2017

Overview

The Health Promotion Case Management (HCPM) program provides short-term (less than six months), outreach-based case management to individuals at ongoing high risk for HIV infection who could use support to remain HIV negative. The program works with clients to decrease their vulnerability to HIV by providing case management to clients to help them develop the self-efficacy and personal skills that strengthen their resiliency. Case managers support clients to make the changes they want to their behaviour, lifestyle, relationships, and emotional and mental health. Case managers also address structural barriers to wellness that impact people at ongoing high risk for HIV, including support to access social assistance, housing and healthcare, and referrals to community, immigration and legal services.

The program provides support to at-risk individuals from the following groups:

1. Indigenous peoples
2. HIV-negative partners in serodiscordant couples
3. Women
4. Newcomers, immigrantsand refugees
5. Gay, bisexual and other men who have sex with men (MSM)

The objective of HPCM is to improve clients’ self-management skills and, through a care plan, to develop a network of service providers that helps clients remain HIV negative in the long term. Through strong community partnerships, HPCM reduces silos and improves integrated healthcare for people at ongoing high risk for HIV infection.

This program element complements a case study and another program element that describe the Health Promotion Case Management program. For more information about the work of the health promotion case managers in general, see the HPCM case study. For more information on the work of the case manager who works with gay, bisexual and other MSM, see the program element on the work of the case manager who serves Fraser Health Authority.

One case manager works with Indigenous peoples in Vancouver who are at ongoing high risk for HIV infection. This case manager works primarily at AIDS Vancouver, but has also spent time working onsite at an Indigenous-serving organization in Vancouver’s Downtown Eastside. This organization is housed in a building that includes many other Indigenous agencies and services and was chosen because it is already known to Indigenous clients, is close to other Indigenous-serving organizations, and is close to where many Indigenous people live. Connections continue to be built with other Vancouver organizations that primarily serve Indigenous people with the possibility that the case manager may offer drop-in hours or other onsite availability from these locations in the future.

Providing culturally safe services to Indigenous peoples

Indigenous clients may have a deep mistrust of the health and social service system because it may not have traditionally served them well. Because of this mistrust, the case manager typically focuses on building trusting and respectful relationships with clients as a bridge to building better relationships between clients and the wider health and social service system.

The case manager aims to be reliable and dependable and demonstrates this to clients by being trustworthy and doing what they say they will. The case manager also intentionally discloses their own identity as an Indigenous person as a way to build trusting relationships with clients. A shared identity as Indigenous peoples can help build trust by acknowledging shared experiences.

The case manager works through Indigenous frameworks to offer culturally competent and culturally safe support to clients. One of the first things the case manager does with clients is gauge their level of comfort and familiarity with Indigenous culture, understanding that the history of colonization and the legacy of residential schools have had an impact on the ability of many Indigenous peoples to remain connected to their culture. Using this information, the case manager can discuss with the client how involved they would like elders, Indigenous peers and Indigenous-serving organizations to be in their support system. Depending on their familiarity with Indigenous practices, the case manager also uses the medicine wheel to talk about holistic health and wellness.

Meeting the needs of Indigenous peoples

With most clients, the first goals are to get identification such as Indian status cards, apply for social assistance and housing, and connect them to Indigenous-serving organizations, Indigenous peers and local elders. The case manager acts as an advocate for clients and navigates them through the social service system. They help clients seek health and social service providers with experience working with Indigenous peoples, and who understand the historical trauma, violence and legacy of residential schools.

Once these structural issues have been addressed, the trusting relationship the client and case manager have developed allows them to work on issues clients may have been hesitant to discuss, such as trauma and substance use. It also allows the case manager to have conversations about sex, drug use, HIV, and HIV prevention that may not have been possible at the beginning of their relationship. If healthcare and HIV services were not identified as immediate needs then, once trust is built, the case manager supports the client to access health services, which can include an HIV test.

Building a network of service providers to support Indigenous peoples

Connecting to the wider network of service providers who work with Indigenous peoples in Vancouver is one of the key ways that the case manager serves their clients. The case manager attends local events and gatherings with other Indigenous service providers. They also often access the drop-in times of local Indigenous-serving organizations to build and maintain connection with their staff and community members. The case manager has also worked to increase support for two-spirit clients by fostering relationships with two-spirit organizations and people in the community who are willing to work with two-spirit clients as peers. Building relationships with other service providers not only improves the case manager’s comfort referring clients to them, but it has also increased referrals to the HPCM program from these organizations.

Ultimately, the case manager uses relationships with other service providers to connect clients to services in a sustainable way so that once clients transition from the HPCM program, they can connect to a variety of service providers who can support them to maintain the positive health and wellness changes they made while working with the case manager.

2017

Overview

The Health Promotion Case Management (HCPM) program provides short-term (less than six months), outreach-based case management to individuals at ongoing high risk for HIV infection who could use support to remain HIV negative. The program works with clients to decrease their vulnerability to HIV by providing case management to clients to help them develop the self-efficacy and personal skills that strengthen their resiliency. Case managers support clients to make the changes they want to their behaviour, lifestyle, relationships, and emotional and mental health. Case managers also address structural barriers to wellness that impact people at ongoing high risk for HIV, including support to access social assistance, housing and healthcare, and referrals to community, immigration and legal services.

The program provides support to at-risk individuals from the following groups:

1. Indigenous peoples
2. HIV-negative partners in serodiscordant couples
3. Women
4. Newcomers, immigrants and refugees
5. Gay, bisexual and other men who have sex with men (MSM)

 The objective of HPCM is to improve clients’ self-management skills and, through a care plan, to develop a network of service providers that helps clients remain HIV negative in the long term. Through strong community partnerships, HPCM reduces silos and improves integrated healthcare for people at ongoing high risk for HIV infection.

This program element complements a case study and another program element that describe the Health Promotion Case Management program. For more information about the work of the health promotion case managers in general, see the HPCM program case study. For more information on the work of the case manager who works with Indigenous peoples, see the program element on providing services to Indigenous peoples.

This program element focuses on the work of one of the HCPM case managers who works with MSM in Surrey and New Westminster, which are suburbs of Vancouver located in the Fraser Health Authority. Although the case manager works at AIDS Vancouver, which has long worked with gay, bisexual and other MSM, they also work twice a week in Surrey and New Westminster. This work is facilitated through partnerships with Health Initiative for Men (HIM) and the Fraser Health STOP Team who offer clinics in those cities.

Providing services to gay, bisexual and other MSM in the Fraser Health Authority

Unlike Vancouver, the geographical area covered by the Fraser Health Authority does not have access to a host of queer and trans-friendly and/or queer and trans-specific services; in some parts of the health authority, homophobia, transphobia and stigma related to substance use and HIV is still high. Without local services, people travel to cities such as Surrey, New Westminster and Vancouver to receive lower barrier and judgment-free healthcare.

Drop-in services for gay, bi and other MSM

Twice a week, the case manager has drop-in hours when HIM clinics are open in Surrey and New Westminster. The clients are mostly men who identify as gay, bisexual or other MSM. Many clients seek brief counselling and support from the case manager related to sexual health, healthy relationships, mental health, and substance use. Some clients are interested in accessing pre-exposure prophylaxis (PrEP). The case manager provides sexual health counselling and brief counselling to clients, and information and referrals for PrEP access, and substance use and mental health treatment services, when needed.

Having drop-in hours, rather than specific appointments, makes the case manager available to build trust and respect with clients over time, to provide brief counselling to those who may need it, and to identify clients who may need long-term support.

Intensive case management for gay, bisexual and other MSM

In addition to drop-in support, the case manager also has gay, bisexual and other MSM clients in the Fraser Health Authority who need more intensive support services. With these clients, the case manager identifies goals the client wants to achieve, such as finding stable housing and connecting with social assistance; provides ongoing counselling; and makes referrals to local services that may be able to support clients to achieve their goals. Although support for these clients can be short—between three and six months—the case manager sees some clients for longer if they continue to need and want support to achieve their goals.

Lack of queer and trans-friendly services is an ongoing challenge

There is a need for additional queer and trans-friendly services to address the needs of gay, bisexual and other MSM who live in the area covered by the Fraser Health Authority. The lack of queer and trans-friendly services in the region to which clients can be referred is a significant challenge to the work of the case manager. In addition, there are increasing referrals from more rural parts of the health authority that the case manager does not currently serve in person. The case manager works with these clients over the phone and through text messaging, and some clients agree to travel to see the case manager at one of the two clinic locations in Surrey and New Westminster.

Los Angeles, United States
2017

Client-centred intervention for people newly diagnosed with HIV is effective at linking people to care

A study out of the United States found that the addition of a linkage to care specialist within the HIV testing protocol of the Los Angeles LGBT Center resulted in over 90% of people newly diagnosed being linked to HIV care. In addition, once in care, over 90% of people were retained in care and attained viral suppression.

The Linkage to Care Specialist Project

In 2012, a clinical social worker was hired as a full-time linkage to care specialist at the LGBT Center in Los Angeles. This position was integrated into the HIV testing protocol at the Center to facilitate linkage to care. The linkage to care specialist uses a client-centred approach, and motivational interviewing and strengths-based case management techniques to help the client develop positive health-seeking behaviours. The specialist works at a pace dictated by the client’s needs and provides referrals and schedules medical and other appointments as needed. Reminders are made the day before appointments to encourage attendance.

The work of the linkage to care specialist can be divided into three phases.

Phase 1: Immediately after the delivery of a positive HIV test result, the client meets with the linkage to care specialist. Using motivational interviewing, the linkage to care specialist encourages the client to explore concerns, and discusses strategies to address any needs that arise. The two objectives of this meeting are to develop a support plan and a linkage plan for the client. Even if the client isn’t ready to be linked to medical care at this time, an appointment to address any of the articulated concerns is scheduled by the end of the first meeting.

Phase 2: Based on the client’s needs, contact is maintained to help the client cope, navigate the healthcare system, and develop the skills required for successful engagement in care. Contact can occur in person, over the phone, by text message or by email depending on the individual’s needs.

Phase 3: For clients who are ready to engage in care soon after diagnosis, the linkage to care specialist tapers contact with the client. For clients who express an interest in receiving care at the Center, introductions are made to care team members to support the development of a relationship. If appointments are subsequently missed, the linkage to care specialist follows up with the client to address any barriers. Finally, for people who do not initially engage with the linkage to care specialist, additional attempts are made to engage them. These attempts cease when the client is either successfully linked to care or they ask the linkage to care specialist to stop calling.

The study

The impact of the linkage to care specialist was assessed for people newly diagnosed with HIV between March 2014 and September 2015.¹ The primary outcome of interest was attendance at a medical visit with any HIV primary care provider within three months of diagnosis. The secondary outcomes were retention in care (two medical visits at least three months apart within a 12- month period) and viral suppression at retention (any viral load less than 200 copies/mL).

Of the 389 newly diagnosed clients, 118 (30%) were enrolled in the study. The majority of participants were gay men, aged 18 to 29, high school graduates, and had stable housing. Of the 118 people enrolled, 94% had a medical visit within three months of diagnosis. The linkage to care specialist spent an average time of 2.1 hours working with each participants, with an average of 4.9 interactions. For those participants who were successfully linked to care, 92% were retained in care, of which 94% achieved viral suppression.

What does this mean?

This study demonstrates that the incorporation of a linkage to care specialist within a testing protocol can result in high rates of linkage to care, retention and viral suppression. Other models of linkage to care have also demonstrated beneficial results. Organizations looking to improve linkage to care for clients newly diagnosed with HIV may want to consider how these interventions could be incorporated into their programming.

Reference

1. Bendetson J, Dierst-Davies R, Flynn R, et al. Evaluation of a Client-Centered Linkage Intervention for Patients Newly Diagnosed with HIV at an Urban United States LGBT Center: The Linkage to Care Specialist Project. AIDS Patient Care and STDs. 2017 Jul;31(7):283–89.

The Netherlands
2017

A Dutch study¹ found that a behavioural intervention provided by nurses that uses feedback from electronic medication monitors to improve HIV treatment (ART) adherence resulted in improved health outcomes. In addition, an economic analysis found that the intervention was cost-saving.

Adherence Improving self-Management Strategy (AIMS)

The Adherence Improving Self-Management Strategy (AIMS) is a one-on-one behavioural intervention, delivered by nurses, that incorporates feedback from Medication Event Monitoring System [MEMS]-caps (an electronic pill bottle, which records the date and time that the bottle is opened). AIMS was designed to fit in with routine clinic visits.

For this study, 21 HIV nurses from seven participating clinics received three training sessions on AIMS including how to use the MEMS-caps and software and deliver the behavioural intervention. Each training session lasted six hours (18 hours in total). A booster session lasting 1.5 hours was given to groups of two to three nurses at each clinic after each nurse had seen two to three patients.

The Study

Researchers in the Netherlands conducted a multicentre, open-label randomised control trial in seven HIV clinics between 2011 and 2014. Participants in the study were randomly assigned to receive either AIMS (109 patients) or routine treatment care (112 patients) in order to assess the AIMS intervention.

Participants were eligible for the study if they were starting their first HIV treatment regimen (treatment-naive) or had been taking ART for at least nine months (treatment-experienced) and had an undetectable viral load but were at risk for their viral load becoming detectable again (viral rebound). Participants were considered at risk for viral rebound if they had at least one detectable viral load in the past three years and were determined to have had suboptimal adherence during two months of baseline MEMS-caps monitoring.

At clinic visits, the nurses downloaded the recorded data from the MEMS-caps and used it to generate reports showing adherence patterns. These reports were used in discussions between the nurse and participant about maintaining or improving the participant’s adherence. If a participant had ongoing problems with adherence, they had the option of more frequent nurse visits.

Plasma viral load and CD4+ counts were measured at baseline and at approximately five months, 10 months and 15 months as part of each participant’s routine care. For participants who were new to treatment, the first follow-up measurement was at six months to allow time for their viral load to become undetectable.

Participants were followed-up for an average of 14.6 months. The average number of visits (3.2) was the same for both the AIMS group and the routine treatment group. In the routine treatment group, the average time spent at each clinic visit was 19 minutes, while the average time for the AIMS group was 29 minutes. Over the whole study, the AIMS group spent an average of 35 minutes longer at visits compared to the routine treatment group.

At the end of the study, more patients in the routine treatment group (16.7%) had a detectable viral load compared to those in the AIMS group (9.6%) These results were the same regardless of which study nurse delivered care. Significantly more patients in the routine treatment group (22.8%) experienced treatment failure (defined as two consecutive detectable viral loads) compared to those in the AIMS group (9.0%). These results were similar for both treatment-naïve and treatment experienced participants.

Average CD4+ cell counts increased across both groups over the course of the study, but was significantly higher at month 15 among participants in the AIMS group compared to the routine treatment group.

An economic analysis of AIMS estimated that it reduced lifetime health costs by €592 (about $CAN 837 or $US 628) per patient. Further analysis showed that if AIMS was implemented for 10,000 patients and continued for 18 months, health systems would save almost €6 million (about $CAN 8.7 million, or $US 6.5 million).

What does this mean for Canadian service providers?

This study showed that patients who received the AIMS intervention to improve adherence resulted in better clinical outcomes including improvements in both viral load and CD4+ counts compared to patients who received regular care. Additionally, the researchers found that the intervention could be cost-saving compared to usual treatment care. One benefit of this intervention is that it can be incorporated into scheduled clinic appointments.

Implementing programs that improve adherence can result in more people living with HIV who have an undetectable viral load. Having an undetectable viral load has long-term health benefits and also dramatically reduces the HIV transmission risk.

Reference

de Bruin M, Oberjé EJ, Viechtbauer W, et al. Effectiveness and cost-effectiveness of a nurse-delivered intervention to improve adherence to treatment for HIV: a pragmatic, multicentre, open-label, randomised clinical trial. Lancet Infectious Diseases. 2017;17(6):595–604.