Linking Clients to Care: A New Tool

It's a common enough story: someone is diagnosed with HIV. That person is told she needs to visit the doctor as soon as possible. Maybe that person calls for an appointment, and maybe she doesn't - but that person doesn't make it to the doctor that week. Or that month. It could be a child care problem, or a transportation problem, or an appointment availability problem.

But in some cases, it's just that people who were just diagnosed with HIV don't know that there is a system of care available to them -- even if they can't pay for services. In 2010, 18% of newly-diagnosed Philadelphians with HIV weren't linked to care within 90 days. We don't know each person's reasons for not getting medical care right away, but lack of knowledge of the care system is an obvious barrier for newly-diagnosed clients. In fact, through our local needs assessments, we've repeatedly found that many people living with HIV/AIDS report not accessing medical care because they couldn't afford it. We're lucky enough to have a comprehensive system of services available through Ryan White, but newly-diagnosed clients won't know about it if no one tells them it's there.



Here's a preview. Download a copy here.

At the same time, we know that it's not always easy for HIV testers to give consistent messaging while getting important information from their clients.  Enter, our new linkage to care tool. We hope that this tool will relieve some of the burden on HIV testers, increase access to care and other services for newly-diagnosed people with HIV, and improve linkage to care performance for our local provider sites.



We developed this tool after an extensive review of treatment readiness assessments in use across the country, and reduced the questions to the most relevant ones for helping clients with their initial linkage to care.  It was developed in partnership with the Points of Integration Workgroup, which spent a great deal of time honing both the language and the questions.  The tool was then presented to both the Philadelphia EMA Ryan White Part A Planning Council and the Philadelphia HIV Prevention Planning Group for additional feedback and adjustments.

We would like to note that we developed this tool as an aid for providers, and we designed it to help individual HIV testers improve access to services for their clients (and, by extension, to improve their own performance). This tool was not designed for data collection. Testers might decide to make copies and use a separate form for each client, in order to provide an “at a glance” summary of what is most needed to make that first linkage.  They might use pieces of this tool as a supplement to their own routines.  They might keep a copy with them to use as a discussion guide.  How they use the tool is up to them, but we do hope that it proves useful in their day-to-day work.

Of course, like all of our documents, this is free to distribute and reproduce.  We made it in black and white to be copier-friendly. We also included fainter lines in the notes section, allowing the neater testers among us to write along the lines and the more out-of-the-box testers to write willy-nilly in whatever direction they choose. We wanted this to be as user-friendly as possible. In that spirit, we welcome feedback and suggestions. Feel free to comment here, or use the contact information on the form to get in touch.

Download the linkage to care tool here - and share widely!
 

Towards more cost-effective HIV prevention planning

Some background: The Philadelphia Prevention Planning Group (PPG) and the City of Philadelphia's AIDS Activity Coordinating Office (AACO) work together to decide which communities have the greatest need for HIV prevention activities, and which interventions work best for those communities.  This is part of what we call "community planning."  AACO decides how the money gets spent and which organizations do the work, keeping in mind the community's needs and what is proven to work best. The PPG provides the community's voice to the process.

In 2011, the Centers for Disease Control and Prevention (CDC) approached the Philadelphia Department of Public Health (PDPH) to participate in the design and testing of a model for how to best spend HIV prevention funds to prevent the spread of HIV. The model was supposed to help health departments make cost-effective decisions to meet the goals of the National HIV/AIDS Strategy.  You can read more about the data used in the model and how the model influenced HIV prevention planning in the 2012 Philadelphia Jurisdictional Plan  (pages 93-95). 

AIDS.Gov recently released a podcast explaining this resource allocation model.  It also talks about the pilot project in Chicago, Nebraska, and Alabama, which is supposed to determine if the model works for those communities and to see if their experiences are similar to Philadelphia's.

The AIDS.Gov blog post explains more about the pilot project, HIV RAMP:

"That model was developed to help Philadelphia’s health department leadership identify the optimal allocation of HIV prevention funds across populations and prevention interventions that would prevent the most new HIV infections. Using local demographic and HIV epidemiological data inputs, and based on calculations of the cost per new infection averted, the model recommended the optimal allocation of the jurisdiction’s HIV prevention budget among several evidence-based interventions for the populations most impacted. Feedback from Philadelphia indicated that the model’s outputs served as a very useful “roadmap” to inform decision making for HIV prevention resource allocation within the jurisdiction, informing both applications for federal funds as well as efforts to strengthen local HIV prevention activities.

The current project, HIV RAMP, involves refining and piloting the original Philadelphia model in three additional jurisdictions that have different local profiles and HIV prevalence rates (Chicago, Nebraska, and Alabama), testing a technical assistance (TA) protocol to support jurisdictions in using the model, and assessing the feasibility of a software or online version of the model that could be more broadly used by other health departments.

“Because making decisions about how to spend HIV prevention funding is never ‘black and white,’ health departments need tools to help them decide how to support the best combinations of effective, evidence-based prevention strategies in their communities,” said Dr. Ronald Valdiserri, Deputy Assistant Secretary for Health and Director of OHAIDP. “Through this pilot project, we hope to develop a practical tool that can help communities apply the principles of the NHAS on the ground.”

Here are some highlights from the Philadelphia jurisdictional plan's discussion of the model development, focusing on the results:

"Cost per new infection averted is an integral part of this resource allocation model. For HIV testing in a clinical setting, the cost per infection averted is $51,293, making it the second most cost-effective intervention for Philadelphia. Testing in non clinical settings for IDU (3) and MSM (1) rounded out the top three most cost-effective interventions for averting HIV transmission at $53,935 and $17,965, respectively. The least cost-effective interventions used in the model were behavioral interventions for HIV- high risk heterosexuals ($15,642,127) and IDU ($2,931,406). Behavioral interventions were not found to be as cost-effective as HIV testing, even for HIV+ individuals. Adherence to ART (4), retention in care (5), partner services, and linkage to care (8) were ranked in the middle of the list of interventions. 

The optimal resource allocations according to those calculations would avert 72 infections in the first year and 245 infections within five years. Testing in clinical settings would receive 39% of the resources and avert 20 infections in one year, 93 infections in five years. Retention in care would receive 29% of the resources and avert 27 infections in year one and 52 infections within five years....Two-thirds of the resources would be allocated to HIV testing in this optimal model, because of the cost-effectiveness of HIV testing (non-targeted), particularly for MSM and IDU communities.  These allocations would serve 1,930 HIV+ individuals and result in 792 new diagnoses. Return on investment ranges (prevention dollars only) from 1.21 in year one to 4.42 in year five....

Recommendations from the model include allocations decisions should be made by both cost and effectiveness. Testing should be prioritized in clinical and non-clinical settings. More resources should be allocated to interventions located in care-settings. Behavioral interventions for HIV- individuals are not allocated resources. Behavioral interventions for MSM can be allocated resources under certain conditions. "

If you want to learn more about the community planning of HIV prevention in Philadelphia, check out the Prevention Planning Group or come to a meeting.