Linkage to Care

Linkage services are critical to helping people living with HIV find and stay in care. For newly diagnosed people, rapid (same day) linkage is becoming a standard. Patients undergoing life transitions (moving, loss of insurance, release from jail or prison) need linkage services that are sensitive to their situations.

Resources 45

Best Practices

  • Dissemination of Evidence Informed-Interventions Project (DEII)

    Evidence-informed HIV care interventions (jail transitional care, buprenorphine, patient navigation, peer support for women of color).

  • IHIP
    Intervention featuring time-limited services and outreach to help identify, treat, and prevent HIV and STIs.
  • Best Practices Compilation
    Buprenorphine Treatment for Opioid Use Disorder in HIV Primary Care is an integrated care approach designed to reduce opioid use and overdose while improving client engagement in HIV care. Greater Lawrence Family Health Center and Med Centro, Inc. implemented this integrated care approach as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. Clients who participated in this intervention received integrated care—treatment for opioid use disorder (OUD) and HIV in a single setting—to improve retention in care, viral suppression, and engagement in OUD treatment.
  • Center for Innovation and Engagement
    The Clinic-Based Surveillance-Informed (CBSI) intervention combines clinic and health department surveillance data to identify people with HIV who are out of care and re-engage and retain them in HIV care.
  • Best Practices Compilation
    This medical-community partnership worked to link clients to care and decrease missed appointments and used peer navigators to successfully re-engage clients in care.
  • Best Practices Compilation
    CoRECT was a data to care project to identify and re-engage people with HIV who were newly out of care. It included a clinic and health department data reconciliation process to identify missed laboratory results or appointments and create the out-of-care list, case discussions via telephone to review the combined list, and field epidemiologist outreach to assist clients with making appointments, securing transportation, and arranging referrals. The intervention employed strengths-based case management techniques and motivational interviewing to contact identified people within 30 days, reengage them in care, and reduce time to viral suppression.
  • Best Practices Compilation
    The CrescentCare Start Initiative is a program of CrescentCare, a Federally Qualified Health Center, and the New Orleans Office of Health Policy. The initiative connects people with newly diagnosed HIV to antiretroviral therapy (ART) through intensive patient navigation and a streamlined intake process. Time between HIV diagnosis and linkage to HIV medical care has decreased from 30 days to only 1.3 days.   
  • Best Practices Compilation
    The Oregon Health Authority awarded contracts to local public health authorities across the state to work with community partners to integrate early intervention services and outreach services, link people to HIV care, and provide support to help clients reach viral suppression. Quick linkage to care resulted in a median of 57 days to viral suppression for Early Intervention Services and Outreach clients in 2019.
  • Best Practices Compilation
    The goals of the Emergency Department and Hospital-Based Data Exchange for Real-Time Data to Care (ED Alert) intervention are to reengage people with HIV in care and to improve viral suppression rates. This is achieved using a real-time data exchange system that connects clients presenting to the emergency department with health department linkage specialists. ED Alert increased viral load testing and viral suppression over six months following a provider visit in the post-intervention period.
  • Center for Innovation and Engagement
    Intervention to re-engage people with HIV to care by utilizing a real-time data exchange system that connects clients with health department linkage specialists when presenting to the emergency department.
  • Best Practices Compilation
    The Enhanced Patient Navigation for Women of Color with HIV intervention uses patient navigators, who are non-medical staff in clinical settings, to reduce barriers to health care and optimize care. The intervention was effective in improving linkage to and retention in care, as well as viral suppression.
  • Best Practices Compilation
    Healthy Divas focuses on empowering transgender women with HIV to achieve their personal health goals. Three sites implemented the intervention as part of the E2i initiative funded through the RWHAP Part F SPNS program from 2017 through 2021. Both engagement in HIV care and having an antiretroviral therapy prescription improved significantly for clients 12 months after enrollment in Healthy Divas.
  • Best Practices Compilation
    The HIV Clinical Pharmacist Services intervention shortens the time between referral to and engagement in care by allowing newly referred clients to see pharmacists in addition to other clinical providers for their initial appointment. This intervention is supported by findings from a retrospective cohort study that took place from 2013 to 2017 at a RWHAP-funded clinic. In addition to significantly decreasing the time between referral and initial visit, clients who saw a pharmacist also experienced shortened time to antiretroviral therapy initiation and viral suppression compared to those who only saw non-pharmacist providers.
  • Best Practices Compilation
    The Huntridge Family Clinic launched the Rapid Start Initiative to provide same-day ART treatment and comprehensive case management to clients with a new diagnosis of HIV. Over 90% of clients received ART on the same day as diagnosis, and 78% of clients were retained in care within the first year of starting treatment.
  • Best Practices Compilation
    Three participating clinics—MetroHealth, the University of Kentucky Bluegrass Care Clinic, and Centro Ararat—participated in a RWHAP Part F SPNS initiative from 2016 through 2019 to implement integrated buprenorphine treatment and HIV care. Research has shown that care integration improves HIV outcomes, engagement in substance use disorder treatment, and quality of life for people with HIV. Clients participating in this intervention received integrated opioid use disorder (OUD) and HIV care to improve retention in care, viral suppression, and engagement in OUD treatment.
  • Best Practices Compilation
    JumpstART launched in 2016 as part of New York State’s Ending the Epidemic initiative, changing the service delivery model of eight sexual health clinics to include an initial prescription of ART after an HIV diagnosis and prior to linkage to the community provider. Between November 2016 and September 2018, 60% of JumpstART clients received ART on the same day as diagnosis. JumpstART clients were also more likely to reach viral suppression within three months compared to non-JumpstART clients.
  • Best Practices Compilation
    Kern County Rapid ART links people with a new diagnosis of HIV to ART. The Kern County Health Officer’s Clinic identifies people with a new diagnosis of HIV through onsite testing, surveillance data, and referrals from local hospital emergency departments. Kern County Rapid ART provides support services and refers clients to other community clinics for ongoing care. A study of clients with a new diagnosis of HIV in 2021 found that on average, Kern County Rapid ART clients were linked to care and provided ART within two days of diagnosis.
  • Best Practices Compilation
    LA Links is a combined data-to-care and client navigation approach that cross-references routinely collected HIV surveillance data with other secondary data sources to identify and locate people with HIV who are not in care, as well as those who are in care, but with high viral loads. Originally implemented in 2013 as part of the Care and Prevention in the United States Demonstration Project, LA Links improved linkage to care, reengagement in care, and viral suppression. Louisiana expanded the program statewide in 2016.
  • Best Practices Compilation
    LINK LA is a 12-session, 24-week peer navigation intervention for people with HIV who are scheduled to be released from incarceration. LINK LA peer navigators focus on behavioral changes that promote medication adherence and retention in care, while providing social support and facilitating communication with medical providers. LINK LA showed improvements in linkage to and retention in HIV care and viral suppression among people with HIV re-entering the community after incarceration.
  • Center for Innovation and Engagement
  • Best Practices Compilation
    The Louisiana Public Health Information Exchange is a bidirectional exchange that connects hospital system electronic health records with state surveillance data. Providers use the exchange to identify and relink people with HIV who are out of care to clinical and supportive services. Since LaPHIE was implemented in 2009, thousands of people with HIV who were out of care have been identified, with a significant number being successfully linked to care.
  • Best Practices Compilation
    The Navigator Case Management intervention helps people with HIV who are incarcerated and are leaving to return to the community. The intervention uses harm reduction, case management, and motivational interviewing techniques to promote healthy behaviors. Enhanced case management including peer support and connection to other needed services both immediately before and after release supports increased linkage to and retention in HIV care for people transitioning to the community from jail.
  • Best Practices Compilation
    One Stop Career Center of Puerto Rico (OSCC-PR) implemented Pay it Forward to increase workforce capacity to connect Puerto Ricans with HIV to community-based HIV care and social supports following release from jail. Pay it Forward included training of OSCC-PR staff in the Transitional Care Coordination model. Eighty percent of clients who were supported by Pay it Forward in Puerto Rico were still in HIV care 12 months after release.
  • Best Practices Compilation
    University Health uses peers and patient navigators to provide support, reduce barriers, and improve linkage and retention to care for women and youth with HIV. Two peers with lived experience were hired as Outreach Specialists to spearhead the program, encourage medication adherence and use of services, and provide mentoring. The intervention was successful in moderately improving the numbers of clients linked to care, retained in care, and virally suppressed.
  • Best Practices Compilation
    From 2016 through 2019, three clinics—AIDS Care Group, Howard Brown Health, and Meharry Medical College—participated in a RWHAP Part F SPNS DEII initiative to implement peer linkage and re-engagement interventions for women of color with HIV. Integrating peers into HIV primary care teams has been effective in better engaging women of color in care.
  • Best Practices Compilation
    Positive Care Center implemented the Rapid Access program in 2018, providing clients with ART on the same day as HIV diagnosis. Pharmacists, embedded within Positive Care Center’s care team, help clients with their treatment plans and adherence strategies. Over 90% of clients served through Rapid Access in 2021 received ART on the same day as diagnosis, and 82% of clients were retained in care at six months.
  • Center for Innovation and Engagement
    Clinic-based mobile health intervention that promotes linkage to and engagement in HIV care in rural areas for people with HIV who are new to care or at risk of falling out of care.
  • Best Practices Compilation
    Avenue 360 Health and Wellness, a Federally Qualified Health Center, and AIDS Foundation Houston, a community-based AIDS Service Organization, implemented Project CORE. This intervention aimed to improve health outcomes for people with HIV through the coordination of supportive employment and housing services. Through Project CORE, 39% of participants were placed in housing and 39% gained employment.
  • Center for Innovation and Engagement
    Using a client-focused, personalized, Incremental Risk Reduction approach, the Project START intervention improves linkage and retention in care among people with HIV who are leaving correctional facilities to return to the community.
  • Best Practices Compilation
    The Ruth M. Rothstein CORE Center launched Proyecto Promover to decrease HIV testing-related stigma, increase awareness of HIV status, and increase early linkage to and retention in care among Mexicanos with HIV. The program operates at the community level through social marketing, educational talks, networking, and testing. On the individual level, Proyecto Promover uses one-on-one conversations to identify and overcome barriers related to care engagement and retention. Evaluation showed promising rates of HIV testing, retention in care, and viral suppression.
  • Best Practices Compilation
    The Virginia Commonwealth University implemented a clinical quality improvement project to increase linkage to HIV medical care within 30 days and initiation of antiretroviral therapy (ART) at the first visit by making “Rapid Access” appointments available each week for people with newly diagnosed HIV.
  • Best Practices Compilation
    Rapid ART Program Initiative for New Diagnoses (RAPID) was designed to connect people with a new HIV diagnosis to ART within five days of diagnosis and within one day of their initial care visit. Linkage navigators counseled people on HIV care, identified an available clinician capable of immediately prescribing ART, scheduled the clinical appointment, and connected people to additional support services. RAPID led to a reduction in median time between initial diagnosis and both ART initiation and viral suppression.
  • Best Practices Compilation
    Routine Universal Screening for HIV (RUSH) provides non-medical case management services, opt-out HIV testing, and linkage to care for emergency department patients. The intervention automatically screens patients for HIV if they are aged 16 years or older, are having an IV inserted, or are having blood drawn for other reasons, unless the patient opts out. RUSH provides access to testing earlier in disease progression, bridging disparities that primarily impact people of color. It also promotes linkage to and retention in care for those with a positive HIV test result. Clients with a positive HIV test in the emergency department who had a prior diagnosis of HIV were more likely to be retained in care and to reach viral suppression.
  • Best Practices Compilation
    Tailored Motivational Interviewing (TMI) delivers brief motivational interviewing counseling sessions customized to encourage people with HIV to engage in HIV care, take HIV medications as prescribed, and improve other health-related behaviors. Three sites implemented TMI as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017 to 2021. Clients who participated in TMI had significant improvement in engagement in care, prescription of antiretroviral therapy, retention in care, and viral suppression.
  • Best Practices Compilation
    The Test and Treat initiative, implemented by Oklahoma State University, connects people to antiretroviral therapy (ART) within 14 days of HIV diagnosis through streamlined intake and initial clinic visit protocols and 30-day medication starter packs. Participants in Test and Treat are linked to care and reach viral suppression sooner, and are more likely to be retained in care, as compared with people in standard care.
  • Best Practices Compilation
    The Alexis Project used social network recruiting and engagement, peer navigation, and contingency management to reach and engage transgender women of color with HIV who were not engaged in HIV care. Participation in the 18-month intervention improved linkage to care and viral suppression.
  • Best Practices Compilation
    Bienestar developed TransActivate to improve timely engagement and retention in HIV care among Latina transgender women. Linkage coordinators/peer navigators use a strengths-based approach to help clients reach their goals of entering and staying in medical care to ultimately reach viral suppression.
  • Best Practices Compilation
    T.W.E.E.T. aims to engage transgender women in HIV care by combining weekly peer-based education and discussion groups, leadership training, community building, and the provision of supportive services. Three sites implemented T.W.E.E.T. as part of E2i, an initiative funded by the RWHAP Part F SPNS program from 2017–2021. Clients had improved outcomes across the HIV care continuum 12 months after enrollment in T.W.E.E.T.
  • Best Practices Compilation
    Transitional Care Coordination (TCC) connects people with HIV who are incarcerated with a transitional care coordinator to facilitate access to HIV primary care and other community-based services and supports, following their transition from jail back to the community. TCC aims to establish vital linkages between jail-based and community-based HIV care, and may be implemented by community-based organizations, clinics, health departments, or jails.
  • Best Practices Compilation
    Virginia Rapid Start launched with HIV care providers across the state with goals to initiate ART for clients within 14 days of HIV diagnosis and to improve access to, and retention in, high-quality HIV care and support services. Through Virginia Rapid Start, providers initiated ART medications within an average of four days of HIV diagnosis, as compared with the statewide average of 28 days. Virginia Rapid Start clients had higher rates of viral suppression compared to both the RWHAP Part B overall and Virginia overall. The success of Virginia Rapid Start led VDH to expand the program to the entire Virginia RWHAP Part B.
  • Best Practices Compilation
    Wellness Web 2.0 is a text message-based intervention that offers health education tools, appointment reminders, and navigation services to increase linkage to and retention in care for youth and young adults with HIV. Clients across 27 counties in South Texas enrolled in the Wellness Web 2.0 program had improvements in linkage to HIV medical care and viral suppression.

Resources

  • University of Washington

    Online clinician training platform with evidence-based core competency training on HIV prevention, screening, diagnosis, care, and key populations.

  • IHIP
    Use of a transnational framework to provide intensive services, including one-on-one educational sessions, to help Latino men and Latina transgender women link to and stay engaged in care and treatment.

Training Modules

Webinars

Conference Presentations

Yale School of Medicine, AIDS Program
Presenters:
Katarzyna Sims, Ditas Villanueva
2022 National Ryan White Conference on HIV Care & Treatment
University of Massachusetts, Lowell
Presenters:
Serena Rajabiun, Brandon Williams
2020 National Ryan White Conference on HIV Care & Treatment
Virginia Commonwealth University
Presenters:
2020 National Ryan White Conference on HIV Care & Treatment
University of Utah Clinic 1A Division of Infectious Disease
Presenters:
2020 National Ryan White Conference on HIV Care & Treatment
Fulton County Government
Presenters:
2020 National Ryan White Conference on HIV Care & Treatment

Technical Assistance

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