used to indicate the interval from initial diagnosis of HIV (non-AIDS) to first HIV-related medical care visit (2003). Of 1928 patients: 1228 (63.7%) initiated care within 3 months of diagnosis, 369 (19.1%) initiated care later than 3 months, and 331 (17.2%) never initiated care. Risk factors for delayed initiation of medical care after diagnosis of human immunodeficiency virus: L V Torian et al; Arch Intern Med. 2008 Jun 9;168(11):1181-7Arch Intern Med.
Predictors of delayed care were as follows: diagnosis at: ▪ a community testing site, ▪ the city correctional system ▪ Department of Health sexually transmitted diseases or tuberculosis clinics nonwhite race/ethnicity injection drug use location of birth outside the United States Risk factors for delayed initiation of medical care after diagnosis of human immunodeficiency virus: L V Torian et al; Arch Intern Med. 2008 Jun 9;168(11):1181-7Arch Intern Med.
A retrospective cohort study of patients initiating outpatient care at the University of Alabama at Birmingham 1917 HIV=AIDS Clinic between January 2000 and December 2005 was undertaken. Multivariable models determined factors associated with: late diagnosis=linkage to care (initial CD4 < 350 cells=mm3), timely antiretroviral initiation, retention across the first two years of care. The therapeutic implications of timely linkage and early retention in HIV care: K B Ulett et al.; AIDS Patient Care STDS. 2009 Jan;23(1):41-9AIDS Patient Care STDS.
Delayed linkage was observed in two-thirds of the overall sample (n = 567) and was associated with: older age African American race. Attending all clinic visits and lower initial CD4 counts led to earlier antiretroviral initiation. Worse retention in the first 2 years was associated with: younger age higher baseline CD4 count, substance abuse. The therapeutic implications of timely linkage and early retention in HIV care: K B Ulett et al.; AIDS Patient Care STDS. 2009 Jan;23(1):41-9AIDS Patient Care STDS.
The multidisciplinary team model of HIV care evolved out of necessity due to the diverse characteristics and needs of people living with HIV disease. It is now accepted as the international standard of care. A multidisciplinary team approach utilize the special skills of: nurses, pharmacists, nutritionists, social workers, case managers, and others.
The multidisciplinary team approach help address patient needs regarding: housing, medical insurance, emotional support, financial benefits, substance abuse counseling, and legal issues. Housing, case management and drug treatment interventions have demonstrated significant improvements in the health status of people with HIV.
The study sought to examine psychological and behavioral variables as predictors of attending an HIV medical care provider among person's recently diagnosed with HIV. The study was carried out between 2001 and 2003. Participants were recruited from: public HIV testing centers, sexually transmitted disease (STD) clinics, hospitals, and community-based organizations. Sites were located in Atlanta, Georgia; Baltimore, Maryland; Miami, Florida; and Los Angeles, California. Psychological and Behavioral Correlates of Entering Care for HIV Infection: The Antiretroviral Treatment Access Study (ARTAS):L I Gardner et. al; AIDS Patient Care and STDs. June 2007, 21(6): 418-425
Predictors measured of attending an HIV care provider were: number of months since HIV diagnosis, readiness to enter care (based on stages of change), barriers and facilitators to entering care, drug use, and intervention arm (case managed versus simple referral Being in care was defined as seen at least once in each of two consecutive 6–month follow-up periods. Psychological and Behavioral Correlates of Entering Care for HIV Infection: The Antiretroviral Treatment Access Study (ARTAS):L I Gardner et. al; AIDS Patient Care and STDs. June 2007, 21(6): 418-425
Seeing a care provider was significantly more likely among participants: Diagnosed with HIV within 6 months of enrollment. Those in the preparation versus precontemplation stages at baseline. Those who reported at baseline that someone (friend, family member, social worker, other) was helping them get into care. Those who received a case manager intervention. Psychological and Behavioral Correlates of Entering Care for HIV Infection: The Antiretroviral Treatment Access Study (ARTAS):L I Gardner et. al; AIDS Patient Care and STDs. June 2007, 21(6): 418-425
HIV health services should take into account that people living with HIV often face stigma and discrimination: because of their infection, because they may belong to groups with particular behavioral or disempowering characteristics: ▪ sex workers, ▪ injecting drug users, ▪ prisoners, ▪ youth, ▪ men who have sex with men.
‘Linkage’ refers to a relationship. ‘Integration’ refers to delivering multiple services or interventions to the same patient by: an individual health care worker by a team of health care workers workers from other fields. Strong linkages (with referral and coordination between service providers) and integrated services are needed in the care of people living with HIV.
First steps to making sure HIV infected patients receive the care they need includes: researching local clinicians, establishing relationships with those clinicians, developing referral processes that help assure patients get the care they need. Connecting HIV Infected Patients to Care: A Review of Best Practices. The American Academy of HIV Medicine 1/20/2009
Identify area HIV/AIDS clinician specialists and their health care coverage requirements, Identifying clinicians who accept patients without health care coverage. Identify area clinicians, including Ryan White Care Act clinicians who provide care to low-income and uninsured patients. Many Ryan White clinicians also see patients who are covered by health insurance. Connecting HIV Infected Patients to Care: A Review of Best Practices. The American Academy of HIV Medicine 1/20/2009
Build relationships with area HIV/AIDS care and service clinicians. Put in place convenient appointment scheduling arrangements with referral clinicians, such as standing times for new appointments, and work with local clinicians to minimize waiting times for appointments. Evidence shows that longer waiting times to get appointments correlate with lower rates of referral completion by patients. Connecting HIV Infected Patients to Care: A Review of Best Practices. The American Academy of HIV Medicine 1/20/2009
If patients will be co-managed, clarify who is managing which medications, who orders what tests, and how such information will be consistently communicated among involved clinicians. It is well accepted that better communication among clinicians improves patient outcomes. Connecting HIV Infected Patients to Care: A Review of Best Practices. The American Academy of HIV Medicine 1/20/2009
Use a simple, standardized referral form that indicates how and when the referring clinician wants to be notified re: a patient’s progress/status. Make sure that specialists receive all pertinent information on a patient prior to appointments. Studies show that when referring clinicians have personal contact with specialists ongoing communication about the patient is much better, and the referral process runs more smoothly and is of higher quality. Connecting HIV Infected Patients to Care: A Review of Best Practices. The American Academy of HIV Medicine 1/20/2009
Involve patients in the referral process by giving patients pertinent referral information to give to the specialist. This is both convenient and empowers patients since they become involved in the referral process and gain a greater understanding of how the system works. After a certain number of days, if you haven’t heard back from the specialist, check whether or not the patient followed through with the appointment. Connecting HIV Infected Patients to Care: A Review of Best Practices. The American Academy of HIV Medicine 1/20/2009
Educate patient on need for ongoing, regular health care – even though they may feel healthy, it’s very important to be monitored regularly. Monitoring and treatment significantly slow the development of symptoms and progression of the disease. HIV patients often cite “feeling healthy” as a reason for not following through with health care appointments. Help patients understand how the health care they need to receive is organized, including who will do what for them and how HIV is managed. Connecting HIV Infected Patients to Care: A Review of Best Practices. The American Academy of HIV Medicine 1/20/2009
Create and nurture trusting, supportive relationships with patients to help alleviate fear. Patient follow-up into care is significantly improved: when clinicians are able to connect with patients, when patients feel they are accepted and valued as a whole person, instead of being labeled as HIV positive, when patients feel their relationship with their provider is one of two-way respect. Connecting HIV Infected Patients to Care: A Review of Best Practices. The American Academy of HIV Medicine 1/20/2009
Address individual needs and concerns, including sources of emotional support, information on HIV infection and transmission, and the need to reduce risk behavior. Offer and assure your continued support to the patient. Tell the patient who to contact should they have questions or concerns to be addressed before their next appointment. Case management referral is essential. Connecting HIV Infected Patients to Care: A Review of Best Practices. The American Academy of HIV Medicine 1/20/2009
Many patients have inaccurate information about HIV infection that can: heighten their anxiety, sabotage treatment adherence, and interfere with prevention behaviors. Patients need assurance that HIV is a treatable disease and that, with successful treatment, they may live a long and healthy life.
Many people are not connected to care after receiving a HIV positive test results. Factors associated with a lower rate of linkage to care include: nonwhite race/ethnicity injection drug use location of birth outside the United States Older age A multidisciplinary team approach improves linkage to care.
31 yo female returns to the clinic and you inform her she has a positive WB. She is a high school graduate, single, with 2 children (3,8). She is unemployed. Lives with her 2 kids whose father is incarcerated. Her older brother died of AIDS 15yrs ago. While crying she states her life is over. Where do you start?
24 yo male from Ethiopia here for results of a confirmatory WB which is positive. He has been in the US x 14 mo. He works at a hotel. He speaks very little English. You call the translation line, then give him the results. He ask “How long do I have to live?” What are the priority issues?
21 yo well dressed transgender here to receive the results that their WB is positive. They missed the last 2 appointments. Stopped college after 1 semester. Multiple sex partners at parties where they use crystal meth. Hx of syphilis x 2, and Chlamydia. Oral Candida on exam. They are unemployed and lives with parents. They does not want to tell them their dx.