The Need for HIV Care Linkage In Baltimore

The Need for HIV Care Linkage
In Baltimore
Presented by: Jennifer Han, Baltimore City Health Department
 Syringe exchange (SEPs) are cost-effective and evidence-based
interventions that not only reduce HIV and Hepatitis C
transmission, but can serve as a bridge for injection drug users
(IDUs) to access medical care and drug treatment1
 The National HIV/AIDS Strategy for the United States stresses
the importance of increasing access to care and improving health
outcomes for people living with HIV by facilitating linkages to
HIV Care Among Injection Drug Users
 IDUs receive a disproportionately high amount of hospital
resources compared to other HIV-positive groups3
 Despite this, studies have demonstrated that IDUs have lower
uptake of HIV care and treatment, including antiretroviral
therapy than other HIV-infected populations4
Consequences of Inadequate HIV Care
 Missed care appointments are associated with5:
 Poor antiretroviral therapy (ART) adherence
 Increased HIV drug resistance
 Higher mortality rates
 Failure to suppress viral load
 Decreased immune function
 High-risk sexual behavior
Proposed Strategy
 Incorporating HIV testing and treatment into harm reduction
services such as SEPs have been identified as a strategy for
improving access to HIV care among IDUs6
 This presentation examines both the potential and need for HIV
care linkage among clients of the Baltimore City Health
Department (BCHD) run SEP
Baltimore Needle Exchange Program
 Started in 1994 as a pilot 1:1 exchange program
 Run by health department
 Expanded services beyond needle exchange
 Client electronic records became available in 2008
 Prior to 2008, BNEP was:
 Anonymous
 Paper and pen method of record keeping
 Currently, BNEP is the only confidential syringe exchange in the
Introducing the location of 2014
National Harm Reduction
HIV Care Linkage Process
• 3,491 NEP
• Check to
see HIV
• Check to
see if
to HIV
 NEP electronic database
 Used for:
 Client registration
 Records all client visits
 Data reports
 Step 1: Generate NEP client list
 Step 2: Check HIV test records for NEP clients
 Database of HIV status and treatment records for individuals
who test in Baltimore City
 Step 1: Searched for NEP clients in STD MIS by name, birthday,
 Step 2: Created separate lists for matches, possible matches,
and no matches
 Step 3: For those with matches and possible matches, pulled
up their HIV status and testing records
ETO Database
 Database of individuals who have accessed any services
funded by Ryan White
 Step 1: Provided list of HIV+ clients to Ryan White staff to
check in their database if client is linked to care
 Step 2: Also provided two other lists
 NEP clients whose last HIV test was negative
 NEP clients with unknown HIV status
 Step 3: Obtain HIV care status for NEP clients that were
found in ETO
HIV status among NEP clients
261 HIV +
3,491 clients
1492 HIV -
11 are actually
1738 w/
unknown HIV
66 are actually
HIV prevalence among NEP clients
HIV Prevalence**
4/20 = 20%
11/74 = 14.9%
12/125= 9.6%
19/136= 14%
26/206= 12.6%
37/352= 10.5%
94/681= 13.8%
 Overall prevalence for NEP
clients is 343/3491 = 9.8%
 Denominator includes
clients with unknown HIV
status and with no recent
HIV test
**Denominator is the number of clients whose last HIV test was in year X
Prioritizing Active Clients for HIV Care Linkage
 Active clients = # of clients with at least one visit to NEP in the
last year
 As of January 24, 2011, there were 1,251 active NEP clients
 Of the 1,251 clients, 144 (11.5%) are HIV+
 Final step: Submitted list of HIV+ clients to Maryland State
Health Department to check HIV care status
NEP Client Characteristics (n=1,251)
65.8% male
Number of visits to NEP in 2011
per client
34% female
26.1% had 1 visit
28.2% had 2-4 visits
20.9% had 5-10 visits
15.3% had 11-24 visits
9.5% had 25+ visits
59.2% Black
38.6% White
Average age is 43.2 years old
HIV status
11.5% HIV+
55.9% HIV-
31.9% Unknown status
HIV Care Linkage Program
 Collaboration between NEP and Ryan White programs
 HIV Care navigators/advocates accompany clients to their
 Strategies:
Shared information to confirm clients’ HIV status and medical care
Provided flyers about HIV Care Linkage Program on SEP mobile units
Inserted alerts into a database for SEP clients who have fallen out of
Field records are generated to locate HIV+ clients who have fallen out
of care
Process Flow for Linking a HIV+ NEP clients
Client comes to SEP
SEP staff member enters visit into database; an alert pops up
Staff asks client about his/her HIV care status
If client is out of care and wants to be linked to care, the HIV
Care Linkage Team is notified immediately by phone and a field
record is generated.
5. A member of the HIV Care Linkage Team picks the client up and
accompanies him/her to their first 2 appointments
6. The client receives a small incentive for keeping each of the 2
7. Outcome of the field record is logged as “linked to care.”
Client Characteristics
N (%)
HIV Care Status
In Care*
Incarcerated and in care
Not In Care
67 (46.5)
14 (9.7)
62 (43.1)
1 (0.7)
Inpatient hospitalizations** (n=62)
35 (56.5)
Recent Visit to SEP (since September 2011)
67 (67.4)
Median viral load (n=47)
Median CD4 count (n=74)
*Clients were categorized as “in care” if the visit occurred within the past 6 months
*All inpatient hospitalizations were among those not in care
HIV Care Status Breakdown and Program Outcomes
1 Deceased
81 In Care
6 Successful
144 HIV+
35 had
Inpatient Care
62 Not In Care
3 In Progress
8 Field Records
5 Refusals
Summary of Outcomes
 Among the 144 HIV+ SEP clients, 43.1% are not receiving HIV
care, of which nearly half have had a inpatient hospitalization as
their source of HIV care
 Among the field records that were generated by BCHD’s HIV
Care Linkage Team, 55% resulted in successful linkages to HIV
 67.4% of HIV+ clients had had a more recent visit to the SEP
(since September 2011).
 Data discrepancies between databases
 Database limitations
 Lag period of reporting
 Data is already outdated
 New NEP clients are added daily
 HIV testing/Ryan White data
 Manual labor
 Took approximately 6 months for interns to complete cross
checking NEP clients in STD MIS
 Took 1 month for Ryan White to check clients in Ryan White
 Multiple databases that do not communicate with one
 Dealing with inaccurate client information
 Missing information (HIV tests, care status, etc)
 Lag period for reporting
Assessment on the barriers to HIV Care
engagement among NEP clients
Target Population:
All HIV-positive Needle Exchange
Program (NEP) clients who are
active users of the NEP van
Survey Sample 1:
NEP Clients
Survey Sample 2:
Non-NEP Clients
Key Findings
• Commonly identified themes related to barriers to engagement
of BNEP clients in HIV care
Lack of transportation, use of alcohol or other drugs, and
mistrust of providers/health care system as significant barriers
mentioned by both clients and care linkage staff.
Assistance with transportation and incentives (e.g. bus tokens,
food vouchers) as BNEP care linkage interventions mentioned by
both clients and care linkage staff.
Support services (e.g. housing referrals, medication assistance) as
a client-identified care linkage intervention for the BNEP.
Recommendations from Assessment
 Reduce structural and practical barriers to care by providing
incentives or contributions for food/transportation costs
 Put up signs on the NEP van to inform clients that they can
receive a monetary incentive if they can keep their first
scheduled HIV care appointment
 Seek further client input to organize care linkage services in a
way that is most acceptable to clients
 Improve efficiency of process for identifying NEP clients who are
Extra Considerations
 Sensitivity of dealing with HIV status
 How to best approach a HIV+ NEP client who visits the van
 Confidentiality concerns
 Disclaimer during client registration
 Multiple clients on the van
Findings from Assessment
 “In what manner would you like to be approached by NEP staff
about your status in HIV care?”
 By sending a letter
 Would not want to discuss while on the van because anyone can
“jump on the van” and does not want others to know personal
 Honestly and directly, “no beating around the bus”
 No preference/doesn’t matter- “they can approach me”
 No preference/doesn’t matter, okay with being approached
Findings from HRC Focus Group
 Some participants displayed some discomfort with this idea, while
others thought it might be helpful if it meant they could receive
targeted health education
 Clients emphasized the importance of confidentiality in the matter-
“Well definitely one-on-one confidential [conversation].. You know
very discreetly about it.”
 “I would want all the people that could help me and teach me [to
know my status]”
 “I don’t think I would mind because they are the kind of people that I
would think you would want to know.”
Moving Forward
 Come up with a method to link clients in different databases
 Focus efforts on active NEP clients
 Create a manual to document procedures, including a schedule
and system for tracking outcomes
 Increase advertising of the HIV Care Linkage Program
 Offer bus tokens
 This study demonstrates that there is a high prevalence of HIV
among Baltimore SEP clients and a low proportion of them are
receiving care
 Of those not in care, approximately 60% have had inpatient
 However, the fact that nearly 70% of HIV+ clients have had a
recent visit to the SEP represents an opportunity to link and relink individuals to HIV medical care and other needed services.
The Potential for HIV Care Linkage in
 Baltimore’s SEP is the only confidential based syringe exchange
program in the U.S. and is also based within a health
 BCHD is in the process of crafting a specific strategy for a
better HIV care linkage process for SEP clients
 The incorporation of HIV testing and care within harm
reduction services such as SEP is an important strategy in
reaching HIV+ IDUs who have fallen out of care
The Motivation Behind What We Do
 “[The NEP] is just about covering everything I think is necessary.
NEP treats us like a social service program so I like it. They have
a lot of people come [to the van] with different services.”
 “The [NEP] van is truly an asset to the community.”
 Baltimore City Health Department’s Needle Exchange staff
 Ryan White HIV Care Linkage Team
 Emeline Mugisha, Anita Ram, Caeden Dempsey
 NEP clients
Thank You!
 Contact information:
 Jennifer Han
Baltimore City Health Department
[email protected]
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