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


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.

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    • "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]. "
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    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
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    • "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 [2,4-6]. Researchers have identified numerous individual-, contextual-, and structural-level factors associated with delayed entry to HIV care [4,7-20]; importantly, such information has served as the foundation for the development of several linkage-to-care (LTC) interventions [21-27]. "
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    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
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    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
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