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