Download PROMOTING HIV TESTING - AETC-NMC

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)
1,106,4001,200,000
~80%
Diagnosed
874,056960,000
~40%
Treated
437,028489,600
Prevalence
Diagnosed
Treated
~20% of All
HIV-Infected
Are HIV RNA
<50 copies/mL
209,773376,992
Viral Suppression
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.

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):1181-7

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):1181-7

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):41-9

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):41-9
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.

www.aetcnmc.org

www.capitolregiontelehealth.org
Howard University HURB 1
1840 7th Street NW, 2nd Floor
Washington, DC 20001
202-865-8146 (Office)
202-667-1382 (Fax)
www.capitolregiontelehealth.org
www.aetcnmc.org