The HIV Continuum of Care Model proposes to characterize the engagement of persons living with HIV/AIDS (PLH) within healthcare systems. Only 28% of U.S. PLH have achieved viral suppression, but nearly half (49.1%) of PLH are out-of-care (OOC), based on ineffective linkage (23%) and retention in care (33.7%). In Connecticut, ~33% of 10,849 prevalent cases are believed to be OOC, defined as not having a pVL or CD4 in the past year and 83% and 93% of the 348 newly diagnosed cases in 2012 were linked to HIV within 3 and 12 months, respectively. Guidelines strongly recommend systematic monitoring of successful entry into care for newly diagnosed individuals and retention in care for those who are linked with use of data sources including surveillance methods, medical records and clinic databases. Achieving systematic monitoring has been problematic due to varying definitions for linkage and retention in care that include clinic visits from electronic medical records (EMR) and/or laboratory surveillance data (CD4/pVL). Pilot studies suggest that surveillance data integrated with EMRs can be leveraged to improve linkage and retention in HIV medical care. Barriers to this approach include restrictive state laws related to sharing of confidential information, lack of provider support and patient perceptions of intrusion and coercion. To improve linkage and re-engagement in care, we propose Project CONNECT, a new CT partnership between the DPH and 93% of CT's HIV treatment sites (Ryan White A clinics (N=19), selected private clinics (N=4) and Yale University School of Medicine). This new multi-disciplinary team will create a new and innovative data monitoring system called CTLink which will integrate 3 independent databases: the eHARS surveillance database, clinical and administrative appointment databases, and an enhanced Ryan White CAREWare database. It will have capacity to more accurately define those who are truly out of care and report standardized measures of healthcare engagement. Evidence-based interventions (EBIs) will include an adapted ARTAS II intervention (Anti-Retroviral Treatment and Access to Services, a 5-session strengths-based case management approach) called ARTAS+. ARTAS+ will be adapted to DPH Disease Intervention Specialist (DIS) workers; it will harness mobile media and the strengths of our existing intensive outreach programs within Ryan White. It provides potential augmentation by adding a voucher-based lottery system for individuals who are linked, but not retained in care. Project CONNECT is highly innovative due to strong existing collaborations, creation of the comprehensive CTLink database that links surveillance and clinical care activities, use of EBIs that are adapted to be effective and cost-effective, the use f an adaptive study design and research partners with long-standing history of multi-site collaborations, including with the CDC, and a strong track record of publishing and disseminating their findings.
Project CONNECT will formalize a collaborative team of key stakeholders in CT who have the expertise to build and use systematic data monitoring to pro-actively identify in real-time PLH who are unsuccessfully linked to or have fallen out of medical care. An evidence-based and innovative intervention carried out by DIS workers from DPH will be piloted to improve linkage to and retention in HIV care. If successful, this approach can be disseminated to other states which can build on partnerships between local Health Departments and clinical sites to help achieve the goals of the U.S. National HIV/AIDS Strategy.
