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Overview
The Antiretroviral Treatment Access Study II (ARTAS II) demonstration project addresses strategy 3 of the Advancing HIV Prevention (AHP) initiative: prevent new infections by working with HIV-infected persons and their partners. ARTAS II explores the effect of linkage case management on getting HIV-positive persons into care. In the linkage case management approach, a person who has recently received an HIV diagnosis is assigned a linkage case manager to ensure that he or she accesses HIV primary care.
Despite significant successes in preventing and treating HIV infection, the annual estimated number of new HIV infections in the United States has remained at 40,000 for nearly 10 years. A contributor to the steady rate of HIV transmission is the delay between receiving an HIV diagnosis and seeking HIV primary care. After testing positive for HIV, approximately 40% of those receiving this diagnosis delay a year or more before entering primary care.
When people delay entry into care, they do not get the personal and public health benefits of treatment, such as reduced viral load, which can reduce the risk of transmitting HIV. In addition, they miss the counseling that could help reduce their risk for spreading HIV to sex- and needle-sharing partners. As CDC and local health authorities focus on increasing the number of at-risk persons tested for HIV, it is vital that those who test positive for HIV are effectively and rapidly linked to an HIV primary care provider and to ongoing case management when available.
ARTAS II is based on the recently completed ARTAS study. ARTAS showed that when persons with a recent diagnosis of HIV infection meet up to 5 times in a 3-month period with a linkage case manager, they have a greater chance of being linked to care (measured by 2 or more visits to an HIV care provider within a 12-month period). By comparison, persons with a recent diagnosis of HIV infection who receive only a passive referral are less likely to be linked to care. In fact, ARTAS showed that 78% of HIV-infected persons who met with a linkage case manager had stayed in care 6 months later (versus 60% of those who received a passive referral) and that 65% of those who met with a linkage case manager had stayed in care 12 months later (versus 49% of those who received a passive referral).
The ARTAS II demonstration project will compare rates of linkage to HIV care providers before and after instituting the linkage case management shown effective in the first ARTAS study. Findings of the study will strengthen our understanding of how well linkage case management works in typical HIV program settings in the United States.
The 10 collaborating sites for ARTAS II include 5 local or state health departments and 5 community-based organizations (CBOs). Each site will have at least one ARTAS II linkage case manager.
Goals The primary objective of this demonstration project is to achieve a rate of use of HIV care associated with linkage case management of at least 75% after 6 months of follow-up. The secondary goals of this project are to:
- Determine if the rate achieved during linkage case management is higher than the rate that existed in the community before the ARTAS case management intervention.
- Evaluate the public health impact, based on cost increases or cost savings from the project, on local HIV health care providers and local agencies responsible for HIV diagnosis and case management.
- Explain why there are differences in linkage to HIV care outcome rates across sites.
Collaborator Projects
Atlanta, Georgia, AIDS Survival Project is a CBO founded in 1987 by a small group of people living with HIV who wanted to promote self-empowerment and enhanced quality of life for HIV-infected persons. The CBO now provides the Atlanta area with HIV/AIDS education, support services, peer counseling, and, more recently, HIV counseling and testing. It will collaborate with another Atlanta CBO, Our Common Welfare, to provide ARTAS II linkage case management services.
Chicago, Illinois, Alliance for Community Empowerment is a CBO that specializes in HIV/AIDS care and, since 1991, has provided services to clients who are primarily poor, African American, and living on Chicago’s South Side. This area is highly impacted by HIV and other public health problems. The alliance will work closely with the HIV Care Center at Michael Reese Hospital to provide linkage case management services to clients.
Jacksonville, Florida, Duval County/Florida Department of Health has provided HIV early intervention services and primary case management since 1986 to residents of Duval Country, Florida. The health department has numerous anonymous and confidential counseling and testing centers within the county, as well as HIV prevention and primary care centers. It serves 60% of the persons diagnosed with HIV infection or AIDS in Duval County. Staff members intend to incorporate ARTAS II linkage case management into their existing care services.
Anniston, Alabama, Health Services Center, Inc. (HSC) is a one-stop shop for HIV/AIDS care in rural northeast Alabama. Since the original clinic was founded in 1987, it has expanded its services to include primary medical care, case management, outreach and retention, adherence, palliative care programs, HIV prevention, and mental health and substance abuse treatment and prevention activities. HSC plans for ARTAS II linkage case managers to work closely with disease intervention specialists to link persons with new HIV diagnoses to medical care.
Kansas City, Missouri, Kansas City Free Health Clinic is a free, volunteer-driven clinic that provides over 25,000 patient encounters annually in general medicine, mental health, dental, and HIV primary care. Started in 1971 to serve underserved youth, it has become the largest provider of HIV primary care, prevention, and outreach in Greater Kansas City (both Kansas and Missouri). It is also a publicly funded HIV testing site, offering the only anonymous testing in the area. The clinic expects to use ARTAS II funding to develop a formal system to track client engagement from testing to retention in care.
New Orleans, Louisiana, Louisiana Department of Health and Hospitals oversees the state’s HIV prevention, services, and surveillance programs. The health department intends to collaborate with two experienced CBOs—Family Service of Greater Baton Rouge and Volunteers of America—to provide linkage case management services to persons living with HIV/AIDS in the greater Baton Rouge/Region II area. Region II is largely rural, but the city of Baton Rouge ranks second in the nation in AIDS case rates among large cities.
Miami, Florida, Miami-Dade County/Florida Department of Health maintains, in collaboration with the University of Miami School of Medicine, three clinics (downtown Miami, South Beach, and South Dade County) dedicated to sexually transmitted disease and HIV counseling and testing. Their staffs intend to recruit participants from these clinics for the project. They also intend to collaborate with the South Florida AIDS Network, the largest CBO in Miami, to provide medical care to persons living with HIV. The Miami-Dade County Health Department collaborated with the University of Miami on the initial ARTAS clinical trial.
Columbia, South Carolina, South Carolina Department of Health and Environmental Control plans to implement ARTAS II in two metropolitan areas—Columbia and Greenville—which together account for about 309 new HIV cases annually. It plans to recruit project participants primarily through local health department HIV counseling and testing services and collaborate with two CBOs (Midlands Care Consortia and AID Upstate) to provide linkage case management.
Baltimore, Maryland, Total Health Care, Inc. has provided primary health care to the poor and medically underserved residents of Baltimore City since 1989. It has five sites, and the area it serves accounts for over 80% of all newly diagnosed HIV cases in the city. It is one of only four organizations in Baltimore that provide HIV counseling and testing, case management, and primary care. ARTAS II funds will be used to help link persons recently diagnosed with HIV to HIV medical care as soon as possible after diagnosis.
Richmond, Virginia, Virginia Department of Health intends to contract with Virginia Commonwealth University (VCU) and its entities, the Central Virginia HIV CARE Consortium (CVHCC) and the Surgery and Evaluation Research Laboratory (SERL) to implement ARTAS II. VCU will coordinate its linkage case management services with publicly funded counseling and testing sites and with HIV care providers in CVHCC and SERL.
Project Milestones
- Funding announcement: June 2004
- Grant recipients announced: September 2004
- Grantee orientation meeting: November 2004
- Grantees attend strengths-based case management training in Dayton, OH: January 2005
- Grantees attend data manager training in Atlanta, GA: March 2005
- Client enrollment begins: April 2005
- 6-month follow-up begins: October 2005
- 12-month follow-up begins: May 2006
Data Collection
Data measuring program effectiveness will be collected through 1-on-1 interviews with clients, A--CASI (audio-computer assisted self-interviewing), and medical records abstraction to verify client self-report.
Pre-intervention data will be collected from state HIV/AIDS reporting and Ryan White and Medicaid encounter data to establish a baseline rate of linkage to HIV care. These data will include date of positive confirmatory HIV test, HIV exposure category or categories, race, ethnicity, and, in some cases, date of HIV care encounter.
Data collected through the ARTAS II demonstration project will be primarily sociodemographic data, although some questions will elicit data on HIV testing, drug use, risk behaviors, depression, and knowledge, attitudes, and beliefs about HIV/AIDS.
At 6 and 12 months after an initial case management visit, each client will be contacted by the project site to return for a follow-up A-CASI to determine if he or she has had medical care since joining the study. The follow-up interviews contain additional questions that elicit data on select barriers to engaging in HIV primary care. The client’s medical record will also be abstracted at that time to verify client self-report.
Program evaluation will measure any increase in the percentage of clients linked to medical care within 12 months of their HIV diagnosis compared with the pre-intervention population. The effect of ongoing case management on linkage to medical care will also be evaluated by comparing rates of linkage to care among those clients who become linked to ongoing case management with rates among those who do not.
Results to Date
As of June 2006,
- Data collection is in progress and will continue through January 2007 for all 10 sites.
- Enrollment is still in progress for 3 grantee sites.
- 609 clients have been enrolled and have completed the baseline ACASI survey.
- 198 clients have completed the 6-month ACASI survey.
- 43 clients have completed the 12-month ACASI survey.
- Medical record abstractions are in progress.
- Data collection to assess client, agency level, and case manger level program costs is ongoing.
- Pre-intervention linkage rate data collection is ongoing.
- Site visits to all 10 grantees have been completed.
- Preliminary estimates of program cost for the case management intervention have been calculated.
For more information . . .
Advancing HIV Prevention
http://www.cdc.gov/hiv/topics/prev_prog/AHP
Resources on the Advancing HIV Prevention initiative
CDC National Prevention Information
Network (NPIN)
1-800-4 58-523 1
http://www.cdcnpin.org
CDC resources, technical assistance, and publications
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