SummaryRecognizing the challenges of the existing system to connect newly diagnosed HIV patients to care, the AIDS Foundation of Chicago developed community-based testing programs and partnerships with 12 medical homes to provide real-time linkages to HIV care for newly diagnosed individuals, particularly young, African-American gay and bisexual men. Known as the HIV-VIP Linkage to Care Program, this initiative uses social media and outreach to promote community-based testing to hard-to-reach populations, offers immediate linkages to a medical home that typically initiates care within 72 hours of diagnosis, and uses culturally competent HIV testers and care coordinators to support patients in choosing and transitioning to the medical home. The program has enhanced access to testing for hard-to-reach populations, nearly doubled the proportion of newly diagnosed patients who are linked to care, and generated high levels of patient satisfaction.Moderate: The evidence consists of pre- and post-implementation comparisons of the proportion of newly diagnosed HIV patients connected to care, along with post-implementation data on the number of individuals screened for HIV and the number testing positive at two community-based programs that partner with the HIV-VIP Linkage to Care Program.
Developing OrganizationsAIDS Foundation of Chicago
Date First Implemented2012
Race and Ethnicity > Black or african american; Vulnerable Populations > Lesbian/gay/bisexual/transgender; Gender > Male
Young, African-American gay and bisexual men have an increased risk of HIV infection, yet face multiple barriers to accessing HIV care on a timely basis. As a result, they remain less likely than the typical HIV-positive individual to achieve reduced or undetectable levels of the virus following a positive diagnosis. The period right after testing and diagnosis often represents a good time to link newly diagnosed individuals to care that can improve long-term outcomes. Yet few organizations focus on this time period.
- Disproportionately at risk: Between 2006 and 2009, young, African-American gay and bisexual men were the only major racial or ethnic group to experience a statistically significant increase in new HIV infections. In 2009, nearly two-thirds (63 percent) of all HIV-positive gay and bisexual men between the ages of 13 and 24 were African American, despite the fact that no significant differences existed between African Americans and other racial and ethnic groups in risky behaviors, including unprotected anal intercourse, substance use, history of HIV testing, or sex with a known HIV-positive partner.1 In Chicago, African Americans account for 45 percent of HIV diagnoses attributed to men having sex with men (MSM), a much higher percentage than in Caucasians (36 percent) and Latinos (17 percent).2
- Multiple barriers to accessing treatment: African Americans and young people with HIV are less likely to initiate and remain in care than are other HIV-positive individuals. Nationwide, 66 percent of people living with HIV get connected to care within 3 months of diagnosis. However, only 62 percent of African Americans and 56 percent of young people do so within this timeframe.3 Many barriers, including stigma, discrimination, lack of insurance, and low-income levels, account for these low linkage rates.4
- Less treatment success: Achieving reduced or undetected levels of the HIV virus following a positive diagnosis requires timely linkage to care and prompt treatment initiation. Delayed care engagement is associated with a greater likelihood of progression to AIDS and a greater risk of ongoing HIV transmission. Delaying the initiation of care results in a 9- to 14-fold increase in the risk of death within a year.5
- Unrealized opportunity to connect patients to care after diagnosis: Recognizing the importance of the window of time right after diagnosis, the National HIV/AIDS Strategy sets a goal of providing a timely connection to care for 85 percent of newly diagnosed individuals by 2015. Yet, to date, few organizations have focused on the critical time right after diagnosis as an opportunity to connect people to care.6
Description of the Innovative ActivityThe AIDS Foundation of Chicago (AFC) developed community testing programs and partnered with 12 medical homes to provide real-time linkages to care for newly diagnosed HIV patients, particularly young, African-American gay and bisexual men. Known as the HIV-VIP Linkage to Care Program, this initiative uses social media and outreach to promote community-based testing to hard-to-reach populations, offers immediate linkages to a medical home that typically initiates care within 72 hours of diagnosis, and uses culturally competent HIV testers and care coordinators to support patients in choosing and transitioning to the medical home. Key program elements are detailed below:
- Programs and social media to promote access to HIV care: AFC offers two community-based testing programs that provide access to rapid HIV screenings to hard-to-reach populations and promotes social media campaigns to encourage these populations to engage in testing and care connections.
- Community-based testing programs: Two testing projects use extensive ties to the local community to identify HIV-positive individuals to link to the HIV-VIP Linkage to Care Program, as described below
- The Bridge Project: A public-private collaborative of AFC, the Illinois Department of Human Services, and Gilead Sciences, Inc., this program offers rapid HIV testing 3 days a week in Family Community Resource Centers located in Chicago communities with the highest rates of poverty and HIV/AIDS. It primarily serves individuals waiting for public assistance benefits. Testers generally come from local community agencies and have undergone extensive training on various topics related to HIV testing, including cultural competency.
- The MSM Testing Initiative (MTI): This program focuses on providing rapid HIV testing to gay and bisexual men in social venues and other nontraditional sites, such as nightclubs and local drug stores. To improve cultural competency and patient buy-in, testers generally come from local community agencies and have similar backgrounds to the clients they serve. They generally work on a contract basis for these local organizations.
- Social media and outreach: AFC uses social media and other forms of outreach to increase awareness of HIV and acceptance of the HIV-VIP Linkage to Care Program by its target population. Many efforts focus on getting at-risk individuals tested and into partner care sites. For example, in August 2013, a public service announcement (PSA) named Say Yes to the Test aired on seven Clear Channel Chicago stations in English and Spanish. This PSA emphasized the importance of HIV testing as part of routine health care and encouraged listeners to visit ChangeMyStory.org to find a nearby testing site and view patient testimonials. AFC also regularly participates in outreach and testing at community events attended by at-risk, hard-to-reach individuals, including Love Fest health festival and North Halsted Market Days street fair.
- Real-time linkage to HIV care in medical home following positive diagnosis: The HIV-VIP Linkage to Care Program educates and engages HIV-positive patients immediately after the diagnosis is made and facilitates the transition to 1 of 12 partner medical homes that initiate care within 72 hours.
- Education and introduction to program: Following a positive diagnosis, the tester provides immediate counseling and reviews the patient’s options, emphasizing the importance of initiating HIV care. The tester explains the HIV-VIP Linkage to Care Program, including information about each medical home and various features of the program, such as assistance from a culturally competent care coordinator and incentives for completing the first two appointments. (More information on these features appears below.)
- Enrollment in appropriate medical home: With assistance and support from the tester, the patient chooses the medical home that will provide the best treatment environment, given his or her unique circumstances.
- First appointment within 72 hours: Patients leave the testing site with a scheduled appointment at the medical home, usually some time within the next 72 hours. AFC has negotiated reserved appointment times with its 12 partner medical homes, thus enabling patients to be connected in a timely manner.
- Transition support from culturally competent program coordinator: After the positive diagnosis, the tester completes a link-to-care (L2C) referral form that includes patient contact information and other relevant data needed for followup. This form goes to the program's full-time L2C coordinator, an individual with extensive knowledge and experience in the local community who has been trained in offering culturally competent social and navigation support to newly diagnosed patients. Within 48 hours of the diagnosis, the L2C coordinator contacts the patient by phone to facilitate the transition to HIV care in the medical home. Key steps in this process are described below:
- Previsit education to normalize HIV care: During the initial contact, the coordinator discusses expectations related to the first medical appointment, provides counseling, and arranges additional assistance (e.g., transportation), if needed. The coordinator uses scripts to guide these conversations. The scripts echo media and outreach messaging by likening treatment for HIV to that provided for other medical conditions and by emphasizing the importance of receiving care from HIV specialists.
- First-visit support: The coordinator offers to meet the patient at the first appointment to be supportive and provides the patient with the name of the designated onsite medical specialist at the medical home (who serves as liaison to the program) so that he or she can ask for that person upon arrival at the appointment. Patients also receive a list of scripted questions they can ask, thus encouraging them to take an active role in the care process. Throughout the visit, the designated medical specialist and L2C coordinator (if present) support the patient by answering his or her questions and explaining each step as it occurs.
- Followup with medical homes: The coordinator maintains ongoing communication with the designated specialist at each medical home, providing timely information on new patients in advance of their first appointments, tracking medical data for existing patients, and following up to ensure that at least the first and second appointment have been completed as scheduled.
- Re-engaging those who miss appointments or refuse care: The coordinator works to reschedule any missed appointments. If a patient refuses services, the coordinator attempts to re-engage the patient through one or more phone calls designed to identify and address any barriers that may be contributing to the problem.
- Incentives for completing appointments: As an incentive to stick with care, the designated medical specialist gives patients who complete the first and second appointments a $50 gift card per appointment. The patient receives the cards in the medical home at the end of each visit.
Context of the InnovationAFC is a nonprofit organization focused on fighting HIV/AIDS and improving the lives of people affected by the disease. The impetus for this project came from two earlier AFC-led initiatives designed to address the disproportionately high rates of HIV/AIDS in the African-American community. The first, known as the Bridge Project, is a public-private partnership with Beyond Care Inc., Brothers Health Collective, Making A Daily Effort (M.A.D.E.), and Gilead Sciences. This initiative focuses on improving HIV testing and linkages to care. Its success led to the development of the MTI project, focused specifically on engaging young, African-American gay and bisexual men. Within a few months, it became evident that increases in the number of people tested and diagnosed through these initiatives were not translating into increases in the number of newly diagnosed patients initiating care. Those being tested (often at odd hours) needed direct access to treatment services, something AFC did not provide. Inspired by the Red Carpet Program in Washington, DC (an HIV-linkage program emphasizing the role of HIV specialists and timely care), AFC developed the HIV-VIP Linkage to Care Program to focus on the often disjointed period following an HIV diagnosis.
The program has enhanced access to testing for hard-to-reach populations, nearly doubled the proportion of newly diagnosed HIV patients linked to care, and generated high levels of patient satisfaction.
Moderate: The evidence consists of pre- and post-implementation comparisons of the proportion of newly diagnosed HIV patients connected to care, along with post-implementation data on the number of individuals screened for HIV and the number testing positive at two community-based programs that partner with the HIV-VIP Linkage to Care Program.
- Enhanced access to HIV services: By streamlining the process between HIV diagnosis and care initiation, the program has identified and linked HIV-positive patients who otherwise may have been missed in traditional health care settings.
- Many HIV-positive individuals identified: Both community-based testing programs have improved access to HIV screenings for high-risk populations. During the 30-month period from April 2011 to September 2013, the Bridge Project tested 10,700 individuals, roughly half of whom were getting tested for the first time. Sixty of these individuals tested positive, 90 percent of whom were African American and 66 percent of whom were male. Over the 18-month period between May 2012 and November 2013, the MTI project tested 3,750 men. Three-quarters of these individuals were African Americans, 76 percent were under the age of 40, and 100 percent identified as MSM. Overall, 137 individuals tested positive.
- Near doubling in linkage-to-care rates: Prior to introduction of the program, roughly 40 percent of newly diagnosed HIV patients got connected to care within 3 months of diagnosis. After implementation, more than three-quarters (78 percent) of patients diagnosed as part of the Bridge Project were linked to care within 3 months, as were 85 percent of those diagnosed as part of the MTI project. In addition, 82 percent of patients newly diagnosed through the MTI project completed their second appointment.
- High patient satisfaction: Among patients linked to care, almost 90 percent reported being very satisfied with the services they received. High patient satisfaction has been found to be associated with improved HIV care and treatment retention rates and thus can lead to improved health outcomes.7
Planning and Development ProcessKey steps included the following:
- Meeting with medical home leader: In 2012, leaders of AFC and Mercy Medical Home met to discuss how HIV testing and care linkages worked in that facility. AFC leaders learned that Mercy and most other medical homes generally had designated walk-in times when newly diagnosed patients come for care. However, these times tended to be underused, and the medical homes generally faced challenges reaching out to newly diagnosed patients and bringing them in for care.
- Partnering with medical homes: After this meeting, AFC leaders decided to actively recruit 12 medical homes as partners for the new program. They chose sites that collectively cover a wide geographic area and provide a variety of specialty services, including drug treatment and adolescent services. Each medical home signed a mutually beneficial linkage agreement with AFC. Under this arrangement, AFC agrees to refer newly diagnosed patients to the medical home in exchange for the home's offering standing appointments within 72 hours of diagnosis, providing followup patient information to AFC, and designating a medical specialist in the medical home to act as the liaison to AFC and the new patients. On an ongoing basis, AFC leaders meet with representatives of each medical home quarterly and also invite regular feedback outside of these meetings.
- Hiring and training coordinators and staff: AFC hired an individual with extensive knowledge of HIV and the local community to help develop the program and facilitate the linkage process. (This individual serves as the L2C coordinator.) Each tester employed by or under contract with AFC undergoes 50 to 60 hours of training each year, including specific training on cultural competency. This training allows them to satisfy requirements of both the city and State departments of health and to meet AFC's internal requirements related to cultural competency.
- Adding incentives to program: At the encouragement of one of the program funders (Gilead Sciences), AFC leaders decided to add an incentive to encourage patients to complete their first two appointments. These leaders felt that such incentives would be cost effective and beneficial to patients and the community. They decided to distribute an allotment of gift cards to each partner medical home, thus allowing patients to receive the card immediately following the first and second appointments.
Resources Used and Skills Needed
- Staff: As noted, the HIV-VIP Linkage to Care Program required the hiring of one full-time staff who serves as the L2C coordinator. Other AFC staff and contractors work on the program as part of their regular responsibilities, including 10 part-time AFC staff who focus on testing and staff from two subcontractors that provide testing support: Brothers Health Collective and M.A.D.E. These organizations were chosen largely because of their extensive expertise and community knowledge.
- Costs: Data on program costs are unavailable; the primary costs consist of salary and benefits for program-related staff (including contractors), testing supplies, incentives, and transportation-related expenses.
Funding SourcesGilead Sciences; Chicago Department of Public Health; Illinois Department of Public Health; Public Health Institute of Metropolitan Chicago
Getting Started with This Innovation
- Meet patients where they are: Program services should be designed with an understanding of where patients are, not just physically (i.e., where they live), but also emotionally and medically. To that end, design the program so that patients can be served in a familiar setting and offered services that take into account the barriers they may be facing and the concerns they may have. This approach helps build trust and engage patients in their care.
- Hire and train high-quality individuals: The success of the program depends in large part on the technical and communication skills of frontline staff. Staff must be culturally competent and able to develop a rapport with, engage, and motivate the patients being served.
- Be realistic about internal strengths and limitations: Consider partnering with community providers for program services that cannot be provided effectively in house. Partnerships allow the sponsoring organization to build on its strengths while still addressing service gaps.
Sustaining This Innovation
- Maintain communication: Remain in regular contact with partners so that any concerns and issues can be identified and addressed quickly.
- Evaluate potential partners carefully: Be selective in choosing partners, as any new partner should share the program's goals and have a positive impact on the program's reputation.
- Build and maintain awareness through multiple avenues: Continually look for ways to raise awareness of the program through social media and community outreach. Name recognition increases trust in the program by the community as a whole and by individuals who may be at risk of or have HIV.
Contact the InnovatorCynthia Tucker
Director of Prevention & Community Partnerships
AIDS Foundation of Chicago
200 West Jackson Boulevard, Suite 2200
Chicago, IL 60606
Innovator DisclosuresMs. Tucker reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.
References/Related ArticlesHIV and young men who have sex with men. Fact Sheet. Centers for Disease Control and Prevention. June 2012. Available at: http://www.cdc.gov/HealthyYouth/sexualbehaviors/pdf/hiv_factsheet_ymsm.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
Gay men & men who have sex with men and HIV/AIDS (2009). Fact Sheet. AIDS Foundation of Chicago. Available at: http://aidschicago.org/pdf/msm_factsheet_2010.pdf.
HIV in the United States: the stages of care. CDC Fact Sheet. Centers for Disease Control and Prevention. July 2012. Available at: http://www.cdc.gov/hiv/pdf/research_mmp_StagesofCare.pdf.
Maulsby C, Millett G, Lindsey K, et al. A systematic review of HIV interventions for black men who have sex with men (MSM). BMC Public Health. 2013;13:625. [PubMed]
Mugavero M. Predictors of late linkage to medical care after a new HIV diagnosis. Medscape Education HIV/AIDS 2011. Available at: http://www.medscape.org/viewarticle/753631.
Office of National AIDS Policy. National HIV/AIDS strategy for the United States, July 2010. Washington, DC: The White House. Available at: http://www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf.
Maulsby C, Millett G, Lindsey K, et al. A systematic review of HIV interventions for black men who have sex with men (MSM). BMC Public Health. 2013;13:625. [PubMed]
Dang B, Westbrook R, Black W, et al. Examining the link between patient satisfaction and adherence to HIV care: a structural equation model. PLoS One. 2013;8(1):e54729. [PubMed]
|Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.|
Original publication: February 26, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: February 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.