An HIV primary care clinic developed a linkage to care (LTC) program to enhance patient engagement in care and viral load suppression among people living with HIV. Linkage to care coordinators worked with newly diagnosed patients and patients who were previously diagnosed, but not engaged in care, to increase engagement in care. The LTC program consisted of individualized patient monitoring and detailed, standardized case management. Viral load suppression rates were compared among participants who were part of the LTC program and those who were linked to care before the program was implemented. Results showed a significant increase in viral load suppression levels (an increase from 74% to 86%) for newly diagnosed patients who were linked in the new program.
Program description
The LTC program was developed to improve patient engagement and viral suppression rates in people living with HIV. Before the implementation of the program, appointments were scheduled by administrative staff but case management was not routinely provided. After an extensive review of the existing process, including determining structural barriers and consulting with people living with HIV, improvements to the process were implemented and the LTC program was created. The LTC program used a linkage to care coordinator (LTCC) to manage new referrals. The LTCC initiated and facilitated the program’s components, including proactive monitoring and follow-up, standardized case management and clinic orientation.
Administrative staff at the LTC program received patient referrals from outside organizations and referred the patients to the LTCC. All referred patients (newly diagnosed and previously diagnosed but unengaged) who were referred to the LTC program were contacted by the LTCC within 24 hours. In some cases, outside organizations referred patients to the LTC program while the patient was still present, and patients who were interested in starting HIV treatment the same day could be connected with an on-call treatment provider.
During an initial phone conversation, the LTCC assessed the patient, including their transportation needs, scheduling preferences, insurance status, income status, urgent social needs and preferred contact method. After this initial phone call, the LTCC scheduled an appointment for the patient.
Appointments were organized in a personalized way for each patient. For example, people living in remote or rural areas could submit relevant and required information and forms via email or fax. For patients who lived close to the clinic, the LTCC organized an appointment at the clinic and met the person at their initial appointment to complete any paperwork for the program and determine whether they needed any other assistance.
The LTC coordinator also facilitated the following:
- Proactive monitoring: including phone contact before the first appointment to address unexpected barriers to attendance (e.g. challenges with transport)
- Patient follow-up: continuous follow-up if a patient missed an appointment; mail follow-up for patients who did not use a phone; quarterly follow-up with all patients who were not successfully linked to care, which continued until their status could be determined (e.g., established at another HIV clinic, relocated)
- Standardized clinic orientation: an information packet that included (but was not limited to) information on clinic hours, treatment provider and case manager contact details, information on the roles and responsibilities of different staff (e.g., LTCC, HIV treatment provider), expectations of patients, available transport, how to get treatment refills and information on available mental health services
- Patient education: an orientation took place across the first few initial contacts and appointments, providing patients with a point person to whom to direct questions and concerns as they arose during initial care engagement
Results
Between 2019 and 2021, 395 people with HIV were referred to the LTC program. This included 258 newly diagnosed patients and 137 previously diagnosed but unengaged patients. This group was compared with the 337 patients who were referred to the clinic between January 1, 2016, and December 31, 2018, before the implementation of the LTC program. This included 213 newly diagnosed and 124 previously diagnosed but unengaged patients.
Most participants in the LTC program (newly diagnosed and previously diagnosed but unengaged) were Black (86%). Additionally:
- 49% were men who have sex with men
- 48% were aged between 30 and 49 years
- 27% were female, 69% were male and 4% were transgender women
- 59% reported having no health insurance
Participants were monitored for viral suppression, defined as an HIV viral load of less than 200 copies/mL. The program had a statistically significant impact on viral suppression for people newly diagnosed with HIV; 86% of LTC program participants reached viral suppression, compared with 74% of patients before the implementation of the program. Additionally, 72% of previously diagnosed but unengaged participants reached viral suppression in the LTC program compared with 66% of patients before the implementation of the program. These results were not statistically significant.
In an adjusted model, statistically significant findings included the following:
- among patients who were newly diagnosed, those in the LTC program were more than twice as likely to achieve viral suppression as those before the implementation of the program
- patients with private insurance were twice as likely as those without private insurance to achieve viral suppression
- older patients were more likely to achieve viral suppression than younger patients (patients aged 30–49 years old were more than 1.5 times more likely and patients aged 50 years old and older were more than two times more likely than those aged 29 years old and younger to achieve viral suppression)
What does this mean for service providers?
The study shows that utilizing a LTCC had a significant impact on viral suppression. For example, prompt and personalized case management including close monitoring, appointment reminders and follow-ups that met the capacity of individual patients significantly increased viral suppression for newly diagnosed people living with HIV.
The success of the program may have specifically been due to the range of communication methods offered, which addressed communication barriers, allowing for prompt appointment reminders and follow-ups from the LTCC.
Related resources
HIV Peer Support and Navigation
Linkage to HIV care: Falling behind and getting ahead
Reference
Hickman AB, Backus KV, Sanders CE et al. Evaluation of a linkage to care quality improvement initiative for people with HIV. AIDS and Behavior. 2024;28:264-73.
Production of this resource has been made possible through a financial contribution from Gilead Sciences Canada, Inc. The views expressed herein do not necessarily represent the views of Gilead Sciences Canada, Inc.