Thank you for your interest in CCO content. As a guest, please complete the following information fields. These data help ensure our continued delivery of impactful education.
Become a member (or login)? Member benefits include accreditation certificates, downloadable slides, and decision support tools.
Chief & Director
VHS-Infectious Diseases Medical Centre
Chennai Antiviral Research and Treatment (CART) Clinical Research Site
Voluntary Health Services
Nagalingeswaran Kumarasamy, MBBS, FRCP, PhD, has no relevant financial relationships to disclose.
In India, where I practice, linkage to care is a crucial step in the HIV care continuum. We know that, for the person living with HIV, antiretroviral therapy (ART) improves survival and quality of life and prevents forward transmission of HIV. In the same way that we now think of treatment as prevention, we also can think of treatment as linkage to care.
Yet, even in high-income countries, there is still much to be achieved.
Many factors delay linkage to care: structural barriers (including transportation issues and distance to the clinic), age, cultural beliefs, substance use, mental health, poverty, fear of medication adverse events, and fear of stigma. Although we have been treating HIV for decades, stigma associated with HIV is still a huge issue in my region. Many of these factors also predict poor adherence to ART, so this is not a simple issue to be addressed.
Organized Strategies to Promote Linkage to Care
The International Association of Providers of AIDS Care has provided recommendations to promote efficient linkage to care. These include immediate referral to HIV care following an HIV diagnosis and use of case managers and patient navigators to facilitate those referrals. These case managers also can implement proactive engagement and reengagement of patients who miss clinic appointments and/or are lost to follow-up, including intensive outreach for those not engaged in care within 1 month of a new diagnosis.
The CDC-supported ARTAS project, an ART and access-to-service project, provided linkage of newly diagnosed people with HIV to medical care. The ARTAS-II study, which included >600 individuals, evaluated a case-based management model in 10 community-based settings and health departments. ARTAS-II implemented an individualized, multisession, time-limited intervention with the primary endpoint of attendance of >1 medical visit within 6 months of enrollment. The factors that were statistically significantly associated with linkage to care were HIV care colocated with other medical care and having 2-5 of the initial individualized sessions vs just 1 session.
Interventions That May Improve Linkage to Care
Several studies in the United States have attempted to define interventions that improve linkage to care. Successful interventions have included intensive outreach and intensive case management (as we saw in the ARTAS-II study), HIV partner services, and shortened wait time for first clinic appointments. Same-day ART initiation programs can reduce time to clinic intake and viral suppression.
A systematic literature survey of 7 studies that included >24,000 participants in sub-Saharan Africa attempted to define the interventions that proved fruitful for linkage to care. A study in Lesotho showed that rapid ART initiation was one of these interventions, in that it improved linkage to care at 3 months after diagnosis. As seen in the United States, assisted partner services and intervention facilitation both were found to be important.
Early Initiation of ART as Linkage to Care
Early ART initiation has both individual and public health benefits. HPTN 052, the seminal treatment-as-prevention study in which persons with HIV were randomized to start early ART (at CD4+ cell counts of 350-500 cells/mm³) or delayed ART (at CD4+ counts <250 cells/mm³ or symptomatic infection), showed the enormous public health benefit of starting ART early in that the partners of persons receiving ART were protected from infection. The START and TEMPRANO studies showed great individual benefit of early ART in preventing opportunistic infection, but early ART also was found to decrease the rate of noncommunicable diseases. These studies transformed our concepts for treatment initiation and had an impact on literally every HIV treatment guideline.
As a result of these studies, the WHO started recommending rapid ART initiation in which people diagnosed with HIV start on ART within 7 days of diagnosis, with the exception of those with cryptococcal meningitis or any other central nervous system manifestations of AIDS. A second recommendation was that same-day ART should be offered at the time of diagnosis for those who have been counseled and are ready. So, in the same way that we now think of treatment as prevention, we also can think of treatment as linkage to care.
Your Thoughts?What interventions are being used in your community to facilitate linkage to care for newly diagnosed persons with HIV? What are some things you’d like to see happen in your community? Join the conversation by answering the poll and leaving a comment about your experiences.