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LINKAGE TO CARE
Experience at a Community-based LGBT Organization with Integrated HIV/STI Testing and
HIV CareR.K. Bolan, M.D., M. Beymer, R. Flynn, D. Prock, J. Rodriguez, D. KerroneL. A. Gay & Lesbian Center, Los Angeles, CA, USA
PHYSICAL RESOURCES OF L.A. GAY & LESBIAN CENTER
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
The Sexual Health Program
(SHP)
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
WHERE LAGLC FITS AMONG L.A. COUNTY HIV/STI DIAGNOSES
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
STUDY INTERVAL: 1/1/2009 -3/31/2011
Gender N
Male 468
Female 3
Trans-sexual MTF 6
Trans-sexual FTM 1
478
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
HIV CLINIC PATIENT POPULATION FINANCIAL/INSURANCE DATA*
* SHP is a public health STD program; no financial screening, no patient billing** Federal Poverty Level (2011) for Family Size of 1 = $10,890
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
STRUCTURAL INTERVENTIONS MADE TO INCREASE ENTRY TO CARE DURING STUDY
INTERVAL
Linkage to Care is defined as the fi rst face to face meeting with a medical provider within 6 months of HIV diagnosis
DEFINITION
DATA
Gay Bisexual Hetero ?/Unk Totals n (%) n (%) n (%) n (%) n (%)
White
Hispanic 116 (28) 11 (23.9) 4 (30.8) 131 (27.5)
Non-Hispanic 134 (32.2) 13 (28.3) 4 (30.8) 1 (33.3) 152 (31.8)
Unknown 4 (1.0) 4 (0.8)
Race Unknown/unreported
Hispanic 68 (16.3) 4 (8.7) 72 (15.1)
Non-Hispanic 3 (0.7) 3 (0.6)
Unknown 2 (0.5) 1 (2.2) 3 (0.6)
More than one race 17 (3.6)
Black or African American 52 (12.6) 13 (28.3) 4 (30.8) 2 (66.7) 71 (14.9)
Asian 14 (3.4) 2 (4.3) 1 (7.7) 17 (3.6)
Hawaiian or Pac Islander 4 (1.0) 4 (0.8)
American Indian or Alaska Native 3 (0.7) 1 (2.2) 4 (0.8)
Grand Total 414 (100) 46 (100) 13 (100) 3 (100) 478 (100)
RACIAL/ETHNIC IDENTITY SHOWN BY ORIENTATIONALL NEWLY POSITIVE HIV TESTERS:
JANUARY 2009 THROUGH MARCH 2011
Positive Tests by Orientation
87.03%
9.62% 2.72%
0.63%
97% male
Average Age at Diagnosis for all Testing Positive (478) 2009 2010 2011 Entire Interval
Age 30.9 33.0 33.9 32.5
AVERAGE AGE AT DIAGNOSIS
Average Age at Diagnosis for Those Who Entered Care (266) 2009 2010 2011 Entire Interval
Age 30.3 32.7 34.3 32.3
2009 2010 2011
Total Pos (n)
In Care (n) %
Total Pos (n)
In Care (n) %
Total Pos (n)
In Care (n) %
White Hispanic 33 25 75.8% 80 66 82.5% 18 14 77.8% Non-Hispanic 45 24 53.3% 87 42 48.3% 19 13 68.4% Unknown 1 0.0% 0 3 2 66.7%Unknown/unreported Hispanic 35 4 11.4% 29 5 17.2% 7 4 57.1% Non-Hispanic 1 0 0.0% 1 0 1 0 0.0% Unknown 2 0 0 0 1 0 0.0%More than one race 9 7 77.8% 7 5 71.4% 1 0 0.0%Black or African American 22 9 40.9% 38 21 55.3% 11 8 72.7%Asian 4 1 25.0% 9 7 77.8% 4 4 100.0%Hawaiian or Pac Islander 0 4 2 50.0% 0 American Indian or Alaska Native 2 1 50.0% 2 2 100.0% 0 154 71 46.1% 257 150 58.4% 65 45 69.2%
ENTRY TO CARE RATE IMPROVED FOR MOST GROUPS DURING STUDY
INTERVAL
Total Linked to care over entire interval = 266/478 = 55.6%
Average Interval between Diagnosis Date and 1st care Date (mos.)2009 2010 2011 Total Interval
Average months 1.38 0.97 0.57 1.01
ENTRY TO CARE INTERVALS IMPROVING
2009 2010 2011 NAverage of Initial CD4
nAverage 1st
CD4 nAverage 1st
CD4 nAverage 1st
CD4WhiteHispanic 25 452 66 438 14 419 105 440Non-Hispanic 23 491 42 497 13 537 78 502Unknown 2 907 2 907
Unknown/unreported 3 530 5 562 4 694 12 605More than one raceHispanic 6 457 2 351 8 430Non-Hispanic 1 480 3 897 4 793
Asian 1 283 7 492 4 472 12 468Black or African American 9 423 21 359 8 457 38 393Hawaiian or Pac Islander 2 446 2 446American Indian or Alaska Native 1 3 2 285 3 191Grand Total 69 456 150 455 45 519 264 465
CD4 AVERAGE UPON ENTRY INTO CARE
Average Interval between Diagnosis Date and 1st ARV Rx Date (mos.)2009 2010 2011 For Study Interval
Average months 4.67 2.66 1.51 3.00
TIME TO 1ST ARV INTERVALS IMPROVING
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
STARTING ARVS AND RETENTION IN CARE
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
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 eff orts of the HIV Testing Counselors, an increase in availability of new patient clinic appointments, and streamlined financial screening.
SUMMARY
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
DISCUSSION
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 careWe will be adding a Linkage to Care Coordinator, our fi rst
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 defi ne their duties
We will encourage other public health workers who do Partner Notifi cation interviews with new positives to help encourage Linkage to Care
FUTURE DIRECTIONS
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 offi ce and always manages
to find calm and gracious time for everyone and is really the one who makes everything work
THANK YOU