Social Work and the HIV Care Continuum: Assisting HIV Patients Diagnosed

Social Work and the HIV Care Continuum: Assisting HIV Patients Diagnosed

Social Work and the HIV Care Continuum: Assisting HIV Patients Diagnosed

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Since the start of the HIV/AIDS pandemic, social workers have played an integral role in society’s response to the crisis ( Caputo, 1985). Over the past three decades, many aspects of HIV care and prevention and our approach to them have changed. One thing that has not changed, however, is the role social workers play in the care of people living with HIV/AIDS (PLWHA) and in HIV pre- vention programs. Social workers have long called for the integration of treatment and prevention pro- grams ( Freudenberg, 1994). Both the medical and social services establishments have come to under- stand that HIV treatment is HIV prevention. When effective antiretroviral (ARV) treatment is combined with more traditional prevention interventions, HIV transmissions can be reduced by more than 95 per- cent ( Cohen et al., 2013). For the first time since what we now know as AIDS was reported in 1981, we can discuss the control and even the end of the global pandemic ( Fauci & Marston, 2013), concepts that were unimaginable even five years ago.

BACKGROUND For more than two decades, routine HIV testing in hospital emergency departments (EDs) has been contemplated as a tool for diagnosing unrecog- nized HIV infection ( Kelen et al., 1988). In 2006, the Centers for Disease Control and Prevention (CDC)

issued revised recommendations for HIV testing in health care settings. These recommendations spe- cifically include hospital EDs as one setting in which routine, opt-out HIV screening should be consid- ered. One goal of the revised CDC recommenda- tions is to increase the number of HIV-infected people who are aware of their infection ( Branson et al., 2006). This awareness of diagnosis is the first step in the HIV care continuum.

The HIV care continuum, a set of sequential stages of HIV medical care and outcomes, provides a population-level snapshot of progress toward optimal health. The population level reviewed can range from a small set of patients, as in this article, up to a global scale. The stages of the HIV care continuum are as follows: diagnosis, linkage to med- ical care, retention in medical care, prescription of ARV medications, and viral suppression ( Gardner, McLees, Steiner, del Rio, & Burman, 2011; Horberg et al., 2010; Horberg et al., 2011). Definitions used for this analysis are included in Table 1. The ultimate goal of the HIV care continuum is for PLWHA to achieve viral suppression. Viral suppression reduces HIV-associated morbidity, prolongs the duration and quality of survival, restores and preserves immuno- logic function, maximally and durably suppresses plasma HIV viral load, and prevents HIV transmission ( U.S. Department of Health and Human Services,

238doi: 10.1093/sw/swv011 © 2015 National Association of Social Workers

Panel on Antiretroviral Guidelines for Adults and Adolescents, 2014). Viral suppression makes talk of control and the potential end of HIV possible.

In the summer of 2010, the Obama administra- tion released the first-ever National HIV/AIDS Strategy for the United States (NHAS) ( White House Office of National AIDS Policy [ONAP], 2010). Two main goals of the NHAS are to reduce new HIV infections and to increase access to care and improve health outcomes for PLWHA. Moti- vated, in part, by these changes to the HIV/AIDS landscape, in October 2010 Maricopa Medical Cen- ter (MMC) began planning for the implementation of nontargeted, routine, opt-out HIV screening in the adult ED. MMC, located in Phoenix, Arizona, is the anchor of the Maricopa Integrated Health System (MIHS), the only hospital-based safety-net health care system for the residents of Maricopa County. The adult ED has approximately 45,000 visits per year. The HIV testing procedure is a CDC-funded program known as Test, Educate, Support, and Treat Arizona (TESTAZ).

During TESTAZ planning, one main concern for ED physicians, social workers, and staff was to ensure that patients newly diagnosed with HIV were linked to outpatient medical care in a timely man- ner. In alignment with the NHAS, it is our expecta- tion that newly diagnosed HIV patients will be linked to medical care within three months of diag- nosis. The NHAS aims to increase linkage to care nationally from 65 percent to 85 percent by 2015. The physicians and staff in the ED at MMC agreed that TESTAZ should strive to meet or exceed the NHAS goals to ensure that patients are appropriately

linked to medical care and support services. Fur- thermore, MIHS is committed to following newly diagnosed HIV patients from the ED through the HIV care continuum for the first year after diagnosis. This article focuses on the critical role social workers play in every stage of program development, imple- mentation, and patient movement through the stages of the HIV care continuum.

METHOD This observational study used data reports and chart reviews. TESTAZ was approved as exempt by the MIHS institutional review board. Data collection was mainly through reports extracted from the MIHS electronic medical record (EMR). Data were analyzed using Microsoft Excel (Microsoft Corpo- ration, Redmond, Washington). During the plan- ning stage, a social worker affiliated with MMC’s adult ED was hired to work as the program coordi- nator. By design, TESTAZ is a procedure of nontar- geted, routine, opt-out HIV screening for all patients of the adult ED between 18 and 64 years of age, if other labs are drawn, regardless of medical com- plaint. Unless the patient declines, consent for opt- out routine HIV screening is inferred and occurs after notifying the patient that the test will be per- formed unless the patient declines testing.

We implemented TESTAZ with few exclusion- ary criteria ( Geren et al., 2014). Exclusions include patients with a known HIV/AIDS diagnosis, who are intoxicated or otherwise unable to consent, who are in the custody of law enforcement, those requir- ing a level I trauma activation, and patients who report having been tested for HIV in the previous

Table 1: Continuum of HIV Care Category Definitions

Category Definition Comment

Diagnosed Confirmed HIV-positive patients aware of their HIV serostatus

Two of the 71 diagnosed patients were discharged prior to their preliminary results being returned. As a result, we have been unable to confirm their HIV serostatus.

Linked Diagnosed patients who attended a medical appointment with an HIV medical provider within 90 days of their diagnosis

Fifty-eight of the 71 diagnosed patients have been linked to medical care, with 50 of them in the 90-day time frame.

Retained Diagnosed patients linked to care, regardless of the time frame, who received a medical service between January 1, 2014, and June 30, 2014

Fifty-two of the 71 diagnosed patients meet the definition.

Prescribed Diagnosed patients prescribed antiretroviral medications

Fifty-four of the 71 diagnosed patients meet this definition.

Suppressed Diagnosed patients whose most recent HIV viral load was ≤200 copies/ml.

Forty-one of the 71 diagnosed patients meet the definition.

Edmonds, Moore, Valdez, and Tomlinson / Social Work and the HIV Care Continuum 239

12 months. Including HIV testing as a standard of medical care in the ED reduces the stigma surround- ing HIV testing. Routine, opt-out HIV screening also reduces the complexity of testing based on medi cal complaints or traditional behavioral assess- ments ( Branson et al., 2006).

EMR customizations were needed for the ED triage process to ensure the capture of required in- formed consent information. Consent for HIV test- ing is included with the general consent for medical care. As with other testing for reportable commu- nicable diseases in the ED, patients are informed of mandatory reporting requirements in writing through the general medical consent for treatment, the conditions of admission and treatment, the MIHS Notice of Privacy Practices, and the Patient and Visitor Information packet. Patients are allowed to ask questions and change their minds about HIV testing at any time during their ED visit. Patients older than 64 years may be tested if requested by the patient or if there is clinical suspicion of undiag- nosed HIV infection. Patients included in this analysis (N = 85) were individuals confirmed HIV positive in the MMC adult ED between July 11, 2011, and April 30, 2014. Patient medical records were analyzed for engagement at each stage of the HIV care continuum.

PROCEDURES During the TESTAZ planning phase, two main concerns expressed by staff were how to best deliver the preliminary diagnosis and how to best ensure that a newly diagnosed patient has access to HIV primary medical care and support services. At MIHS, ED-based social workers could be called on to help the patient take those crucial first linkage-to-care steps. The final decision was that, ultimately, the on-duty social worker would assist the physician with notification and initiate linkage to care due to each person’s established role in the ED. Until social workers could be trained with regard to TESTAZ, a different process was in place (as described in the next paragraph).

The procedure implemented at MMC in July 2011 indicated that when the laboratory identified a preliminary HIV-positive result, the program co- ordinator was contacted and asked to come to the ED to meet with the patient and the physician. The coordinator and the physician would meet with the patient, and the physician would inform the patient of the preliminary result. The physician and the

coordinator emphasized the need for additional laboratory work to confirm the result. During the ED visit, the coordinator provided support and con- firmed contact information for the patient to com- plete the necessary follow-up. Once the diagnosis was confirmed, the coordinator contacted the pa- tient to set up a meeting at the ED to inform the patient of the confirmatory result and start the link- age to medical care and support services processes. A patient navigator was later hired and trained by the coordinator to assist the newly diagnosed pa- tients from the ED. The patient navigator also works at the McDowell Healthcare Center (MHCC), the MIHS-operated HIV primary care clinic. The pa- tient navigator is available to assist with notifications when a social worker is not on duty or when ad- ditional help is requested.

A significant focus for EDs is to respond to the increasing health concerns and medical needs of underserved, underinsured, and marginalized pop- ulations. Social workers and patient navigators in an ED are well positioned to link patients to commu- nity resources, support services, and outpatient follow-up due to the characteristic function that an ED imbues as a liaison between hospitals and the populations served ( Madden, Carrick, & Manno, 2012). For this reason, MMC ED staff support the active involvement of the coordinator, patient nav- igator, and social workers as integral to the HIV testing process. Social workers employed in hospital EDs are well equipped to offer emotional support, crisis counseling, and appropriate referrals in these situations ( Silverman, LaPerriere, & Haukoos, 2009). Social workers refer patients to the patient navigator to facilitate engagement in care and retention in medical care and services.

The patient navigator continues to follow newly diagnosed HIV patients for one year post diagnosis to ensure linkage to and retention in medical care. During the follow-up period, the patient navigator assists the newly diagnosed patient to establish a habit of regular medical care and engagement with support services. In an effort to move patients along the HIV care continuum, the patient navigator also works with patients to encourage adherence to pre- scribed ARV medications.

After TESTAZ was established, a true routine, opt-out HIV testing environment required social work integration into the formal ED work flow for preliminary HIV-positive results. ED social workers are now involved with result notification, referral to

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the patient navigator, and provision of support dur- ing the ED visit. The MMC ED has established a system known as “5–30–5.” The system, developed by the adult ED medical director, is used when critical test results are returned to the patient. Al- though the system is not specific to HIV test results, we describe how 5–30–5 interacts with TESTAZ. Under the 5–30–5 system, the physician, accompa- nied by a social worker, delivers the preliminary HIV-positive result to the patient. The physician stays with the patient for about five minutes to an- swer questions and provide support. The physician then leaves the patient with the social worker for about 30 minutes. During this half-hour, while the physician attends to other patients, the social worker provides support to the patient and begins the link- age-to-care process by providing a one-page hand- out about what to expect. This handout does not mention HIV or AIDS, to preserve patient confi- dentiality and self-determination. Both the hand- out and the social worker inform the patient that the Maricopa County Department of Public Health (MCDPH) will be in contact for follow-up and partner services. Social workers explain the pro- cess of public health and partner notification in de- tail to the patient and encourage him or her to work with public health to identify partners who may need to be tested for HIV so they are aware of their status. At the end of the 30 minutes, the physician returns to the patient to see if additional questions have arisen and to check on the general well-being of the patient.

RESULTS MIHS was one of the evaluation sites for the new CDC HIV laboratory testing algorithm ( CDC, 2013, 2014). Our HIV testing procedure includes the collection of an HIV viral load blood sample to confirm a preliminary diagnosis. Data collected from the EMR allow us to monitor patient progress through the HIV care continuum. Additional de- mographic information is also collected. Table 2 includes selected demographic information from the confirmed HIV-positive patients, the general MMC adult ED population, patients who were tested, and those who actively opted out of HIV screening. Not included in the table are the patients who were not tested due to the exclusionary cri- teria discussed earlier. Opt-out testing in the ED has been crucial in identifying previously HIV unaware patients who may not have otherwise been

tested for HIV. Of the patients who were diagnosed with HIV in the ED, 45 (52.9 percent) had been tested for HIV in the past. Anecdotally, a main reason for patients not having been tested before is the self-perception that the patient was not at risk for HIV infection. This particular aspect of routine, opt-out HIV screening warrants further research. Another avenue for additional research is to explore how many of the 85 newly diagnosed HIV patients had sought care from other EDs prior to their visit at MMC.

Our results demonstrate the importance of a routine opt-out testing program to identify indi- viduals who may not seek out more traditional targeted testing venues because they do not believe they are at risk of contracting HIV. For example, Table 2 shows that 28.2 percent of the new HIV diagnoses in the ED report a heterosexual trans- mission risk. More traditional, targeted HIV test- ing programs have tended to concentrate less on this particular population ( Lyons et al., 2013). This is more than double the rate of the larger PLWHA populations in both Maricopa County and the state of Arizona. Through routine opt-out HIV testing, TESTAZ reduces stigma because it is of- fered to all patients who present to the ED regard- less of medical complaint. TESTAZ, as designed and implemented at MIHS, offers the additional benefit of assisting patients with linkage to medi- cal care and following patients for one year after diagnosis.

During the review period, the ED experienced an opt-out rate of 15.3 percent for HIV testing, which is lower than expected. The population with the highest opt-out rate (44.1 percent) self-identified as Hispanic or Latino. This ethnic group also repre- sents the highest proportion (48.2 percent) of the newly diagnosed patients. Although Hispanic/Latino patients represent the largest percentage of those who tested positive, it is interesting to note that the case-finding rate for this population is 120 per 100,000. Among black or African American newly diagnosed patients, the case finding rate is 233 per 100,000. In the state of Arizona, there are 207 His- panic/Latino PLWHA per 100,000 population and 739 black/African American PLWHA per 100,000 population. TESTAZ demonstrates that health dis- parities can be narrowed through routine opt-out HIV screening in an ED. For every Hispanic case identified per 100,000 in our ED, we identified 1.94 African American cases.