John W. Hogan, M.D. Howard University College of Medicine

Upon completion of this training the participants will be able to:  Identify services offered by the National HIV/AIDS Clinicians Consultation Center.  Discuss the problems associated with delayed linkage to care.  Understand the rationale behind test and treat strategies.

 The National HIV/AIDS Clinicians Consultation Center (NCCC) which is part of the AIDS Education and Training Centers (AETC), provides clinical consultation with HIV experts about:  Indeterminate tests,  HIV diagnosis,  HIV management and  Referral issues.  Clinicians with questions about HIV are encouraged to call the NCCC Warmline at

 The National HIV/AIDS Clinicians’ Consultation Center’s (NCCC) Warmline is a confidential and free service that can be especially helpful for those clinicians identifying new cases of HIV infection when HIV experts are unavailable or referrals to HIV experts have not yet been identified.  This service provides free expert consultation on HIV testing (e.g., interpreting indeterminate tests and false positive tests) and can help guide the initial steps in workup and management of newly diagnosed patients.

 NCCC consultation services include:  The National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline HIV-4911) for advice on managing occupational exposures to HIV and hepatitis;  The National Perinatal Consultation and Referral Service (Perinatal HIV Hotline ) for consultation on preventing mother-to-child transmission of HIV. The NCCC website is

 On July 13, 2010, the White House released the National HIV/AIDS Strategy (NHAS).  This ambitious plan is the nation’s first-ever comprehensive coordinated HIV/AIDS roadmap with clear and measurable targets to be achieved by 2015.

 Goals of the National HIV/AIDS Strategy  By 2015, increase from 79% to 90% the percentage of people living with HIV who know their serostatus (from 948,000 to 1,080,000 people).  By 2015, increase the proportion of newly diagnosed patients linked to clinical care within three months of their HIV diagnosis from 65% to 85% (from 26,824 to 35,078 people).  Improve access to prevention and care services for all Americans.

Source: CDC. MMWR. 2006;55(RR-14):1-17. HIV-Infected + Support Services HIV Prevention Services Clinical Care Reporting and Notification Document HIV Test Result Partner Notification Report HIV to Health Department Connecting to Services

Source: Torian LV, et al. Arch Intern Med. 2008;168: Within 3 Months Later than 3 Months Never 64% 19% 17% Analysis: Time to Initiation of Care

Linkage To Care:  The large majority of people newly diagnosed with HIV in 2010 (89%) were linked to care within 12 months of their initial diagnosis.  76% were linked to care within three months of their diagnosis.  The share of people entering care has increased since 2006, yet there are still people with HIV who are not getting the care and treatment they need. Fact Sheet-The HIV/AIDS Epidemic in Washington, D.C.; The Henry J. Kaiser Family Foundation

 The International Association of Physicians in AIDS Care (IAPAC) convened an expert panel to develop evidence- based recommendations to optimize entry into and retention in care and ART adherence and to monitor these processes.  These guidelines aim to define best practices that can be used by practitioners and health systems to improve adherence and, in turn, health outcomes.  The recommendations are based on the best published science; however, the evidence base remains insufficient in many areas. Guidelines for Improving Entry Into and Retention in Care and Antiretroviral Adherence for Persons With HIV: Evidence-Based Recommendations From an International Association of Physicians in AIDS Care Panel: M Thompson et al: Ann Intern Med. 5 June 2012; 156(11):

 1-Systematic monitoring of successful entry into HIV care is recommended for all individuals diagnosed with HIV.  2-Systematic monitoring of retention in HIV care is recommended for all patients  3-Brief, strengths-based case management for individuals with a new HIV diagnosis is recommended.  4-Intensive outreach for individuals not engaged in medical care within 6 months of a new HIV diagnosis may be considered.  5-Use of peer or paraprofessional patient navigators may be considered. Guidelines for Improving Entry Into and Retention in Care and Antiretroviral Adherence for Persons With HIV: Evidence-Based Recommendations From an International Association of Physicians in AIDS Care Panel: M Thompson et al: Ann Intern Med. 5 June 2012;156(11):

 Providers who offer HIV tests to their patients should be prepared to play a role in helping assure their patients newly diagnosed with HIV infection are linked to appropriate care.  The patient should be immediately connected with the case worker, who then addresses any unique barriers to care that the patient may face.  Clinicians cite strong provider relationships with an open dialog as the most important part of their testing and referral systems.

 There have been major advances in the development of effective antiretroviral treatments (ARTs) that have reduced morbidity and improve survival for patients infected with human immunodeficiency virus type 1 (HIV-1).  These advances in medicine have allowed HIV infection to become a chronic, manageable condition and have already resulted in millions of years of life saved.  Despite the availability of highly active antiretroviral therapy (HAART), there still are hundreds of thousands of Americans living with HIV infection who are undiagnosed, not in medical care, or not receiving HIV treatment. Introduction: Linkage, Engagement, and Retention in HIV Care: Essential for Optimal Individual- and Community-Level Outcomes in the Era of Highly Active Antiretroviral Therapy; K Mayer et al. Clinical Infectious Diseases;2011, 52(6), S205-S207

 A large number of HIV-infected Americans are aware of their status but not engaged in care.  Delayed entry into care is defined as care entry >3 months after HIV diagnosis.  Many patients present beyond the clinical period recommended by current guidelines, which advocate initiating ART when CD4 cell counts fall below 500 cells/mm 3.  Longer delays in linkage with medical care are associated with greater likelihood of progression to AIDS by CD4 cell criteria.  Similar to individuals with undiagnosed infection, HIV-infected individuals not engaged in care pose a greater risk of ongoing HIV transmission. Introduction: Linkage, Engagement, and Retention in HIV Care: Essential for Optimal Individual- and Community-Level Outcomes in the Era of Highly Active Antiretroviral Therapy; K Mayer et al. Clinical Infectious Diseases; 2011, 52(6), S205-S207

 HIV-infected individuals who are engaged in care have 4 main barriers to successful treatment with antiretroviral medications:  delay or failure to initiate therapy,  lack of persistence with therapy,  poor adherence to therapy, and  viral resistance to antiretroviral medication. Introduction: Linkage, Engagement, and Retention in HIV Care: Essential for Optimal Individual- and Community-Level Outcomes in the Era of Highly Active Antiretroviral Therapy; K Mayer et al. Clinical Infectious Diseases;2011, 52(6), S205-S207

 In 2009, Bristol-Myers Squibb commissioned a national survey to assess perceived barriers to HIV testing, care, and treatment.  Interviews were conducted over the telephone, online, and in person with healthcare providers and HIV-infected patients to assess reasons why people living with HIV were not receiving care or treatment.  The survey revealed that healthcare providers generally underestimate the impact of emotional rather than circumstantial barriers that prevent people from seeking testing, care, and treatment for HIV infection. “Barriers to accessing HIV testing, care, and treatment in the United States”. Presented at XVIII International AIDS Conference. Vienna, Austria, 18–23 July D Seekins et al.

 Healthcare providers were more likely to view:  structural barriers (finances, transportation, family care) and  substance abuse as important barriers to patients seeking care.  Emotional barriers such as:  fear of HIV medication side effected,  fear of people knowing, and  Stigma were the most commonly reported reasons for not seeking care by HIV-infected patients. “Barriers to accessing HIV testing, care, and treatment in the United States”. Presented at XVIII International AIDS Conference. Vienna, Austria, 18–23 July D Seekins et al.

 Opportunistic illnesses, such as Pneumocystis jirovecii pneumonia, are most common in individuals with unknown HIV serostatus and in those who are not receiving HIV care.  Three population-based studies from the United States have found that 45%–55% of known HIV-infected individuals fail to receive HIV care during any year.  Over longer periods, approximately one-third of HIV-infected individuals fail to access care for 3 consecutive years in some communities.  Multiple cohort studies have found that 25%–44% of HIV-infected individuals are entirely lost to follow-up in many settings, although these individuals may eventually re-establish care. The Spectrum of Engagement in HIV Care and its Relevance to Test-and- Treat Strategies for Prevention of HIV Infection: E Gardner et al;Clinical Infectious Diseases-2011,52(6),

 Nonadherence to antiretroviral therapy and antiretroviral medication resistance were long viewed as barriers to controlling the HIV epidemic.  The advent of more potent regimens has shifted the challenge toward earlier steps in the process of recognition and treatment of HIV infection.  The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection: E Gardner et al;Clinical Infectious Diseases-2011,52(6),

 A series of studies funded through a US Health Resources and Services Administration (HRSA) Special Programs of National Significance (SPNS) found that greater engagement in HIV care was associated with greater use of:  case-management services,  mental health services,  substance abuse treatment,  transportation assistance, and  housing assistance. The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection: E Gardner et al;Clinical Infectious Diseases-2011,52(6),

 Some localities have developed peer intervention programs that have demonstrated meaningful results.  Peer intervention programs educate, train and employ staff who have similar socioeconomic and health characteristics as the patients being served.  Trained peers work to build trusting relationships with patients and help them improve their understanding of how to successfully access services.

 Peers also work as Health Systems Navigators. Health Systems Navigators support case management services by helping patients follow through with referrals.  HSNs use a variety of strategies including:  accompanying patients to appointments,  helping them learn how to be their own advocates,  coaching patients on how to effectively talk with their clinicians, and  providing translation services.

 Antiretroviral therapy has become more potent therefore better treatment outcomes can be achieved despite lower adherence.  With modern initial antiretroviral regimens, 70%–80% adherence leads to durable viral suppression in most individuals.  In 2 recent studies from large North American cohorts, 60%– 80% of individuals achieved adequate levels of adherence by this new standard. The Spectrum of Engagement in HIV Care and its Relevance to Test-and- Treat Strategies for Prevention of HIV Infection: E Gardner et al;Clinical Infectious Diseases-2011,52(6),

 Nonpersistence occurs when therapy is halted prematurely.  Patients may stop their medications as a result of medication adverse effects or competing priorities.  Providers may recommend cessation of therapy in response to clinical or laboratory adverse events or barriers to adherence.  In 3 large cohort studies, 4 %–6% of individuals who remained in care discontinued their antiretroviral regimen each year. The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection: E Gardner et al;Clinical Infectious Diseases-2011,52(6),

 Nonpersistence, nonadherence, and antiretroviral resistance are barriers to effective antiretroviral therapy, contributing to detectable HIV viremia in 15%–25% of individuals receiving therapy.  The majority of individuals receiving antiretroviral therapy in 2010 have undetectable viral loads.  Therefore, most HIV-infected individuals receiving therapy are at low risk for clinical progression and low risk to transmit HIV to others. The Spectrum of Engagement in HIV Care and its Relevance to Test-and- Treat Strategies for Prevention of HIV Infection: E Gardner et al;Clinical Infectious Diseases-2011,52(6),

 Mathematical models have been published which suggest that widespread use of antiretroviral therapy in HIV-infected individuals could reduce the incidence of HIV infection.  Epidemiological data have suggested that antiretroviral therapy reduces the risk of HIV transmission in heterosexual sero-discordant couples by 92%–98%.  Ecological data have revealed that the incidence of HIV infection decreases in communities with high treatment coverage. The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection: E Gardner et al; Clinical Infectious Diseases-2011,52(6),

 The most widely cited transmission study entailed a retrospective analysis of nearly 15,000 persons living in the Rakai District of Uganda.  HIV transmission was studied among couples retrospectively assembled through careful analysis of the data.  The probability of an HIV transmission was reflected in the blood viral burden in the index patient.  No transmission events occurred among individuals with a blood HIV RNA level <3500 copies/ mL.  Nearly half of the transmission events could be traced to infected persons with a blood HIV RNA level >35,000 copies/mL. Treatment to Prevent Transmission of HIV-1: M Cohen et al; Clinical Infectious Diseases:2010;50,S85-S90

 Linkage and retaining individuals in care is an essential part of the National HIV/AIDS Strategy.  The team approach is incorporated in linkage and retaining patients in care  There are many patient and public benefits of retaining patients in care.  The test and treat model has the potential benefit of decreasing the number of new patients acquiring HIV.

 A 31 yo Latina female was diagnosed HIV+ 4 mo ago. She initially presented with a complaint of a rash on her vagina x 3 days which was treated as genital herpes and her Oraquick was positive. She returned 1 wk later for her confirmatory results and has missed 3 FU appointments. She is a single mother of 2 and has a job as a store clerk. She is in a committed relationship. She always promises to keep her appointment but doesn’t show.  Discuss linkage to care strategies for this patient.  Do you feel any urgency?

 A 57 yo AA man is accompanied by his 28 yo daughter for his FU visit. He was dx HIV+ 9 mo ago. His most recent CD4 count was 389 so last visit (he has missed the following 2 visits) you discussed starting him on ARV’s. Today he smells of ETOH as he has on subsequent visits. He insists that he does not drink ”that much” and states he has cut back after you questioned him about his drinking last visit. His daughter has remained quiet.  How do you proceed?

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