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LINKAGE TO CARE

LINKAGE TO CARE. Experience at a Community-based LGBT Organization with Integrated HIV/STI Testing and HIV Care. R.K. Bolan, M.D., M. Beymer, R. Flynn, D. Prock , J. Rodriguez, D. Kerrone. L. A. Gay & Lesbian Center, Los Angeles, CA, USA.

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LINKAGE TO CARE

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  1. LINKAGE TO CARE Experience at a Community-based LGBT Organization with Integrated HIV/STI Testing and HIV Care R.K. Bolan, M.D., M. Beymer, R. Flynn, D. Prock, J. Rodriguez, D. Kerrone L. A. Gay & Lesbian Center, Los Angeles, CA, USA

  2. Physical resources of l.a. gay & lesbian center The Sexual Health Program (SHP) • Main Location: Hollywood • HIV Testing & Counseling • STI Clinic • HIV Clinic • Pharmacy • Mental Health Services and Substance Use Treatment • The SPOT (located in a popular club area) • HIV Testing & Counseling • STI Testing • STI Treatment (one night per week) • POW Van (mobile testing unit) • HIV Testing & Counseling Located on same floor

  3. Where laglc fits among l.a. county hiv/sti diagnoses • Los Angeles County is the most populous in the US (9.8 M) • 15% of all HIV infections identified in L.A. County are diagnosed at LAGLC sites • 10% of all early syphilis cases identified in L.A. County are diagnosed at LAGLC sites

  4. Study Interval: 1/1/2009 -3/31/2011 • 14,997 unduplicated testing visits where HIV test was either negative or newly positive • 478 clients had newly positive HIV test results (rapid blood, or NAAT) • 4.78% positivity rate for unique individuals • 47 of these were acute infections (10%) • 0.31% of tests, or 1/320 tests are acute infections

  5. HIV Clinic Patient Population financial/insurance data* • Our HIV clinic serves mostly a poor population • 55% of our patients are below 100% of the U.S. FPL** • Most patients have their HIV care covered by federal Ryan White funds, about 20% by combinations of Medicaid and Medicare and about 6% by private insurance * SHP is a public health STD program; no financial screening, no patient billing ** Federal Poverty Level (2011) for Family Size of 1 = $10,890

  6. Structural interventions made to increase entry to care during study interval • Over the study interval • 1 FTE HIV Testing Counselor added in 7/2010 [total 4] • Increased number of tests done but also allowed counselors to spend more time with new positive clients • On the clinic side • Added 0.5 FTE medical provider [total 4.75] (increased capacity) • Added 1 FTE Nurse Case Manager [total 3] (helps retention in care) • Designated appointment slots for newly diagnosed patients that can only be released for others if still unfilled 24 hours before appointment time • Added Financial Screener [total 2] (more appointments, including walk-in, for financial screening) • Arranged granting presumptive financial eligibility based on minimal initial patient documentation (allowing 30 days for the patient to bring in remaining documentation), which enables faster entry to care

  7. Definition • Linkage to Care is defined as the first face to face meeting with a medical provider within 6 months of HIV diagnosis

  8. data

  9. Racial/Ethnic Identity shown by orientationall Newly Positive HIV testers: January 2009 through March 2011 97% male

  10. Average age at diagnosis

  11. Entry to care rate improved for most groups during study interval Total Linked to care over entire interval = 266/478 = 55.6%

  12. Entry to care intervals improving

  13. CD4 Average upon entry into care

  14. Time to 1starv Intervals improving

  15. Starting ARVs and retention in care • Only for White (Hispanic and Non-Hispanic) and for Blacks were there enough patients who entered care to perform this analysis • Among both Hispanic and non-Hispanic Whites: • About 66% of those started on ARVs had their last visit within 3 months of reference date • About 45% of those not started on ARVs had their last visit within 3 months of reference date • Among Blacks: • only 50% of those started on ARVs had last visits within 3 months of reference date • Most blacks were started on meds (28/37) and 6/9 of those not starting meds had last care dates 6 or more months prior to reference date

  16. Summary • Racial/Ethnic Disparities • Entry to Care • White Hispanics are the most likely to enter care • Followed by White Non-Hispanics • Blacks initially were less likely to enter care but improved over the study interval • Hispanics who did not identify Race were least likely to enter care although this group also showed significant improvement over the study interval • Retention in care • White Hispanics and Non-Hispanics are more likely than Blacks to adhere to recommended care visit intervals • ARV-related retention in care • 2/3 of White Hispanic and Non-Hispanics who started ARVs returned within the recommended 3 months • 1/2 of Blacks started on ARVs returned within the recommended three months

  17. Summary • The average CD4 count is <500, the point at which treatment is currently recommended. • The interval from diagnosis to care date has steadily decreased and currently averages 1 month • Our integrated program has improved linkage to care mostly due to efforts of the HIV Testing Counselors, an increase in availability of new patient clinic appointments, and streamlined financial screening.

  18. discussion • We are unable to explain the disparity of entry to care for Hispanics who do not designate race • It does not relate to being monolingual Spanish-speaking nor to distance from the clinic of their place of residence • There may be a stronger Hispanic ethnic identity for this group that is also linked with health beliefs, or fears, or some other factors • Possible reasons for low documented Linkage to Care • LAGLC cannot verify L to C at other facilities • While LAGLC is a favored testing site it is not geographically convenient for all who test positive to receive care in the Los Angeles area

  19. Future directions • The National AIDS Strategy (July 2010) calls for a goal of 85% linkage to care within 3 months of diagnosis • Further increasing the proportion of patients linked to care will require better understanding of the special barriers posed to Blacks and to Hispanics who do not designate race • More attention must be focused on retention in care • We will be adding a Linkage to Care Coordinator, our first full time position dedicated to reducing the challenges of linkage to and retention in care • We will be using the results of this study and further analysis to help define their duties • We will encourage other public health workers who do Partner Notification interviews with new positives to help encourage Linkage to Care

  20. Thank you • Thanks • to all the dedicated staff in the Center’s Department of Health and Mental Health Services • to my co-authors, • Matt Beymer, MPH, Epidemiologist, Sexual Health Program • Risa Flynn, Program Manager, Clinical Research • Jeffrey Rodriguez, Nurse Manager, Sexual Health Program • Dustin Kerrone, Program Manager, Sexual Health Program • Especially to Dave Prock, our Department geeky IT guy (a true wizard), who taught me how to use Excel Pivot Tables, and • Lisa Kimsey who runs the front office and always manages to find calm and gracious time for everyone and is really the one who makes everything work

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