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.