Linkage to Care Intervention

In 2014, UNAIDS proposed an ambitious set of targets for the global scale-up of HIV treatment. This approach to the HIV response is based on research showing that early, life-long HIV treatment can dramatically improve the health of people living with HIV¹ and can also dramatically reduce HIV transmission.²

Despite the clear benefits of care and treatment, Canada is not meeting UNAIDS targets that, if achieved, may end the epidemic spread of HIV by 2030.³ By 2020, UNAIDS proposed that:

• 90% of all people living with HIV will know their status;
• 90% of all people with diagnosed HIV infection will receive sustained ART;
• 90% of all people receiving ART will have viral suppression (undetectable viral load).

If these targets are achieved, 81% of all people living with HIV will be on treatment and 73% will have an undetectable viral load. Although Canada has not published national data for the UNAIDS targets, data from British Columbia and Ontario show that Canada is not doing as well as other countries. For example, only 35% of people living with HIV in British Columbia are estimated to have an undetectable viral load and only 27% to 40% of people living with HIV in Ontario have an undetectable viral load.^4,5 This is significantly lower than the  UNAIDS target of 73% and means we need to do more to engage clients across the continuum of care.

To achieve the 90-90-90 goals, people living with HIV will need to be engaged in their HIV care. Effective programs that improve engagement in HIV care for people living with HIV are needed to help us achieve the UNAIDS targets.

Wisconsin’s Linkage to Care Intervention

Wisconsin’s Linkage to Care Intervention assigns linkage-to-care specialists (non-medical professionals who receive specific training on the basics of HIV disease transmission, progression and treatment, principles of case management, motivational interviewing, and professional ethics) to HIV-positive participants who are newly diagnosed with HIV, recently released from prison, or who are not currently engaged in HIV medical care.

Specialists provide and coordinate services, referrals and appointments, attend appointments with participants, and help participants navigate the healthcare system. Specialists can work with participants for up to nine months; each specialist has a maximum of 15 clients on their case load at any given time.

The study

Between February and August 2013, 16 participants from the pilot phase of the Linkage to Care Intervention were interviewed about their experience of the program.

Overall, participants reported that it was the relationship with their linkage-to-care specialist that was critical to their successful engagement in HIV medical care.⁶ The personal connection with their specialist helped participants become comfortable with medical care despite perceptions and experiences of HIV stigma, which had kept them from getting care in the past. Participants also reported that the relationship with their specialist was a motivator for prioritizing their health in a way that they had not done before.

Fuel to the fire

This study shows that an intensive, time-limited linkage-to-care intervention is acceptable to participants. It also demonstrates that interventions which ensure the development of strong relationships between participants and service providers can have a positive impact on client engagement in care.

This study adds to the growing body of evidence that health navigation for people living with HIV can have a positive impact on engagement, linkage to and retention in care. There are a numberof similar navigation programs already operating in Vancouver, Kamloops and Regina.

References

1. Samji H, Cescon A, Hogg RS, et al. Closing the Gap: Increases in Life Expectancy among Treated HIV-Positive Individuals in the United States and Canada. Okulicz JF, editor. PLoS ONE. 2013 Dec 18;8(12):e81355.
2. Cohen M, Chen YQ, Macauley M, et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. New England Journal of Medicine. 365(6):493–505.
3. Joint United Nations Programme on HIV/AIDS (UNAIDS). 90-90-90: An ambitious treatment target to help end the AIDS epidemic [Internet]. Geneva, Switzerland: UNAIDS; 2014 Oct [cited 2014 Nov 18] p. 33. Available from: http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf
4. Nosyk B, Montaner JSG, Colley G, et al. The cascade of HIV care in British Columbia, Canada, 1996–2011: a population-based retrospective cohort study. Lancet Infectious Diseases. 2014 Jan;14(1):40–9.
5. Gilbert M, Gardner S, Murray J, et al. Quantifying the HIV Care Cascade in Ontario: Challenges and Future Directions [Internet]. Poster presented at: 24th Annual Canadian Conference on HIV/AIDS Research; 2015 May 30; Toronto, Ontario. Available from: http://www.cahr-acrv.ca/wp-content/uploads/2012/10/InfDis_26_SB_MarApr2015_Final.pdf
6. Broaddus M, Hanna CR, Schumann C, Meier A. “She makes me feel I’m not alone”: Linkage to Care Specialists provide social support to people living with HIV. AIDS Care. 2015 Apr 9.