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Systems Linkages and Access to Care Initiative

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The Special Projects of National Significance Program’s Systems Linkages and Access to Care for Populations at High Risk of HIV Infection initiative is a multistate demonstration project and evaluation of innovative models of linkage to and retention in HIV care. The initiative is funding six demonstration states for up to four years to design, implement and evaluate innovative strategies to integrate different components of the public health system such as surveillance, counseling and testing, and treatment, to create new and effective systems of linkages and retention in care for hard-to-reach populations who have never been in care, have fallen out of care or are at-risk for falling out of care.  Populations of interest are limited to those persons who at high risk for and/or infected with HIV but are unaware of their HIV status; are aware of their HIV infection but have never been referred to care; or are aware but have refused referral to care.

The University of California at San Francisco, the Evaluation and Technical Assistance Center for this initiative, will coordinate the multistate evaluation and provide programmatic technical assistance to the Demonstration States.



Grants for this initiative were awarded to the six States listed below. The following abstracts provide a brief description of each project.


The Office of Public Health STD/HIV Program in Louisiana will focus on linkages within two systems that have the potential to access hard-to-reach populations at high risk of HIV infection: the correctional system and the health care system. Louisiana will use a continuum of care model framework to implement a streamlined process through which HIV infected persons will move from testing to linkage and maintenance in HIV care and services.

The state plans to expand opt-out rapid HIV testing to jails and prisons in the state and maintain current testing activities. Prison/Jail Linkage Coordinators and Peer Coordinators will be utilized to provide pre-release planning services to HIV infected inmates and ensure they are linked with appropriate medical and social services before release. Louisiana will install and/or utilize existing video consultation technology in correctional facilities and case management agencies to virtually connect inmates with HIV medical providers and case managers while incarcerated.

This project seeks to expand the Louisiana Public Health Information Exchange (LaPHIE) electronic system (developed under an earlier SPNS initiative) to a private non-profit health system and modify its criteria so that PLWHA who are out of care be quickly and easily identified when they receive health services at other health facilities.



The Massachusetts Department of Public Health proposed the MIDDLEMARCH (Massachusetts Initiative for Data-Driven Linkage, Engagement, Management and Retrieval for Continued Health) Project to address the problem of HIV positive individuals who are not yet linked to or have disconnected from HIV care. The project is employing a multi-faceted strategy to be piloted in Boston, Springfield, and Worcester. MA plans to integrate its  surveillance, lab and service delivery data (client level HIV/AIDS data system, or CHADS) to identify HIV+ patients who have not entered care, fallen out of care, or use services on a sporadic basis. Routine HIV testing will be expanded at hospitals and health centers and through mobile outreach. Peer Linkage Specialists will be based at provider agencies to serve as system navigators, counselors and outreach workers. Their goal is to ensure engagement and maintenance in HIV care.


New York 

The New York State Department of Health will develop innovative and systemic models of linkage to care to improve access to and retention in high quality HIV care, bringing providers and communities together in local collaborative partnerships toward common improvement goals. NY will implement a model of regional public health collaboratives, which are formed in geographic areas that have been prioritized, based upon surveillance and epidemiologic data, to bring providers together including testing and prevention providers, non-traditional providers, and community representatives.


North Carolina 

The Communicable Disease Branch of the North Carolina Department of Public Health is partnering with Duke University and University of North Carolina – Chapel Hill to improve the coordination of HIV care in the state. The NC- LINK project plans to create a connection between HIV surveillance and HIV care data systems. A programmer will be used to develop electronic transfers of data between surveillance, lab reports and CAREWare for regional and state-level assessments and interventions to promote entry and retention in care. NC-LINK also will facilitate dialogues between medical care providers and labs to promote HIV test reporting completeness. Finally, NC-LINK will promote surveillance and location of PLWHA who are unaware of being HIV positive.



Virginia Department of Health (VDH) will develop and implement a health care model to utilize active referrals and strengthening of partnerships to improve continuous engagement and retention into primary medical care for people diagnosed with the HIV/AIDS. The overall goals of this project are to increase the percentage of newly-diagnosed clients who engage in care within three months post-diagnosis; to increase the retention rate in care; and to develop a referral system maximizing funding and linkage resources while coordinating and streamlining client services. This project will consist of three distinct components to be piloted in the Central and Southwest (SW) health regions. First, an active referral process will be implemented allowing Disease Intervention Specialists (DIS) to ensure client needs are met in a more efficient fashion. Second, Patient Navigators will assist clients in the treatment process, keeping them engaged and linking them to all available resources. Finally, a newly-established Central Care Coordinator position will coordinate the efforts of staff in both regions and assist with meeting the needs of clients’ transitioning out Virginia Department of Corrections facilities.



The State of Wisconsin plans to bridge the service gap between prevention and care through the provision of intensive, time-limited, case management services provided by Linkage to Care Specialists (LTCS). The project will target African-American men who have sex with men (AAMSM), since this population has seen a 144% increase in HIV diagnoses over the past decade. Five overarching goals have been established: 1) Increase engagement in and retention to medical care; 2) Improve health outcomes; 3) Improve linkage to care for newly infected individuals; 4) Increase identification of acute infection; and 5) Decrease percent of individuals who are unaware of their HIV status in the AAMSM target population.




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