Enhanced Comprehensive HIV Prevention Plans (ECHPP): A Multi-method Study of Barriers and Facilitators of Timely Linkage to HIV Primary Care in New York City
The Centers for Disease Control and Prevention (CDC) has implemented a planning process for to support the 12 US metropolitan statistical areas (MSAs) most affected by the HIV epidemic. It is designed to improve implementation of HIV prevention, care and treatment services; identify the optimal mix of interventions and target groups; and reduce the number of new HIV infections. For the last decade, the New York City Department of Health and Mental Hygiene (NYC DOHMH) has partnered with members of the Einstein-Montefiore Center for AIDS Research (CFAR) to design and implement HIV prevention initiatives. The Einstein-Montefiore CFAR acts as the lead agency of a partnership between the Einstein-Montefiore CFAR, the HIV Center for Clinical and Behavioral Research at the NY State Psychiatric Institute and Columbia University (HIV Center), and the NYC DOHMH. The partnership will use a multidisciplinary, multi-method approach to address a key vulnerability in HIV prevention: variation in timely linkage to care at HIV testing sites in New York. A comprehensive approach to HIV testing and treatment must ensure that patients who test positive for HIV are informed of their status and engaged into HIV care in a timely manner. Engagement in HIV treatment, including highly active anti-retroviral therapy, has been shown to reduce HIV transmission by decreasing plasma HIV-RNA levels and reducing risk behaviors. However, linkage to care has proved to be a challenge. This project has two parts. Part I will be secondary analyses of existing data sets to identify populations and communities that are more vulnerable to delayed linkage to care. Part II will be a mixed method study of HIV testing sites to document the barriers and facilitators of timely linkage to care. This proposal will enhance the ECHPP evaluation process by providing needed data on patient and testing site characteristics associated with delayed linkage to care, and identifying strategies in real world community settings that facilitate timely linkage.
Aim 1 – Use two existing NYC DOHMH data sets to identify populations and communities that experience delayed linkage to care. The project will examine data on variations in linkage to care in the Bronx, the borough with the poorest congressional district in the country and the highest HIV prevalence in the city. The Bronx was recently the target of a 3-year NYC DOHMH initiative called “Bronx Knows” which successfully completed 383,484 HIV tests on Bronx residents in its first 2 years. Using existing data analysis of NYC DOHMH surveillance data, we will identify health disparities in timely linkage using person-level factors such as age, race/ethnicity, gender, language, drug and alcohol use, and access to care. We will also identify neighborhood-level characteristics associated with higher rates of delayed linkage to care, including poverty, single parent household, violence, and number of medical clinics. New analyses will explore different ways to operationalize linkage to care.
Aim 2 – Conduct a survey of Bronx HIV testing sites on linkage to care. We will collect new data from the 70 existing Bronx Knows HIV testing partners to supplement existing data that the NYC DOHMH collected on testing, confirmation of newly identified HIV+ patients and linkage to care. Preliminary results, based on the Initiative’s first two years, showed that 68% of newly diagnosed individuals had been linked to care, but linkage rates varied considerably by site type, hospital, primary care clinic or community based organization. We will conduct a phone interview with the directors of each testing site to document systematically the reasons for site-based variation in linkage to care.
Aim 3 – Identify model testing sites with timely linkage to care and conduct case studies. We will use the survey of Bronx testing sites (Aim 2) to identify testing programs with model approaches to linkage to care and conduct in-depth on-site research to document their linkage to care procedures. We will describe how different kinds of testing sites assure high rates of timely linkage to care and which approaches are successful and cost effective. The results of this initiative will be a nuanced understanding of the predictors of linkage to care and a manual of linkage to care procedures that will be adopted in future testing initiatives, the next one scheduled being Brooklyn Knows.