Integration of HIV Testing and Linkage to Care by the Baltimore City Health Department

Abstract

To the Editor: With an estimated 25% of HIV-infected persons nationwide unaware of their infection status,1 HIV testing and then connection to care is crucial care. In response to the high HIV incidence in Baltimore,2 the Baltimore City Health Department (BCHD) developed strategies to increase status awareness among HIV-infected individuals who are difficult to reach, including utilizing alternative venue testing (AVT) methods.3,4 This letter describes the outcomes of BCHD's effort to connect into care individuals identified through the enhanced and integrated HIV testing and care linkage program. To connect people with care, BCHD first checked names of individuals testing HIV-positive in Baltimore against names in the BCHD, MD state, and clinic HIV-databases. If it was determined to be new case and/or the individual was not currently in care, the case was followed up for care linkage by health department disease intervention specialist. The possible care linkage outcomes where the individual was (1) linked to care, (2) already in care, (3) refused care, (4) out of jurisdiction, or (5) not located. Data were collected as usual practice by BCHD with the secondary data analysis approved by the Johns Hopkins School of Medicine Institutional Review Board. During 2007 to 2008, BCHD performed 51,454 HIV tests identifying 867 new HIV-infections (total 1940 duplicated positive tests). A majority of HIV-positive individuals were tested as part of alternative venue testing (559; 64.5%) compared to clinics (308; 35.5%). Among those who tested positive, 724 (83.5%) were black, 587 (67.7%) were men, and 540 (62.3%) were less than 45 years old. Fifty individuals were found to be in care (76.0% record search; 24.0% field investigation). Of the remaining 817 cases, 290 (35.5%) were linked to care, 25 (3.1%) refused care, 84 (10.3%) were out of jurisdiction, and 418 (51.2%) were not located/files closed. The BCHD integrative program was able to link 290 of the newly diagnosed HIV-infected individuals with care. While there is still room for improvement, the percent of newly infected individuals connected to care is a marked improvement from nonintegrated programs, meets cost-effectiveness criterion,5 and may increase life quality especially with a quick transition from diagnosis to presentation for care.6 A challenge, especially in cities with high HIV prevalence, is access to current and accurate HIV databases. While the results of the study indicate that BCHD is becoming increasingly skillful in linking new HIV-positive individuals into care, the limited available resources are not always maximized—illustrated by the number of individuals contacted through field investigation already in care. These resources could be redirected to linking other clients into care and highlights the need for more accurate data management. Overall, the integrated program was able to identify (through ATV) and link a substantial number of individuals into care and the next steps will be to assess retention and adherence.7,8 The improvement through integration and thoughtfulness around data management should be helpful for other urban HIV prevention and treatment efforts. Amanda E. Tanner, PhD, MPH Department of Public Health Sciences University of North Carolina-Charlotte Charlotte, NC Ravikiran Muvva, MBBS, MPH,MPA Rafiq Miazad, MD, MPH Sheridan Johnson, BA Phyllis Burnett, BA Glen Olthoff, MHA Sherell Jackson, AA Bureau of STD & HIV Prevention Baltimore City Health Department Baltimore, MD Denise Freeman, BS, MA Division of STD Prevention Centers for Disease Control and Prevention Atlanta, GA Jonathan M. Ellen, MD Department of Pediatrics School of Medicine Johns Hopkins University Baltimore, MD