Source: Marion County Public Health Department, Epidemiology Request DR2370
Prepared by: Morgan T. Rebeck (MRebeck@MarionHealth.org) and Tammie L. Nelson (TNelson@MarionHealth.org)

The Marion County Public Health Department’s¹ Ryan White Services Program (RWSP)² oversees the Ryan White Part A, Part C (Outpatient Early Intervention Services) and Minority AIDS Initiative grants in the Indianapolis-Carmel Metropolitan Statistical Area (MSA). These programs serve the needs of persons newly infected with HIV, living with HIV/AIDS (PLWH/A) and out of care, and/or uninsured or medically underserved. RWSP goals are based on the HIV continuum of care³ and the National HIV/AIDS Strategy.⁴ The goal discussed this month is linkage to care.

Importance of Linkage to Care: Linkage to care is defined as having attended one’s first HIV medical visit within 90 days of HIV diagnosis (measured by receipt of first CD4 or viral load).⁵ Delayed linkage to HIV care has been associated with increased risk of HIV transmission, accelerated progression to AIDS, and increased morbidity and mortality.^6,7,8,9

RWSP Target: Among MSA residents newly diagnosed with HIV during 2013, 79.2% (N=187 of 236) were linked to care within 90 days.¹⁰ RWSP’s goal is to increase this measure to 85% of those newly diagnosed with HIV.

Guidelines for Improving Linkage to Care: When informed of their diagnoses, all patients should be educated about the importance of receiving HIV medical care in terms of maximizing personal health outcomes and preventing secondary transmission.¹¹ In addition, strengths-based case management is recommended for most newly diagnosed PLWH.¹² Routine monitoring of successful engagement in care could lead to significant increases in linkage to care.^8,12 Moreover, for those patients who have not entered HIV medical care within six months, intensive outreach can be considered if patient circumstances warrant such action.¹²

Increasing Awareness to HIV Care and Treatment (IAHCT) Best Practices: The U.S. Department of Health and Human Resources Administration’s (HRSA) IAHCT Best Practices Initiative¹³ recommends the following practices to increase the number of PLWH being linked to care.

• Endeavoring to get all patients to enter HIV medical care within five days of HIV diagnosis
• Promoting close contact between newly diagnosed patients and the provider’s linkage staff
• Hiring of additional staff experienced in HIV primary care and/or expansion of medical provider service hours
• Use of social media to encourage engagement in care

Additional Considerations: Less overt actions can be taken to improve linkage to care. Items to consider include:

• Psychosocial support¹⁴
• Increased awareness of supportive services (e.g., mental health, medical transportation, short term housing)¹⁴

• Utilization of peer or paraprofessional patient navigators for support and counseling^12,14

Barriers to Care: Reduction of barriers is vital to improving linkage to care. Three categories of barriers to care identified as being related to linkage to, and retention in, HIV care. The categories identified are:

• Financial Barriers
  • May include those uninsured/underinsured or competing subsistence needs such as food and housing.¹⁵
• Structural and Administrative Barriers
  • May refer to unavailable or inconveniently located services; long wait times for appointments; unemployment or job insecurity; lack of transportation; and/or language barriers.¹⁶
• Personal Barriers
  • Includes, but is not limited to, stigma related to HIV/AIDS and/or sexual identity; substance use; mental health issues; lack of trust in the medical system; and, low health literacy.¹⁶

The effects of barriers to care can be especially detrimental with regard to linkage to care among youth 13-24 years of age.¹⁶ When evaluating linkage to care among MSA residents, the largest single disparity was among those of younger age. Residents 20-24 years of age experienced the worst outcomes in linkage to care with only 67.3% (N=37 of 55) linked to care within 90 days of diagnosis.10 More disheartening was the nearly 22% (N=12) who received no HIV primary care during the year following their diagnosis. Among adolescents 15-19 years of age, about 80% were linked to care within 90 days;10 however, nearly 15% had received no HIV primary care during their first post-diagnosis year.

1 Marion County Public Health Department, http://www.mchd.com/

2 Ryan White Services Program, http://www.ryanwhiteindytga.org/

3 Nelson, T. L. (2014, December 5). HIV care updates for the Indianapolis-Carmel Metropolitan Statistical Area. MATEC Indiana Newsletter, 65.

4 National HIV/AIDS Strategy, https://www.aids.gov/federal-resources/national-hiv-aids-strategy/.

5 U.S. Department of Health & Human Services. (n.d.). Common indicators for HHS-funded HIV programs and services. Retrieved from https://www.aids.gov/pdf/hhs-common-hiv-indicators.pdf.

6 Antiretroviral Therapy Cohort Collaboration. (2008) Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet, 2008(372), 293-299.

7 Cohen, M. S., Chen, Y. Q., McCauley, M., Gamble, T., Hosseinipour, M. C., Kumarasamy, N., . . . HPTN 052 Study Team. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med, 365(6), 493-505.

8 Centers for Disease Control and Prevention. (2013). Prevention benefits of HIV treatment. Available at http://www.cdc.gov/hiv/prevention/research/tap/.

9 Gardner, E. M., McLees, M. P., Steiner, J. F., del Rio, C., and Burman, W. J. (2011). The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis, 52(6), 793-800.

10 Centers for Disease Control and Prevention. (2014). Enhanced HIV/AIDS Reporting System (eHARS).

11 Centers for Disease Control and Prevention. Linkage to and retention in HIV Medical Care. 2012. Available at http://www.cdc.gov/hiv/prevention/programs/pwp/linkage.html.

12 Thompson, M. A., Mugavero, M. J., Amico, K. R., Cargill, V. A., Chang, L. W., & Gross, R., . . . Nachega, J. B. (2012). Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: Evidence-based recommendations from an International Association of Physicians in AIDS Care panel. Ann Intern Med, 156(11), 817-833.

13 U.S. Department of Health & Human Services. (2014). Increasing Access to HIV Care and Treatment.

14 Liau, A., Crepaz, N., Lyles, C. M., Higa, D. H., Mullins, M. M., DeLuca, J., … & Marks, G. (2013). Interventions to promote linkage to and utilization of HIV medical care among HIV-diagnosed persons: A qualitative systematic review, 1996–2011. AIDS and Behavior, 1-22.

15 Bauman, L. J., Braunstein, S., Calderon, Y., Chhabra, R., Cutler, B., Leider, J., … & Watnick, D. (2013). Barriers and facilitators of linkage to HIV primary care in New York City. J Acquir Immune Defic Syndr, 64, S20-6.

16 Philbin, M. M., Tanner, A. E., Duval, A., Ellen, J., Kapogiannis, B., & Fortenberry, J. D. (2014). Linking HIV-positive adolescents to care in 15 different clinics across the United States: Creating solutions to address structural barriers for linkage to care. AIDS Care, 26(1), 12-19.