Program links newly HIV-diagnosed patients to care

Intervention uses well-trained case finders

The Baltimore (MD) City Health Department has found success with an HIV program that is modeled after an intervention already employed in sexually transmitted disease (STD) care.

The city health department has used a disease intervention specialist (DIS) to bring people infected with STDs into treatment, and now a similar model is being used to bring people infected with HIV into care, says Steven L. Dashiell, Ryan White Minority AIDS Initiative (MAI) outreach program coordinator in the health promotion and disease prevention office. Dashiell presented an abstract about the disease intervention techniques at the 2006 National STD Prevention Conference, titled, "Beyond The Hidden Epidemic: Evolution or Revolution?" held May 8-11, 2006, in Jacksonville, FL.

"The disease intervention specialist is assigned to individuals, who are told they have been exposed to an STD, and the specialist gets these people into care and breaks down the barriers to getting them into care," Dashiell explains.

With funding of $210,000, provided last year from the Health Resources and Services Administration and the MAI, the method employed for HIV clients involves working with HIV-positive individuals, who are found through city outreach. They're assigned as active cases to three case finders.

"Our problem was how do we get a person from HIV testing sites to HIV care sites if those sites are not in the same places," Dashiell says. "We have plenty of individuals who find out they are positive at one site that is not a care place, and they are not linked to care."

Traditionally, when people tested positive for HIV they were given a lot of information, but were not assisted further in entering treatment, he says.

"This critical gap simply existed because none of us in the field nationally realized the level of stress the individual might go through when given an HIV diagnosis," Dashiell says. "When we gave clients information at the post-test counseling, there was the expectation that people would follow-up for the benefit of their own health."

What health officials failed to understand was that all of the information in the world might not be enough to get some people to the door of an HIV clinic, he adds.

"We didn't recognize the financial factors of 'I simply cannot afford a place of care,' or 'I work from nine to five, when the clinic is open,'" Dashiell says.

"You get this huge news of an HIV infection, and someone gives you all of these papers and expects you to read them and go somewhere for help," says Kima Joy Taylor, MD, MPH, assistant commissioner of the health promotion and disease prevention branch of the Baltimore City Health Department.

"People are completely shocked and can't take in the information," Taylor adds.

Their solution was to use techniques employed by DIS workers by giving specially trained case finders the names of people who the health department had tested and found to be positive, Dashiell says.

Case finders also serve a case manager role by assisting HIV clients with finding transportation, obtaining treatment for substance use, and other issues, Dashiell notes.

"They make sure the clients get to their clinic appointments and provide them with bus passes or whatever they need," he says.

"It is not considered a successful intervention unless the individual the case finder is assigned gets to at least two appointments," Dashiell adds.

Training case finder is very intensive and includes the best elements of the CDC STD intervention training and traditional HIV outreach training. Case finders include both DIS workers and community partners who have better access to at-risk populations, including men who have sex with men, substance users, and others.

Caseloads number 15 to 20 people, he says. Building caseloads was the easy part. The Baltimore health department tested more than 8,000 people for HIV last year, Dashiell says. "We take the list of those with positive HIV tests and cross-reference it to look at the clinic database to see if the people have been informed that they're HIV positive."

Case finders also are encouraged to find, through their own community work, people who are HIV positive and then link them to care. And some clients are found through the corrections system.

Those who have been newly-diagnosed are then referred to a case finder who recruits them, asking clients to sign releases permitting the health department to collect information about their health clinic appointments, CD4 cell counts, and viral load, Dashiell says.

Clients can refuse, but those who agree to be part of the program will be contacted by the case finder until they have attended two primary care and case management appointments.

The care centers have been able to handle the extra clients and are participating in referring patients to the program, Dashiell says. "It's obvious that the good work of the health department is bearing fruit, so they want us to refer people to their care sites," he adds. "Other methods of going out to a group of people, testing them, and then attempting to link them to care is far more involved, and the end result is the same."