TLC+: Best Practices to Implement Enhanced HIV Test, Link-to-Care, Plus Treat (TLC-Plus) Strategies in Four U.S. Cities

August 2011

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Components of Successful TLC-Plus Programs

Increased HIV Testing

Increased HIV testing in communities and populations with high seroprevalence is a key objective of TLC-Plus, as all subsequent components are dependent upon identifying HIV-infected individuals.

In the past few years, San Francisco has experienced a strong community uptake in testing: In 2008, 72% of undiagnosed men who have sex with men (MSM) in the City received an HIV test in the past 12 months compared to 65% in 2004, with over half (53%) testing in the last 6 months of 2008.8 The increase in HIV testing is a result of a two-pronged approach that uses routine, opt-out screening in clinical settings and screening in non-clinical community-based counseling and testing sites such as Magnet (a provider of community-based sexual health services by and for gay men in the Castro).

Screening in Clinical Settings

Routine opt-out screening in clinical settings can contribute significantly to reducing the rates of unidentified HIV infection by reaching individuals who do not identify with high-risk groups (e.g., MSM or injection drug users [IDU]) or who experience other barriers to HIV testing. Detecting HIV infection in patients presenting in emergency departments (ED) is an important component of routine screening in clinical settings. According to data from the City to CDC, the San Francisco General Hospital ED has a positivity rate of 1.26% among those not previously identified as HIV-infected. Of 80 new cases identified in the ED between June 2008 and September 2010, 30% were heterosexual, 21% IDU, 26% were homeless, 30% reported having an HIV-positive partner, and 35% reported no prior HIV test -- all astounding figures, which speak to the fact that routine testing in EDs reaches many individuals who may have gone undiagnosed for years, perhaps until advanced HIV disease.


In Washington, D.C., opt-out HIV screening was scaled up in 7 of 8 EDs and as part of hospital admissions. Los Angeles County has been working to move toward routine, rapid HIV testing in EDs but acknowledges the enormity of such efforts, particularly in a county as large as Los Angeles. Recently, LAC and the USC Medical Center, the largest ED in the county, have been able to implement routine HIV testing, yielding a 1.7% positivity rate in the first 3 months of the program.

Although positivity rates in public primary care settings may not be as high as in EDs, primary care settings represent opportunity for diagnosing HIV among those most likely to be unaware of their status -- those who do not identify as high risk and those who have barriers to testing. San Francisco Department of Public Health clinics are scaling up routine, opt-out testing and officials expect this approach to reduce the percentage of HIV-infected individuals unaware of their status.

Health officials in Washington, D.C. increased the number of HIV tests to 93,000 in 2009 from a base of 20,000 in 2004 largely through opt-out HIV testing in medical and other settings and through the use of a social marketing campaign. The campaign promoted routine HIV testing to providers and patients alike.

Targeting Social and Sexual Networks

Los Angeles County has increased testing by targeting sexual networks to identify HIV-infected people in communities most at risk and that may otherwise be difficult to reach. For example, the County has increased testing for HIV in STD clinics with high STD incidence. High STD incidence in a population suggests behavior that puts individuals at risk for HIV acquisition or transmission -- in many cases among those who are coming to the clinic for symptomatic treatment of STDs rather than regular STD/HIV screening. As a measure of success for such targeted testing, the county has generally achieved positivity rates ranging from 1% in the general population seeking STD treatment, to 2% to 4% among high-risk MSM and IDUs in STD clinic settings.

Furthermore, in 2009, the County implemented a social network testing program, which focused on recruiting persons to test from the social and sexual networks of HIV-positive or high risk MSM pockets in the South LA and Metro areas of LA, two geographic areas with the highest HIV burden. This project resulted in an overall positivity rate of 8.0% (new positivity rate of 7.1%). Given its success in effectively identifying new infections, it has been replicated in 2 additional sites in LAC, and further scale-up of this methodology is likely.

Additionally, through the LAC Partner Services program, partners of individuals who are newly diagnosed, or who are HIV-infected with a concomitant STD are elicited, interviewed, and tested for HIV and STDs. This program, while time and staff intensive, has been another effective way of identifying HIV through sexual networks. In 2009, of 2,911 individuals with HIV who were referred to the Partner Services program, 1,223 partners were elicited. Of those partners, 588 accepted an interview and 426 were tested for HIV, resulting in 97 HIV diagnoses, and a positivity rate of 23% among those tested. Efforts to enhance Partner Services as an approach to case identification focus on improving acceptance rates of Partner Services interviews for index patients and partners through expanding the network of "embedded Disease Investigation Services (DIS)", which are individuals who work in community clinic settings with a high burden of HIV disease and perform partner services in collaboration with the health department.

Testing for acute HIV infection can be a valuable way of identifying early infection during the period in which viremia spikes and many patients are highly infectious. San Francisco has increased the identification of acute infections over recent years, primarily through viral load pooling -- a method in which pooled samples screen multiple specimens at one time. If any sample in the pool is reactive, then all samples are tested to identify the individual infection. The City now has a CDC grant to compare results from viral load pooling with 4th generation antibody tests at high volume testing sites.

In LAC, public health officials have been screening for acute HIV infection using viral load pooling in clinical settings serving large numbers of MSM with high rates of syphilis, gonorrhea and chlamydia. LAC plans to move to the 4th generation antibody tests for its lab-based HIV testing algorithm in the next year, which will further enhance the ability to detect acute HIV infection among those tested for HIV through conventional testing.

Non-clinical community-based testing sites continue to identify new infections among those who identify as members of a high-risk group, e.g., gay men, and should augment HIV screening in clinical settings. These non-clinical sites contribute to lowering rates of unknown HIV infection by reaching individuals who seek testing outside medical settings for any number of reasons, including an affinity with the testing site or organization, physical or psychological safety, privacy, and/or convenience. In San Francisco, the new positivity rate among such sites (such as Magnet or the STOP AIDS mobile testing sites) was 1.4% for 2009.

Despite the success of community-based testing sites, some cities (including San Francisco) experience an annual gap among MSM, IDU, and transsexual females to males. To help bridge this gap, San Francisco Department of Public Health plans to triple the number of tests among MSM, IDUs and transfemales compared with 2009. Even this ambitious increase would only address approximately 28% of the testing gap, but is achievable by removing structural issues (such as eliminating the counseling requirement if it is a barrier to testing) and if sufficient support is given to the message that testing among these populations is needed every 6 months.

Improved Linkage to Care

The full benefit of HIV testing cannot be realized without appropriate linkage to care and treatment. Approximately 50% of known HIV-infected individuals are not engaged in regular care.11 Components of successful strategies of linkage to care include: effectively targeting those most at risk, using existing public health resources and evidence-based interventions (which may differ by population/community), and developing innovative ways to optimize linkage to care for newly diagnosed patients and those lost to care. Some exemplary strategies are discussed below.

Patient Incentives

The HTPN 065 trial is evaluating whether financial incentives for patients can facilitate increased contact with care. Upon completion of a confirmatory HIV laboratory test at an HIV care site, a patient is given a $25 gift card. A $100 gift card is received upon completion of a care visit that includes interaction with a health care provider and discussion of lab test results. It is too early to tell the effects of such incentives on city-wide level, but Community Education Group, a D.C. nonprofit that seeks to stop the spread of HIV and eliminate health disparities in disproportionally affected neighborhoods through community health workers and educating and testing the hard-to-reach, tests nearly 10,000 individuals per year in venue-based settings and has used incentives to link to care since October 2009. The group has found a combination of financial incentives as well as providing transportation and physically escorting patients to care sites to be exponentially more effective than simple referrals to care: Before 2009, only about 5% of newly diagnosed individuals could be confirmed in care, perhaps due in part to data collection issues; now that percentage has increased to more than 90%.

New clients (or those re-emerging into care) are given appointments the next business day after they contact any public health clinic in Washington, D.C. They are assigned a "Red Carpet Concierge" who can be contacted directly to arrange these appointments and a phrase or "code word" that they can use when they arrive at the clinic as a Red Carpet member. Clients first see a caseworker who does an initial intake and completes lab work. Within 7 to 10 days of the intake, clients meet with a physician to go over baseline lab results and determine a course of treatment.

Birmingham has a similar goal of getting patients into the clinic for an evaluation, ideally within 2 days but no longer than 7 days. After more than 7 days, the clinic experiences a high rate of no-shows. Clinic 1917 uses a volunteer or caseworker for the initial 1-hour appointment during which time the patient is oriented to the clinic and baseline labs are performed. Within 2 to 3 weeks of this appointment, patients see a clinician. While time to enter care can vary among jurisdictions, the common goal is to obtain definitive laboratory results of CD4 counts and viral load within 3 months of diagnosis.

Streamlined Linkages

Los Angeles County has used a variety of strategies to increase those linked to care within 3 months of an HIV-positive test from 45.1% in 2006 to 59.6% in 2008. These linkage to care activities include:

  • Incentivize linkage to care for the service provider: Fund testing sites through a fee structure that pays an additional $80 to $120 for linking newly diagnosed clients to HIV care. Linkages to partner services are also incentivized.
  • Deliver presumptive diagnosis at each testing episode: Use two rapid tests for a presumptive diagnosis of HIV-positive and link the patient to care without waiting for confirmatory testing. This strategy is currently used in shelters, routine testing sites, and jails.
  • Implement routine opt-out testing: Routine opt-out HIV testing is used at clinical sites in high burden areas with same-day linkage to care.
  • Youth-focused linkage worker: Use a linkage worker specially trained to link newly diagnosed youth with care.
  • Jail-based transitional case management (TCM) and peer navigator programs: Used in LAC jails with all HIV-positive inmates to establish linkage to medical care and other services upon release.
  • HIV non-occupational post-exposure prophylaxis (nPEP): A pilot program in which nPEP is offered with intensive risk reduction counseling. Includes HIV testing and direct linkage to HIV care.

These approaches shift responsibility from patient to provider for patient entry into care and are more effective than passive referrals to patients. In Birmingham, the clinic has noted a decrease in no-show rates from 31% to 18% during a 1-year period. D.C.'s most recent request for applications for HIV testing will require testing sites to demonstrate at least 70% of those testing HIV-positive are linked to care.

Predictors and Consequences of Missed Visits

Decreasing missed clinic visits is an important component of a TLC-Plus Program, as early missed visits may identify patients at risk for poor long-term health outcomes. In fact, missed visits are associated with higher rates of mortality. A single missed visit in the last year is a higher predictor of mortality than age, CD4 count, viral load, or start date of ART.12

According to data analyzed by LAC, several multivariate predictors are associated with patients who are unlinked to care (defined as a client who did not receive a CD4 count or viral load test within 1 year of testing positive). The characteristics most associated with being unlinked to care, according to these data, were African American or Latino race/ethnicity, being homeless, identifying as transgender, and receiving an HIV test at a mobile testing site.

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This article was provided by Proyecto Inform.

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