Article

Engaging HIV-Positive Individuals in Specialized Care from an Urban Emergency Department

Jacobi Medical Center, Bronx, New York 10461, USA.
AIDS patient care and STDs (Impact Factor: 3.5). 02/2011; 25(2):89-93. DOI: 10.1089/apc.2010.0205
Source: PubMed
ABSTRACT
Linking patients who test positive for HIV in an emergency department (ED) setting to HIV care can be challenging. The aim of this study was to assess whether a multimedia HIV testing model utilized in an inner-city ED can effectively link HIV-positive individuals into specialized medical care. A prospective cohort study was performed from October 2005 to January 2009 at an urban academic hospital with a Level 1 trauma center and in-house specialized HIV clinic. Patients were HIV tested in the ED using a multimedia video counseling program which included computer-assisted data collection. Patients who tested positive were linked to care by the same counselor who gave the test result. Linkage was immediate for discharged patients during clinic hours and patients tested during off-hours were scheduled a visit on the next business day. All follow-up was conducted through chart review. The public health advocates (PHAs) tested 24,495 patients over the course of the study, of whom 116 (0.47%) were HIV positive and 93 were newly diagnosed. A total of 83.6% (97/116) of HIV-positive individuals were linked into specialized care, defined here as an outpatient clinic visit within 30 days of diagnosis in the ED. The findings suggest that a multimedia testing model that includes a counselor who acts as tester and navigator can successfully link a high percentage of patients into specialized care.

Full-text

Available from: Jade Fettig, Feb 12, 2016
Engaging HIV-Positive Individuals in Specialized Care
from an Urban Emergency Department
Jason Leider, M.D., Ph.D.,
1,2
Jade Fettig, M.S.,
1
and Yvette Calderon, M.D., M.S.
1,2
Abstract
Linking patients who test positive for HIV in an emergency department (ED) setting to HIV care can be
challenging. The aim of this study was to assess whether a multimedia HIV testing model utilized in an inner-
city ED can effectively link HIV-positive individuals into specialized medical care. A prospective cohort study
was performed from October 2005 to January 2009 at an urban academic hospital with a Level 1 trauma center
and in-house specialized HIV clinic. Patients were HIV tested in the ED using a multimedia video counseling
program which included computer-assisted data collection. Patients who tested positive were linked to care by
the same counselor who gave the test result. Linkage was immediate for discharged patients during clinic hours
and patients tested during of f-hours were scheduled a visit on the next business day. All follow-up was con-
ducted through chart review. The public health advocates (PHAs) tested 24,495 patients over the course of the
study, of whom 116 (0.47%) were HIV positive and 93 were newly diagnosed. A total of 83.6% (97/116) of HIV-
positive individuals were linked into specialized care, defined here as an outpatient clinic visit within 30 days of
diagnosis in the ED. The findings suggest that a multimedia testing model that includes a counselor who acts as
tester and navigator can successfully link a high percentage of patients into specialized care.
Introduction
T
he 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 recommen-
dations 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 in-
formed of their status and engaged into specialized HIV
treatment in a timely manner.
1
The CDC recommends en-
gagement 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 out-
comes 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 outpa-
tient 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
1
Jacobi Medical Center, Bronx, New York.
2
Albert Einstein College of Medicine, Bronx, New York.
AIDS PATIENT CARE and STDs
Volume 25, Number 2, 2011
ª Mary Ann Liebert, Inc.
DOI: 10.1089/apc.2010.0205
89
Page 1
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 hospi-
tal.’
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 engage-
ment 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 ap-
proaches 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 diag-
nosed 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 ab-
sorption of patients into medical care, minimizing barriers
and allowing expedited expert evaluation of newly diagnosed
HIV patients by HIV experts.
Methods
Study participants
This prospective cross-sectional study was conducted from
October 2005 to January 2009. Stable patients, aged 13 years
and older and not already in HIV care, presenting to an inner-
city municipal hospital Urgent Care Area (UCA) and ED were
recruited. Previously developed and evaluated videos for
HIV pre- and posttest counseling based on New York State
Department of Health requirements were used.
15,16
Over the
course of 3 weeks, 1.5–8 full-time equivalent public health
advocates (PHAs) were interviewed, hired, and trained in
HIV counseling by clinical staff and through a formal training
session from Cicatelli Associates. PHAs were required to pass
a test developed and administered by clinical staff prior to
performing tests. PHAs’ lone responsibility was to actively
recruit clinically stable patients aged 13 and above to partic-
ipate in the rapid HIV testing program by approaching pa-
tients in a nontargeted manner in their rooms and offering the
test. Clinical supervisors met regularly with PHAs to monitor
performance. Documented informed consent was obtained
from all patients and no incentives were offered. The research
protocol received approvals from the institutional review
boards at the Albert Einstein College of Medicine and the
Health and Hospitals Corporation.
Patients who chose to participate in the intervention wat-
ched a pretest video after which point the PHA returned to
answer any further questions and obtain informed consent for
HIV testing. Patients were tested using the OraQuick AD-
VANCE
Rapid HIV- 1/2 Antibody Test (OraSure Technol-
ogies, Inc. Bethlehem, PA) and watched a posttest HIV
prevention education video while the test was running. Pa-
tients also answered a risk factor questionnaire on the tablet
computer and the results were downloaded wirelessly into a
secure database. The PHA returned after approximately
20 min to answer questions about HIV prevention, provide
more focused counseling tailored to the needs of the indi-
vidual based upon their self-reported risk factor profile and
deliver the test results.
Data on demographic characteristics, risk factors, and
sexual history were collected from those patients who both
agreed to and refused testing. Data were also collected on the
number of patients tested, number of HIV identified patients,
and number linked to care. The risk factor and sexual history
data collected included information on alcohol use, drug use,
homelessness, condom use, number of sexual partners, and
sexual practices. In keeping with the program’s objective of
providing a brief model of counseling and testing (C&T),
patients were prompted to answer either the satisfaction
survey or the knowledge measure, not both. Patients ran-
domized to a satisfaction survey provided data on their
satisfaction of with the model, including the ability of the
videos to convey information, how they would prefer HIV
testing in the future and the helpfulness of rapid HIV test-
ing in the ED. Patients who were randomized to complete
the knowledge measure answered a series of questions
about material covered in pretest and posttest counseling,
providing data on the amount of HIV education conveyed by
the videos. The results of this study have been reported in
detail elsewhere.
17
The data collected on HIV-positive patients included CD4
and viral load levels at the time of diagnosis, time interval
between diagnosis and the patient’s first medical clinic ap-
pointment, time interval between diagnosis and the patient
being placed on treatment, baseline resistance to antiretroviral
treatment, reasons for the patients’ ED visit, admitting diag-
nosis, presence of comorbid diseases, the number of patients
eligible for highly active antiretroviral treatment (HAART),
the number of patients eligible patients started on HAART
and the outcomes of treatment. All medical data collected on
positive patients were obtained through chart reviews by
their medical provider.
Positive patient protocol
Patients who had a reactive rapid oral screening test result
were given a rapid blood screening test via finger-stick using
the OraQuick ADVANCE
Rapid HIV- 1/2 Antibody Test.
The PHA also drew blood for a confirmatory Western blot,
initial CD4 count and baseline viral load, but all preliminary
positive patients were treated as if they were positive and staff
did not wait for Western blot results to facilitate linkage. Pa-
tients who were tested between 9:00 am and 5:00 pm were
personally escorted by the PHA to the Adult Comprehensive
Services (ACS) open-access HIV care clinic (Fig. 1). These
patients had an initial encounter with a member of the HIV
expert medical staff, either a nurse, social worker or case
manager, who could answer medical questions, provide
counseling and support and facilitate enrollment into insur-
ance, as needed. Whenever possible, patients were also seen
by a physician during this time, and if a physician was not
available, a comprehensive medical visit was scheduled.
If a patient was tested during clinic off-hours, the PHA
exchanged contact information with the patient and sched-
uled to meet the patient in the ED the next business day. The
PHA then personally escorted the patient to ACS at the pa-
tient’s earliest possible convenience. Each PHA was person-
ally responsible for linking each and every patient to medical
90 LEIDER ET AL.
Page 2
care and following up with patients who did not attend ap-
pointments, as needed.
A patient was not considered successfully linked into
medical care until he completed an initial comprehensive
examination with an HIV expert physician, which was con-
firmed by retroactive chart review.
Results
The PHAs tested 24,495 patients over the course of the study,
of whom 116 (0.47%) were HIV positive and 93 were newly
diagnosed. The demographics of the HIV positive patients are
as follows: average age 39.94 years standard deviation (SD)
11.18 years (range, 13–71 years); 69.8% male (including one
transgender individual). One hundred one patients had an
initial CD4 count drawn that indicated that 48.5% (n ¼ 49) of
these patients had AIDS at diagnosis. Complete demographic
and risk factor data is summarized in Table 1.
There were 81 males, average age 40 years (range, 13–71).
These patients were slightly older and had lower initial CD4
counts and viral loads than the female cohort. The males also
had less contact with the North Bronx Healthcare Network
(NBHN), which includes Jacobi Medical Center and North
Central Bronx Hospital, than the females before their HIV
diagnosis (Table 2). Of patients who had an initial CD4 count
drawn (n ¼ 101), 49 had AIDS at within 12 months of their
initial diagnosis.
Eighty-four percent (n ¼ 97) of patients were successfully
linked into outpatient HIV care services. Of these, 88% (n ¼ 86)
were linked into HIV services at NBHN. In most cases, the
patient was walked over to the ACS clinic immediately fol-
lowing diagnosis, but the patient was not considered linked
into care until he or she received a comprehensive examination
Table 1. Positive Patient Characteristics
Gender (%)
Male 69.8%
Female 30.2%
Race/ethnicity (%)
Black/ African American 50.9%
Hispanic 40.5%
Multiracial 5.2%
White 2.6%
Language
English 78.4%
Spanish 20.7%
Newly diagnosed 80.2%
HIV tested before 71.6%
Condom use (past 3 months) (%)
Never 27.8%
Almost never 4.1%
Sometimes 16.7%
Almost every time 26.4%
Every time 25.0%
Ever had sex without a condom 79.3%
Vaginal sex (past 3 months) 62.8%
Men who have sex with men 25.9%
Sex with drug user 25.2%
Previous STI diagnosis 24.3%
Anal sex (past 3 months) 21.5%
Sex with partner with HIV 20.8%
Use street drugs before sex 17.2%
Consume more than 3 drinks before sex 17.2%
Exchanged sex for money/drugs 6.3%
Past intravenous drug use 4.5%
Homeless in the past 6 months 3.6%
STI, sexually transmitted infection.
Patient tests
HIV+ in the ED
Patient is discharged
from ED during clinic
hours
Patient is discharged
from the ED outside
of clinic hours
PHA walks patient to
clinic for introductory
visit
PHA schedules to
meet the patient in
the ED the next
business day
Patient is admitted to
inpatient floors
Patient receives HIV
services from
inpatient HIV team
until discharge
PHA meets patient
and walks him to
clinic for
introductory visit
PHA follows up
with patient if he
does not return to
the ED
PHA walks patient
to clinic following
discharge
FIG. 1. Positive patient procedure. ED, emergency department; PHA, public health advocate.
ENGAGING ED-TESTED, HIV-POSITIVE INDIVIDUALS IN SPECIALIZED CARE 91
Page 3
by an HIV expert physician. Twenty-three patients were aware
of their HIV-positive status and were tested in the ED either to
confirm previous positive results or to be linked into care at
ACS. Eligibility for HAART treatment was assessed using US
HHS guidelines which indicate that HAART is appropriate
when the patient’s CD4 count is below 350 cells per milliliter.
Outcome data is summarized in Table 3.
Limitations
Follow-up data were only available for those patients
linked into care at NBHN Patients who chose to enter care at
another clinic or with their personal doctor could not be in-
cluded because research staff was not able to access their
medical record. This missing data could affect the overall
average of days to first medical visit. Chart reviews were
completed in January 2009 and the patients’ most recent CD4
count and viral load were used. Any subsequent change has
not been documented. The percentage of eligible patients
started on HAART is limited by the number of patients who
returned to outpatient clinic to assess their eligibility for
HAART treatment.
Discussion
This study is the first to analyze linkage to care from the ED
using existing testing staff as the facilitators of linkage.
Bradford et al.
18
examined the efficacy of four types of pro-
grams that used a navigator to engage HIV-positive patients
into care based on similar models used for patients with
cancer. These patients were not newly diagnosed and the
navigator’s role was to engage the patient into care not es-
tablish initial contact with primary HIV care. Another crucial
difference is that all of these studies used nonclinical staff as
the navigators, while our study used the testers as navigators.
Another important difference is that these studies continued
to use the navigators over longer periods of time as patient
advocates while our PHAs were navigators on a more tem-
porary basis and then handed off the long-term care to social
workers and case managers at the HIV clinic. Given the dif-
ferent roles of navigators between these two studies, they are
not entirely comparable but Bradford et al.
18
showed statis-
tically significant improvement in the number of patients who
had received HIV primary care in the past 6 months and the
number of patients who had undetectable viral loads over
baseline.
The use of the tester as navigator is the factor that differ-
entiates this testing program from others that offer routine
testing the ED. The high rates of linkage to care should alle-
viate some of the concerns of testing in the ED without having
a linkage mechanism that has been proven to be effective.
19,20
By changing a passive referral process to an active seamless
engagement in care using the PHA as facilitator, we have
changed the role of the ED HIV tester. The PHA can provide
focused counseling to high risk patients when needed and
becomes a client navigator to immediately engage a person
who tests positive into care. The PHA can elucidate the pro-
cess of receiving HIV care in a community with low health
literacy. Uninsured or underinsured patients frequently do
not realize that they are eligible for AIDS Drug Assistance
Program (ADAP) insurance which covers both HIV primary
care and prescription medications. Patients are fearful of the
expense involved in HIV care until the PHA clarifies the
process and the resources that are available to them.
It is likely that the fact that patients are linked into care
immediately following their HIV diagnosis contributes to
their likelihood of attending their first clinic appointment and
remaining in care. We believe that this instant access to HIV
clinic services is extremely important to patients. Highly
trained social workers are available to immediately address
the stress and anxiety that patients can feel when they are
newly diagnosed HIV-positive. We believe that rapid HIV
testing in the ED necessitates rapid access to care. The
HIV clinic at Jacobi Medical Center has been structured to
Table 2. Male and Female Characteristics
at HIV Diagnosis
Male
(n ¼ 81)
Female
(n ¼ 35)
Total
(n ¼ 116)
Average age 40 (range,
21–71)
38 (range,
13–56)
40 (range,
13–71)
No. NBHN visits
prior to diagnosis (total)
4.3 13.5 7.1
No. of patients newly
diagnosed HIV positive
67 26 93
No. NBHN visits
1 year prior to diagnosis
1.8 2.8 2.1
Initial CD4 count
(cells/mm
3
)
291 374 316
Median initial viral
load (copies/mL)
68,350 90,700 74,450
NBHN, North Bronx Healthcare Network.
Table 3. Outcome Data
Newly diagnosed patients (n ¼ 93)
Linked to care (n ¼ 78) 84%
Linked at ACS (n ¼ 71/78) 91%
No. of days to comprehensive examination Mean: 12.6
Median: 6
Range (0–79)
No. of patients eligible for HAART 52
No. of days from HIV diagnosis to HAART Mean:46
Median: 38
Range: (1–160)
Eligible patients started on HAART 67%
No. of patients with viral load
<400 cells/mL
29
No. of patients with viral load <50 cells/mL 18
Known positive patients (n ¼ 23)
Linked to care (n ¼ 19) 83%
Linked at ACS (15/19) 79%
No. of days to comprehensive examination Mean: 108
Median: 21
Range (0–696)
No. of patients eligible for HAART 11
No. of days from HIV dignosis to HAART Mean:45
Median: 27
Range: (1–116)
Eligible patients started on HAART 91%
No. of patients with viral load
<400 cells/mL
5
No. of patients with viral load <50 cells/mL 1
ACS, Adult Comprehensive Services; HAART, highly active
antiretroviral therapy.
92 LEIDER ET AL.
Page 4
accommodate open access by having each attending available
for walk in patients for 1 h each day. The clinic has also been
organized to provide comprehensive care including expert
nursing, mental health, social work, and nutrition services in
addition to medical care in order to further ease patient access
to care. Gardner et al.
12
found that there was a 60% increase in
linkage-to-care rates for patients who were contacted by a case
manager within 6 months of their HIV diagnosis compared
with those who had been diagnosed with HIV between 6 and
12 months earlier. It is encouraging that the linkage rates for
both newly diagnosed patients and known positive patients
are similar and provides evidence that this type of linkage
mechanism may be more effective for all types of patients.
Implementation of a successful linkage mechanism within
an ED HIV testing program could help to alleviate the dis-
proportionate burden of poor HIV outcomes that currently
rests upon minority groups of lower socioeconomic status.
21
A
high rate of successful linkage to outpatient care within 30 days
of diagnosis in the ED using existing staff could be replicated
by other ED testing programs by making testers responsible for
linkage and becoming a resource for the patients.
Acknowledgments
Data were presented in part at: XVII International AIDS
Conference, Mexico City, Mexico, August 3–8, 2008; National
Summit on HIV Diagnosis, Prevention, and Access to Care,
Washington, D.C., November 19–21, 2008.
Funding for this study was provided by: Public Health
Solution of New York City, Inc/ HIV Care Services (PHS/
HIVCS), Contract # 07-RTX-583 for HIV Rapid Testing in
Clinical Facilities.
Funding for this study was partially provided by the
New York City Department of Health and Mental Hygiene
RTX-583 and the U.S. National Institutes of Health Institute
of Child Health and Human Development Grant #5K23-
HD054315.
Author Disclosure Statement
No competing financial interests exist.
References
1. Branson B, Handsfield H, Lampe M, et al. Revised Re-
commendations for HIV Testing of Adults, Adolescents, and
Pregnant Women in Health-care Settings: US Department of
Health and Human Services, Centers for Disease Control
and Prevention, 2006.
2. Lyss SB, Branson BM, Kroc KA, Couture EF, Newman DR,
Weinstein RA. Detecting unsuspected HIV infection with a
rapid whole-blood HIV test in an urban emergency de-
partment. J Acquir Immune Defic Syndr 2007;44:435–442.
3. Branson BM, Handsfield HH, Lampe MA, et al. Revised
recommendations for HIV testing of adults, adolescents, and
pregnant women in health-care settings. MMWR Recomm
Rep 2006;55:1–17; quiz CE11–14.
4. Haukoos JS, Mehta SD, Harvey L, Calderon Y, Rothman RE.
Research priorities for human immunodeficiency virus and
sexually transmitted infections surveillance, screening, and
intervention in emergency departments: consensus-based
recommendations. Acad Emerg Med 2009;16:1096–1102.
5. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis
of high-risk sexual behavior in persons aware and unaware
they are infected with HIV in the United States: Implications
for HIV prevention programs. J Acquir Immune Defic
Syndr. 2005;39:446–453.
6. Castilla J, Del Romero J, Hernando V, Marincovich B, Garcia
S, Rodriguez C. Effectiveness of highly active antiretroviral
therapy in reducing heterosexual transmission of HIV. J
Acquir Immune Defic Syndr 2005;40:96–101.
7. Samet JH, Freedberg KA, Savetsky JB, Sullivan LM, Stein
MD. Understanding delay to medical care for HIV infection:
The long-term non-presenter. AIDS 2001;15:77–85.
8. Giordano TP, White AC, Jr., Sajja P, et al. Factors associated
with the use of highly active antiretroviral therapy in pa-
tients newly entering care in an urban clinic. J Acquir Im-
mune Defic Syndr 2003;32:399–405.
9. Molitor F, Kuenneth C, Waltermeyer J, et al. Linking HIV-
infected persons of color and injection drug users to HIV
medical and other services: The California Bridge Project.
AIDS Patient Care STDs 2005;19:406–412.
10. Molitor F, Walsh RM, Leigh JP. Determinants of longer time
from HIV result to enrollment in publicly funded care and
treatment in California by race/ethnicity and behavioral
risk. AIDS Patient Care STDs 2002;16:555–565.
11. Ulett KB, Willig JH, Lin HY, et al. The therapeutic implica-
tions of timely linkage and early retention in HIV care. AIDS
Patient Care STDs 2009;23:41–49.
12. Gardner LI, Metsch LR, Anderson-Mahoney P, et al. Efficacy
of a brief case management intervention to link recently di-
agnosed HIV-infected persons to care. AIDS 2005;19:423–431.
13. Lyons MS, Lindsell CJ, Haukoos JS, et al. Nomenclature and
definitions for emergency department human immunodefi-
ciency virus (HIV) testing: Report from the 2007 conference
of the National Emergency Department HIV Testing Con-
sortium. Acad Emerg Med 2009;16:168–177.
14. Cheever LW. Engaging HIV-infected patients in care: Their
lives depend on it. Clin Infect Dis 2007;44:1500–1502.
15. Calderon Y, Haughey M, Leider J, Bijur P, Bauman L. The
Evaluation of an Educational Video Program for HIV Test-
ing: A Comparative Analysis. Paper presented at: Academic
Emergency Medicine, Orlando, FL 2004.
16. Calderon Y, Haughey M, Bijur PE, et al. An educational HIV
pretest counseling video program for off-hours testing in the
emergency department. Ann Emerg Med 2006;48:21–27.
17. Calderon Y, Leider J, Hailpern S, et al. High-volume rapid
HIV testing in an urban emergency department. AIDS Pa-
tient Care STDs 2009;23:749–755.
18. Bradford JB, Coleman S, Cunningham W. HIV System Na-
vigation: An emerging model to improve HIV care access.
AIDS Patient Care STDs 2007;21(Suppl 1):S49–58.
19. Burke RC, Sepkowitz KA, Bernstein KT, et al. Why don’t
physicians test for HIV? A review of the US literature. AIDS
2007;21:1617–1624.
20. Arbelaez C, Wright EA, Losina E, et al. Emergency provider
attitudes and barriers to universal HIV Testing in the
emergency department. J Emerg Med (in press).
21. Mugavero MJ. Improving engagement in HIV care: What
can we do? Top HIV Med 2008;16:156–161.
Address correspondence to:
Yvette Calderon
Jacobi Medical Center
1400 Pelham Parkway South
Building 6, Room 1B27
Bronx, NY 10461
E-mail: yvette.calderon@nbhn.net
ENGAGING ED-TESTED, HIV-POSITIVE INDIVIDUALS IN SPECIALIZED CARE 93
Page 5
Page 6
  • Source
    • "Indeed, most participants noted kindness, compassion, and seamless linkage to the HIV clinic. “Active” linkage to care, in which testing or clinic staff members walk patients to the HIV clinic for the first time or patients meet a clinic staff member in the ED/UC, is an effective and increasingly popular method of linkage [20]. Indeed, the idea of a “first responder” to guide a patient through the diagnosis and linkage experience is not new [19]. "
    [Show abstract] [Hide abstract] ABSTRACT: We sought to understand patient perceptions of the emergency department/urgent care (ED/UC) HIV diagnosis experience as well as factors that may promote or discourage linkage to HIV care. We conducted in-depth interviews with patients (n=24) whose HIV infection was diagnosed in the ED/UC of a public hospital in San Francisco at least six months prior and who linked to HIV care at the hospital HIV clinic. Key diagnosis experience themes included physical discomfort and limited functionality, presence of comorbid diagnoses, a wide spectrum of HIV risk perception, and feelings of isolation and anxiety. Patients diagnosed with HIV in the ED/UC may not have their desired emotional supports with them, either because they are alone or they are with family members or friends to whom they do not want to immediately disclose. Other patients may have no one they can rely on for immediate support. Nearly all participants described compassionate disclosure of test results by ED/UC providers, although several noted logistical issues that complicated the disclosure experience. Key linkage to care themes included the importance of continuity between the testing site and HIV care, hospital admission as an opportunity for support and HIV education, and thoughtful matching by linkage staff to a primary care provider. ED/UC clinicians and testing programs should be sensitive to the unique roles of sickness, risk perception, and isolation in the ED/UC diagnosis experience, as these things may delay acceptance of HIV diagnosis. The disclosure and linkage to care experience is crucial in forming patient attitudes towards HIV and HIV care, thus staff involved in disclosure and linkage activities should be trained to deliver compassionate, informed, and thoughtful care that bridges HIV testing and treatment sites.
    Full-text · Article · Aug 2013 · PLoS ONE
  • Source
    • "Unfortunately, approximately 20% to 40% of newly diagnosed HIV-positive patients in the United States fail to be linked to care in a timely fashion [2,456. Researchers have identified numerous individual-, contextual-, and structural-level factors associated with delayed entry to HIV care [4,7891011121314151617181920; importantly, such information has served as the foundation for the development of several linkage-to-care (LTC) interventions21222324252627. Despite the potential to improve patient and public health outcomes123428,29], existing evidence-based HIV LTC interventions have yet to be widely and systematically disseminated and implemented in community-based organizations (CBOs) and health departments throughout the United States. "
    [Show abstract] [Hide abstract] ABSTRACT: Widespread dissemination and implementation of evidence-based human immunodeficiency virus (HIV) linkage-to-care (LTC) interventions is essential for improving HIV-positive patients' health outcomes and reducing transmission to uninfected others. To date, however, little work has focused on identifying factors associated with intentions to adopt LTC interventions among policy makers, including city, state, and territory health department AIDS directors who play a critical role in deciding whether an intervention is endorsed, distributed, and/or funded throughout their region. Between December 2010 and February 2011, we administered an online questionnaire with state, territory, and city health department AIDS directors throughout the United States to identify factors associated with intentions to adopt an LTC intervention. Guided by pertinent theoretical frameworks, including the Diffusion of Innovations and the "push-pull" capacity model, we assessed participants' attitudes towards the intervention, perceived organizational and contextual demand and support for the intervention, likelihood of adoption given endorsement from stakeholder groups (e.g., academic researchers, federal agencies, activist organizations), and likelihood of enabling future dissemination efforts by recommending the intervention to other health departments and community-based organizations. Forty-four participants (67% of the eligible sample) completed the online questionnaire. Approximately one-third (34.9%) reported that they intended to adopt the LTC intervention for use in their city, state, or territory in the future. Consistent with prior, related work, these participants were classified as LTC intervention "adopters" and were compared to "nonadopters" for data analysis. Overall, adopters reported more positive attitudes and greater perceived demand and support for the intervention than did nonadopters. Further, participants varied with their intention to adopt the LTC intervention in the future depending on endorsement from different key stakeholder groups. Most participants indicated that they would support the dissemination of the intervention by recommending it to other health departments and community-based organizations. Findings from this exploratory study provide initial insight into factors associated with public health policy makers' intentions to adopt an LTC intervention. Implications for future research in this area, as well as potential policy-related strategies for enhancing the adoption of LTC interventions, are discussed.
    Full-text · Article · Apr 2012 · Implementation Science
  • Source
    [Show abstract] [Hide abstract] ABSTRACT: The objective was to describe the proportions of successful linkage to care (LTC) and identify factors associated with LTC among newly diagnosed human immunodeficiency virus (HIV)-positive patients, from two urban emergency department (ED) rapid HIV screening programs. This was a retrospective analysis of programmatic data from two established urban ED rapid HIV screening programs between November 2005 and October 2009. Trained HIV program assistants interviewed all patients tested to gather risk behavior data using a structured data collection instrument. Reactive results were confirmed by Western blot testing. Patients were provided with scheduled appointments at HIV specialty clinics at the institutions where they tested positive within 30 days of their ED visit. "Successful" LTC was defined as attendance at the HIV outpatient clinic within 30 days after HIV diagnosis, in accordance with the ED National HIV Testing Consortium metric. "Any" LTC was defined as attendance at the outpatient HIV clinic within 1 year of initial HIV diagnosis. Multivariate logistic regression was performed to determine factors associated with any LTC or successful LTC. Of the 15,640 tests administered, 108 (0.7%) were newly identified HIV-positive cases. Nearly half (47.2%) of the patients had been previously tested for HIV. Successful LTC occurred in 54% of cases; any LTC occurred in 83% of cases. In multivariate analysis, having public medical insurance and being self-pay were negatively associated with successful LTC (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.12 to 0.96; OR = 0.34, 95% CI = 0.13 to 0.89, respectively); being female and having previously tested for HIV was negatively associated with any LTC (OR = 0.30, 95% CI = 0.10 to 0.93; OR = 0.23, 95% CI = 0.07 to 0.77, respectively). In spite of dedicated resources for arranging LTC in the ED HIV testing programs, nearly 50% of patients did not have successful LTC (i.e., LTC occurred at >30 days), although >80% of patients were LTC within 1 year of initial diagnosis. Further evaluation of the barriers associated with successful LTC for those with public insurance and self-pay is warranted.
    Preview · Article · May 2012 · Academic Emergency Medicine
Show more

Similar Publications