The Need for HIV Care Linkage In Baltimore

1. The Need for HIV Care Linkage In Baltimore Presented by: Jennifer Han, Baltimore City Health Department ACCESS Care Treatment

2. Background • Syringe exchange (SEPs) are cost-effective and evidence-based interventions that not only reduce HIV and Hepatitis C transmission, but can serve as a bridge for injection drug users (IDUs) to access medical care and drug treatment1 • The National HIV/AIDS Strategy for the United States stresses the importance of increasing access to care and improving health outcomes for people living with HIV by facilitating linkages to care2

3. HIV Care Among Injection Drug Users • IDUs receive a disproportionately high amount of hospital resources compared to other HIV-positive groups3 • Despite this, studies have demonstrated that IDUs have lower uptake of HIV care and treatment, including antiretroviral therapy than other HIV-infected populations4

4. Consequences of Inadequate HIV Care • Missed care appointments are associated with5: • Poor antiretroviral therapy (ART) adherence • Increased HIV drug resistance • Higher mortality rates • Failure to suppress viral load • Decreased immune function • High-risk sexual behavior

5. Proposed Strategy • Incorporating HIV testing and treatment into harm reduction services such as SEPs have been identified as a strategy for improving access to HIV care among IDUs6 • This presentation examines both the potential and need for HIV care linkage among clients of the Baltimore City Health Department (BCHD) run SEP

6. Baltimore Needle Exchange Program • Started in 1994 as a pilot 1:1 exchange program • Run by health department • Expanded services beyond needle exchange • Client electronic records became available in 2008 • Prior to 2008, BNEP was: • Anonymous • Paper and pen method of record keeping • Currently, BNEP is the only confidential syringe exchange in the country

7. Introducing the location of 2014 National Harm Reduction conference…

9. HIV Care Linkage Process

10. Insight • NEP electronic database • Used for: • Client registration • Records all client visits • Data reports • Step 1: Generate NEP client list • Step 2: Check HIV test records for NEP clients

11. STD MIS • Database of HIV status and treatment records for individuals who test in Baltimore City • Step 1: Searched for NEP clients in STD MIS by name, birthday, etc. • Step 2: Created separate lists for matches, possible matches, and no matches • Step 3: For those with matches and possible matches, pulled up their HIV status and testing records

12. ETO Database • Database of individuals who have accessed any services funded by Ryan White • Step 1: Provided list of HIV+ clients to Ryan White staff to check in their database if client is linked to care • Step 2: Also provided two other lists • NEP clients whose last HIV test was negative • NEP clients with unknown HIV status • Step 3: Obtain HIV care status for NEP clients that were found in ETO

13. HIV status among NEP clients

14. HIV prevalence among NEP clients • Overall prevalence for NEP clients is 343/3491 = 9.8% • Denominator includes clients with unknown HIV status and with no recent HIV test **Denominator is the number of clients whose last HIV test was in year X

15. Prioritizing Active Clients for HIV Care Linkage • Active clients = # of clients with at least one visit to NEP in the last year • As of January 24, 2011, there were 1,251 active NEP clients • Of the 1,251 clients, 144 (11.5%) are HIV+ • Final step: Submitted list of HIV+ clients to Maryland State Health Department to check HIV care status

16. NEP Client Characteristics (n=1,251) • Sex • 65.8% male • 34% female • Race • 59.2% Black • 38.6% White • Average age is 43.2 years old • HIV status • 11.5% HIV+ • 55.9% HIV- • 31.9% Unknown status • Number of visits to NEP in 2011 per client • 26.1% had 1 visit • 28.2% had 2-4 visits • 20.9% had 5-10 visits • 15.3% had 11-24 visits • 9.5% had 25+ visits

17. HIV Care Linkage Program • Collaboration between NEP and Ryan White programs • HIV Care navigators/advocates accompany clients to their appointments • Strategies: • Shared information to confirm clients’ HIV status and medical care history • Provided flyers about HIV Care Linkage Program on SEP mobile units • Inserted alerts into a database for SEP clients who have fallen out of care • Field records are generated to locate HIV+ clients who have fallen out of care

18. ACCESS Care Treatment

19. Process Flow for Linking a HIV+ NEP clients • Client comes to SEP • SEP staff member enters visit into database; an alert pops up • Staff asks client about his/her HIV care status • If client is out of care and wants to be linked to care, the HIV Care Linkage Team is notified immediately by phone and a field record is generated. • A member of the HIV Care Linkage Team picks the client up and accompanies him/her to their first 2 appointments • The client receives a small incentive for keeping each of the 2 appointments • Outcome of the field record is logged as “linked to care.”

21. Outcomes *Clients were categorized as “in care” if the visit occurred within the past 6 months *All inpatient hospitalizations were among those not in care

22. HIV Care Status Breakdown and Program Outcomes

23. Summary of Outcomes • Among the 144 HIV+ SEP clients, 43.1% are not receiving HIV care, of which nearly half have had a inpatient hospitalization as their source of HIV care • Among the field records that were generated by BCHD’s HIV Care Linkage Team, 55% resulted in successful linkages to HIV care. • 67.4% of HIV+ clients had had a more recent visit to the SEP (since September 2011).

24. Limitations • Data discrepancies between databases • Database limitations • Lag period of reporting • Data is already outdated • New NEP clients are added daily • HIV testing/Ryan White data

25. Challenges • Manual labor • Took approximately 6 months for interns to complete cross checking NEP clients in STD MIS • Took 1 month for Ryan White to check clients in Ryan White database • Multiple databases that do not communicate with one another • Dealing with inaccurate client information • Missing information (HIV tests, care status, etc) • Lag period for reporting

26. Assessment on the barriers to HIV Care engagement among NEP clients Target Population: All HIV-positive Needle Exchange Program (NEP) clients who are active users of the NEP van (n=144) Survey Sample 1: NEP Clients (n=4) Survey Sample 2: Non-NEP Clients (n=2)

28. Key Findings • Commonly identified themes related to barriers to engagement of BNEP clients in HIV care • Lack of transportation, use of alcohol or other drugs, and mistrust of providers/health care systemas significant barriers mentioned by both clients and care linkage staff. • Assistance with transportation and incentives (e.g. bus tokens, food vouchers) as BNEP care linkage interventions mentioned by both clients and care linkage staff. • Support services (e.g. housing referrals, medication assistance) as a client-identified care linkage intervention for the BNEP.

29. Recommendations from Assessment • Reduce structural and practical barriers to care by providing incentives or contributions for food/transportation costs • Put up signs on the NEP van to inform clients that they can receive a monetary incentive if they can keep their first scheduled HIV care appointment • Seek further client input to organize care linkage services in a way that is most acceptable to clients • Improve efficiency of process for identifying NEP clients who are out-of-care

30. Extra Considerations • Sensitivity of dealing with HIV status • How to best approach a HIV+ NEP client who visits the van • Confidentiality concerns • Disclaimer during client registration • Multiple clients on the van

31. Findings from Assessment • “In what manner would you like to be approached by NEP staff about your status in HIV care?” • By sending a letter • Would not want to discuss while on the van because anyone can “jump on the van” and does not want others to know personal business • Honestly and directly, “no beating around the bus” • No preference/doesn’t matter- “they can approach me” • No preference/doesn’t matter, okay with being approached

32. Findings from HRC Focus Group • Some participants displayed some discomfort with this idea, while others thought it might be helpful if it meant they could receive targeted health education • Clients emphasized the importance of confidentiality in the matter- “Well definitely one-on-one confidential [conversation].. You know very discreetly about it.” • “I would want all the people that could help me and teach me [to know my status]” • “I don’t think I would mind because they are the kind of people that I would think you would want to know.”

33. Moving Forward • Come up with a method to link clients in different databases • Focus efforts on active NEP clients • Create a manual to document procedures, including a schedule and system for tracking outcomes • Increase advertising of the HIV Care Linkage Program • Offer bus tokens

34. Conclusions • This study demonstrates that there is a high prevalence of HIV among Baltimore SEP clients and a low proportion of them are receiving care • Of those not in care, approximately 60% have had inpatient hospitalizations. • However, the fact that nearly 70% of HIV+ clients have had a recent visit to the SEP represents an opportunity to link and re-link individuals to HIV medical care and other needed services.

35. The Potential for HIV Care Linkage in SEPs • Baltimore’s SEP is the only confidential based syringe exchange program in the U.S. and is also based within a health department • BCHD is in the process of crafting a specific strategy for a better HIV care linkage process for SEP clients • The incorporation of HIV testing and care within harm reduction services such as SEP is an important strategy in reaching HIV+ IDUs who have fallen out of care

36. The Motivation Behind What We Do • “[The NEP] is just about covering everything I think is necessary. NEP treats us like a social service program so I like it. They have a lot of people come [to the van] with different services.” • “The [NEP] van is truly an asset to the community.”

37. Acknowledgements • Baltimore City Health Department’s Needle Exchange staff • Ryan White HIV Care Linkage Team • Emeline Mugisha, Anita Ram, Caeden Dempsey • NEP clients

38. Thank You! • Contact information: • Jennifer Han Baltimore City Health Department Jennifer.han@baltimorecity.gov 410-215-7818

39. References • Strathedee SA, Vlahov D. The effectiveness of needle exchange programs: A review of the science and policy. AIDS Science 2001; 1(16) • National HIV/AIDS Strategy for the United States. July 2010. Available at www.aids.gov/federal-resources/national-hiv-aids-strategy/nhas.pdf • Fleishman JA, Mor V, Laliberte LL. Longitudinal patterns of medical service use and costs among people with AIDS. Health Services Res 1995; 29(5):527-548 • Celentano DD, Vlahov D, Cohn S, ShadleVm, Obasanjo O, Moore RD. Self-reported antiretroviral therapy in injection drug users. JAMA 1998; 280:544-546 • Horstmann E, Brown J, Islam F, Buck J, Agins BD. Retaining HIV-infected patients in care: Where are we? Where do we go from here? Clinical Infectious Diseases 2010; 50(5): 752-761 • Altice FL, Springer S, Buitrago M, Hunt DP, Friedland GH. Pilot study to enhance HIV care using needle exchange-based health services for out-of-treatment injecting drug users. J Urban Health 2003;80:416-427.