The United States Centers for Disease Control and Prevention
(CDC) recommends routine HIV screening for individuals aged 13–64 in medical settings including emergency departments (EDs), which tend to have high rates of undiagnosed HIV infection.1,2
Current CDC recommendations focus on HIV counseling and testing (C&T) as the primary mechanisms for HIV prevention; once an individual is identified as being infected with HIV, they should be informed of their status and engaged into specialized HIV treatment in a timely manner.1
The CDC recommends engagement in treatment within 6 months, and standard ED protocol defines linkage as engagement into primary care within 30 days of diagnosis.3,4
Engagement in HIV treatment, including highly active antiretroviral therapy (HAART), has been shown to reduce HIV transmission by encouraging adoption of risk reduction behaviors and decreasing plasma HIV-RNA levels.5,6
It is clear that identification of existing HIV infection alone is not sufficient to improve patient outcomes and delayed entry into medical care is associated with worse disease progression.7,8
HIV C&T programs have a significant challenge linking patients into HIV care from an ED setting.9,10
Limited resources and the incident-specific nature of the ED visit could contribute to low linkage rates, which range between 60–80% of patients establishing care within 6 months.9,11
The highest rate of linkage was found in a study by Gardner et al.12
in which the researchers conducted a randomized controlled trial to assess the efficacy of a case management intervention to ensure linkage into care as compared with the standard of care of passive referral to outpatient treatment. The case manager in this study acted as a client navigator in order to address client needs and barriers to care and accompany the patient to the clinic, if desired.12
These researchers defined linkage as one outpatient clinic visit in two consecutive 6-month periods, for a total of at least two clinic visits in 12 months. In this study, 78% of the intervention group was linked to care, while only 60% of the control group visited an outpatient HIV clinic in the six months following diagnosis.12
This multisite study did not focus specifically on patients who tested for HIV in an ED setting but it provides encouraging evidence that a low-cost case manager-type intervention can have a significant impact on bringing HIV patients into care.
While Gardner et al.12
defined linkage to care as two clinic visits in 12 months, this study applied the consensus definition used by the Society for Academic Emergency Medicine, which defines successful linkage as “linkage less than 30 days after the initial ED encounter; includes patients hospitalized after the ED encounter, provided that the inpatient physician was aware of the diagnosis while the patient was in the hospital.”13
The importance of patient engagement in HIV care, in addition to successful linkage, has been recognized by the United States Health Resources and Services Administration and has established a continuum by which patient engagement can be measured.14
The goal of this investigation was to assess effectiveness of linkage to care in our ED model of HIV testing. Our process involves public health advocates (PHAs) serving in a dual role: an actively recruiting HIV counselor/tester who approaches patients in a non-targeted fashion (assisted and armed with a state-of-the-art tablet PC for HIV counseling and automated touch screen data entry allowing for increased capacity to work with several patients in parallel) and a navigator of the health care system who links patients diagnosed with HIV into care immediately. The PHA component of our model is complemented by a frequently scheduled open access outpatient expert HIV clinic which permits absorption of patients into medical care, minimizing barriers and allowing expedited expert evaluation of newly diagnosed HIV patients by HIV experts.