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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Viral Suppression With Improved Adherence to Treatment and Care

Patient adherence to treatment includes taking medications as prescribed but also transcends to other aspects of care, particularly clinic visits. Although getting patients into care after a diagnosis with HIV is sometimes the most significant hurdle, providers are reminded that a single, initial physician visit does not equal HIV care. A lack of continuity of care is one of the biggest predictors of mortality. Those with only 1 office visit per year are 94% more likely to become ill or die than those who had 4 visits in a year.13 Strategies used to streamline patients to care (such as those described for Los Angeles above) can also be effective in maintaining patients in care or for patients re-emerging into care. In LAC, of newly diagnosed HIV infections during 2007-2008, 81% of those individuals were retained in care 12 months after diagnosis.


Men who have been incarcerated for any period of time within 1 year of diagnosis have a low probability of visiting a care provider within a 1-year period after release from jail or prison: Of these men, only 40% have had a clinic visit within a year. Strategies in Los Angeles for maintenance in care include a peer-led navigation program to improve adherence to care for HIV-positive individuals released from jail. This study is funded by the National Institute on Drug Abuse and includes cost analysis to understand the impact the program may have on the county as a whole from a cost perspective. If the program is demonstrated effective, it may be replicated in other cities or possibly used with other patient populations.

Viral Suppression

Reducing HIV viral load is an important strategy to improve individual health outcomes as well as reduce HIV transmission though lowered CVL. A combination of increased uptake in HIV testing, improved linkage to care, and greater uptake of ART at an earlier stage leads to more individuals who are virologically suppressed, which in turn lowers CVL and, ultimately, the number of new HIV infections.

In San Francisco, a number of public health measures related to TLC-Plus helped to achieve suppressed viral load in 78% of patients in 2008 (compared with 47% in 2005).

Los Angeles has achieved similar results as San Francisco: of those in care, 71% in the Ryan White system achieved suppressed viral load (with 82% having 2 visits or more in the previous year).

According to Casewatch data from January to December 2009 in the Ryan White system of care, various characteristics predicted a person's unlikelihood to achieve an undetectable viral load. Predictors of a detectable viral load based on a multivariate analysis of Ryan White clients include:

  • Race: African Americans, Asian/Pacific Islanders, or Latinos were more likely to have detectable viral loads than white individuals;
  • Age: Youth (0-24 years) and young adults (25-39 years) were 4 times and 2 times more likely, respectively, to have detectable viral loads than adults 50 years or older.
  • Living at or below the federal poverty level;
  • Homeless (or in transitional housing);
  • Not having health insurance;
  • Recent history of substance abuse;
  • History of incarceration;
  • CD4 count of less than 200; and
  • New infection (≤ 1 year from time of diagnosis).

CVL and individual viral load reduction are important outcomes for HIV prevention and care programs and inform targeted prevention services. In LAC, prevention services, particularly testing and linkage to care, have targeted those communities likely to have the highest seroprevalence, e.g., MSM. By targeting testing and other prevention programs to those with highest risk of being positive, more positives can be identified and entered and retained in care, which in turn generally reduces CVL. Specific testing strategies are discussed above.

Patient Incentives for Reduced Viral Load

As part of the HTPN 065 trial, researchers in Washington, D.C. are studying whether financial incentives can enhance clinical outcomes such as suppressed viral load. At 20 HIV care sites in the city, clients are randomized to either a financial incentive -- those who achieve a viral load of less than 400 copies/mL at quarterly visits will receive $75 gift cards -- versus the current standard of care, without financial incentives. (These incentives are in addition to those for linkage to care and the completion of initial laboratory tests, described above.) According to Community Education Group, the D.C. nonprofit, the same services that link patients to care (e.g., transportation to initial appointments) apply in many cases to subsequent medical appointments, so trends are pointing to adherence to care and treatment and decreased viral loads.

Washington D.C.'s "It's Free to Treat Your HIV" campaign in 2007-08, part of the broader direct-to-consumer campaign previously described, increased community awareness about the availability of free drug therapy for low-income patients and increased ADAP enrollment by 50%.

Most jurisdictions discussed in this paper are fortunate to have stable ADAP programs that generally meet the demand for ART. Some jurisdictions, such as Alabama, have ADAP waiting lists. However, according to officials in the state, most patients can still get the medications they need through patient assistance programs from the pharmaceutical manufacturers.

Enhanced Prevention With Positives & Other Services

Services such as partner notification and prevention with positives are important steps in preventing HIV transmission once a patient has been identified as HIV-infected and is in stable care. A few strategies to enhance these services are described here.

Washington, D.C. strives to link medical providers to other providers such as mental health and substance abuse treatment so that referral mechanisms are in place when they are needed. They also use other tools to examine client trends and organizational needs within the public health infrastructure.

D.C.'s enhanced care includes an expanded standard of care for prevention with positives programs. Their model reduces loss to follow-up, increases the availability of mental health and substance abuse services, and develops innovative interventions. Also included is expanded hepatitis C subspecialty care.

San Francisco's Positive Health Access to Services and Treatment team (PHAST) provides linkage, engagement, and retention services to all newly diagnosed persons on San Francisco General Hospital campus. All these individuals are referred for Partner Services through San Francisco's City STD Clinic. San Francisco is currently expanding the PHAST team to become city-wide and provide linkage and partner services to all newly diagnosed individuals and re-engagement and retention support to out of care patients.10

In LAC, partner services staff deliver up to 5 sessions to all new HIV-positive clients with the goal of linking them to HIV care. These sessions include strengths-based case management to identify barriers to care, as well as prevention messaging and education. Public Health Investigator staff use techniques from the ARTAS case management model to assure that newly diagnosed HIV-infected individuals receive comprehensive prevention, education and linkage services along with partner elicitation and partner services. Some resources have been shifted to support this enhanced model of partner services programs.

Finally, the role of condoms and syringes in preventing the transmission of HIV has not been forgotten. The D.C. condom program distributed 3.2 million condoms in fiscal year 2009, in turn normalizing their use and increasing availability. San Francisco distributes over 2.5 million syringes annually; over 1.5 million condoms through the condom distribution program, and supports all community-based organizations in provision of condoms through outreach and programmatic efforts.

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This article was provided by Proyecto Inform.

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