Southern Success: How a Rural Ryan White Clinic Reached 90% Viral Suppression

Senior Editor
View as:|
1 of 5
Jeff Vollman, M.P.A., at Adherence 2018, Miami, Fla. (Credit: Kenyon Farrow)

Living Bridge Center Succeeds in a Difficult Region

Effectively managing HIV -- a chronic illness that requires daily medication and somewhat regular medical visits -- can be difficult for many people. But for people living with HIV in rural areas where medical care can be far away, the availability of fewer HIV specialists and the fear that one's status could be exposed in a small town can create some very real challenges.

However, the Living Bridge Center, a Parts B and C Ryan White Clinic located in Dalton, Georgia, has found ways to reach, engage, and retain patients who are living with HIV. At a breakfast session of International Association of Providers in AIDS Care's Adherence 2018 conference, Jeff Vollman, M.P.A., district HIV director with the Georgia Department of Health, presented the Living Bridge Center's F.A.S.T. strategy (find, assess, stabilize, and treat), which has led to viral suppression rates higher than the state or national average.

Kenyon Farrow is the senior editor of and Follow Kenyon on Twitter: @kenyonfarrow.

omersukrugoksu via iStockphoto

Finding and Diagnosing Folks Who Are HIV Positive

Vollman said that, while their prevention program has only one staff member, their strategy to find people who are undiagnosed primarily involves outreach to those communities most vulnerable to HIV, as well as training and supporting other providers in the region in order to increase the range of providers who offer HIV testing.

Finding people who are undiagnosed can be difficult, especially in rural communities where people may not want to be tested at sites where they could be recognized by other community members or that are known as centers of HIV care. With limited staff and resources, the Living Bridge focuses their testing outreach program on reaching people twice a month at a criminal justice diversionary program for people with low-level first-time drug charges and people in drug court for felony-level charges, as well as on providing monthly testing at Dalton State College and testing in their pre-exposure prophylaxis (PrEP) clinic.

In addition, they use their epidemiologist to look at parts of the district where there is a cluster of diagnoses or people who are most at-risk in order to provide targeted education and outreach to community members, as well as to reach nurses and other providers in those areas and thereby increase testing and PrEP education and linkage.

According to Vollman, this strategy has proven effective. From 2013 to 2017, they saw a 62% increase in the number of people tested at the health department, a 181% increase in the number of people tested through targeted outreach efforts, and a 200% increase in new HIV diagnoses.

jarun011 for iStock via Thinkstock

Once Diagnosed, Assessing

The challenge for the Living Bridge is not just finding people who are living with HIV who are undiagnosed or out of care, but also assessing their needs to help them remain in care. Being in a rural county with high rates of poverty, the Living Bridge staff schedules an initial visit with a case manager and physician not only to get people's baseline health status established (viral load and CD4 count), but also to determine what other needs they may have to help them get into care and stay engaged in care over time. This includes assessing people's HIV status, insurance coverage, place of residence, and proof of income.

One thing Vollman noted about their model at the Living Bridge is their employment of a nursing case manager. Before working at the Living Bridge, the nurse had seven years of experience working in child and family services. She maintains a relatively small caseload of 20 patients, compared with 75 patients per nonmedical case managers. She also works directly with the health department's communicable disease specialists, which means near-instant linkage to care for newly diagnosed people. The first visit is often within one week of diagnosis.

With the nurse case manager, further assessments are done to determine whether there are additional barriers to treatment adherence, including food/housing insecurity, mental health needs, and intimate partner violence, to name a few. The nurse case manager then develops an individual service plan with the patient, which may include intensive case management for people who need more support.

Masanyanka for iStock via Thinkstock

Stabilizing Patients With the Biggest Antiretroviral Treatment Adherence Challenges

One main function of the case management nurse is to increase adherence to medical treatment plans by patients that need more support. Her caseload currently consists of people with mental health and substance abuse issues, ongoing contact with the criminal justice system, and a documented history of falling out of care.

She has near-daily contact with her patients via phone calls, onsite visits, and home visits. In a handful of cases, the Center has used direct observed therapy, or DOTS, which involves watching patients take their medications to ensure adherence.

The results of this strategy, according to Vollman, are better than average retention in care numbers for their clinic. Almost 90% of their patients are currently retained in care, which beats the state of Georgia and national averages, which are 79.75% and 75.39%, respectively.

nixki for iStock via Thinkstock

Treating HIV With High Rate of Viral Suppression

Often people with several challenges, such as mental health, substance abuse, and unstable housing, face the biggest struggle in achieving viral suppression. But Living Bridge is seeing positive results with their F.A.S.T. strategy and having their case management nurse do intensive work with these patients. Of her current caseload of 24, 80% have a suppressed viral load. The other five patients with a detectable viral load are newly diagnosed and not yet on medications.

Across their entire clinic, over 90% of patients are virally suppressed and, according to Vollman, this is higher than the average across the state of Georgia.

Despite being a clinic in the rural South, the Living Bridge has proven that, with a clear strategy to do outreach to people most at risk in clinical and non-clinical settings, assessing patients with a higher set of needs from a holistic perspective and providing them more engaged case management could be a model for other clinics in rural and urban areas.