Effective HIV care leads to earlier and greater engagement in care, effective viral control, improved immune status, near-normal life expectancy, enhanced quality of life, and prevention of HIV transmission [4
]. These goals can be achieved through increased HIV testing within communities, efficient linkage to HIV primary continuity care and specialty care, access to HIV medications, medication adherence support, efforts to retain patients in care, and social services that address the unmet psychosocial needs of HIV-infected patients [11
]. However, if these essential aspects of effective care are fragmented, that is, not integrated, patients receive either incomplete care or no care at all. The NHAS estimates that 35% of patients newly diagnosed with HIV are not linked to HIV care within 3 months of diagnosis, which is recommended by the Centers for Disease Control and Prevention. However, higher levels of linkage are found in integrated care systems [7
]. Previous reports estimated that between 30% and 50% of HIV patients are not in ongoing care and do not have reliable access to HIV treatment. Ryan White clinical programs report that 73% of patients are in continuous care, defined as at least 2 visits, 3 months apart, within 1 year [7
]. Stigma and health disparities also lead to inconsistent care [1
]. Delayed entry into care and cycling in and out of care can lead to poor clinical outcomes, development of drug-resistant virus, and transmission of HIV to others [18
As the goals of HIV care suggest, integrated medical care for HIV-infected patients is essential. In general, this has been achieved through the “medical home” model. In this model, access to primary and specialty care is coordinated and monitored by the HIV primary care team, as are psychosocial and social services for patients based on their needs. HIV providers have subscribed to this model of care since the early 1990s, with Ryan White Part C clinics, Veterans Administration (VA), and other health care systems as strong examples [19
]. The high rates of care and treatment adherence required for ongoing suppression of HIV are best supported within this type of integrated service delivery environments, such as Ryan White–funded clinics and the VA [22
]. This is particularly true for patients with 2 or more co-occurring conditions.
The extent and type of care integration vary according to the complexity and needs of a clinic’s HIV patient population. The simplest category of collaborative services is coordinated care that is delivered in different settings but with information sharing among the programs. Colocated (services delivered at one location, with data sharing) and integrated (merged medical and behavioral health care components, including mental health and substance use treatment in one treatment plan) medical services are used for patients with complex needs to prevent barriers or gaps in service delivery. Electronic health records (EHRs) that can be shared by the entire care team, specialists, and others who provide the patient’s care are a key component of the integrated care model.
Lower levels of integration can be sufficient for the care of some HIV patients. Critical system components for all levels of integration include established relationships with providers and ongoing communication between the HIV primary care team or the HIV expert and other specialty, primary care, mental, and social service providers. Effective HIV programs allow for a tailored approach for a service population and an individualized approach for patients, using a variety of methods to meet a broad range of needs.