LA Links (Louisiana 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. Linkage-to-care coordinators (LCCs) help them to access care and support services. Originally implemented in 2013 as part of the Care and Prevention in the United States (CAPUS) Demonstration Project, this evidence-informed intervention improved linkage to care, reengagement in care, and viral suppression. Louisiana expanded the program statewide in 2016 using the U. S. Department of Health and Human Services Secretary’s Minority AIDS Initiative Fund (now referred to as the Minority HIV/AIDS Fund) and Ryan White HIV/AIDS Program (RWHAP) Part B funds to support regional LCCs.
Baton Rouge, New Orleans, and Shreveport, LA
At the time of the 2013 implementation, Louisiana ranked third highest in the United States for HIV estimated case rates, and approximately 79% of people with a new diagnosis of HIV were linked to care within 90 days.1 In addition, 30% of people with HIV in Louisiana were not in care and only 70% had reached viral suppression.1 Successful linkage to care for people with newly diagnosed HIV—or reengagement in care for people with HIV but not in care—is a key step in the HIV care continuum that leads to optimal HIV treatment and, ultimately, to viral suppression. The key goals of LA Links were to optimize linkage to and reengagement in care by leveraging HIV surveillance and other data, in conjunction with client navigation services.2 During statewide implementation, staff recognized that people who are engaged in care but have high viral loads would also benefit from working with LCCs to obtain additional support to address social barriers to engaging in care and reaching viral suppression.
HIV surveillance data are used weekly to identify and prioritize people for follow-up. Other secondary data sources, such as vital records and driver’s license information, are used to locate people who do not have current telephone numbers or addresses. The presence or absence of CD4 and/or viral load laboratory test data is used to determine not-in-care status. People with high viral loads (i.e., two recent viral load test results >1000 copies/ml) are also prioritized for follow-up. Health department staff generate these lists and share them with LCCs.
LCCs are nurses or social workers who have specific training in medical case management, treatment adherence counseling, and medication management. LCCs attempt contact with clients on their lists, explain the purpose of the program, and assess barriers to care and other challenges. Once enrolled in LA Links, LCCs provide client navigation services for an average of 90 days. LCCs make initial appointments and accompany clients to case management and/or laboratory appointments or social service appointments to help facilitate interactions between provider and client. Clients are provided with treatment adherence counseling and supportive services such as transportation. Clients also have access to the full range of services normally available, including case management, oral health care, housing assistance, and nutrition services. The LCCs stay in frequent contact and provide assistance to meet clients’ needs. The LCCs have flexibility to work outside of traditional work hours to support their clients and have smaller caseloads than traditional case managers.
The Louisiana Office of Public Health STD/HIV Program evaluated LA Links for the two-year implementation period. The intervention improved linkage to care for people with newly diagnosed HIV; reengagement in care for people with HIV but not in care; and improved viral suppression for people in care but with high viral loads.
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* statistically significant |
Sources: Anderson S, Henley C, Lass K, Burgess S, Jenner E. Improving Engagement in HIV Care Using a Data-to-Care and Patient Navigation System in Louisiana, United States. J Assoc Nurses AIDS Care. 2020;31(5):553-565. Sweeney P, Hoyte T, Mulatu MS, et al. Implementing a Data to Care Strategy to Improve Health Outcomes for People With HIV: A Report From the Care and Prevention in the United States Demonstration Project. Public Health Rep. 2018;133(2_suppl):60S–74S.
- Establish a not-in-care definition and generate list. In order to generate the lists of people who were not in care, the Louisiana Department of Health’s planning and implementation team had to define “not-in-care” and coordinate with multiple stakeholders to share data, integrate systems, and combine HIV surveillance data with other data sources.
- Prioritize and disseminate the not-in-care list for program follow-up. Louisiana prioritized people with HIV who had been out of care for an extended period of time or those who had a viral load that was detectable, later adding those with high viral loads.
- Distribute list for follow-up. The referral list was exported to a database, and notifications were generated to alert LCCs about individuals’ not in care status, or newly reported surveillance or viral load information.
- Train staff. LCCs were trained to provide navigation services, instructing clients on how to access HIV care, make appointments, and communicate with clinicians. Staff also received training on structural barriers such as institutional racism, homophobia, and transphobia.
- Track information. CAREWare was used to capture process and outcome data, including enrollment, intake, services, and discharges; a referral list program was used to track progress, such as contact attempts and outcomes data.
“Staff delivering the intervention were trained to provide information about accessing HIV care and guiding individuals through the process of identifying providers and making appointments.”
- LA Links made use of existing HIV surveillance infrastructure and added client navigation to create a targeted data-to-care model to facilitate connection to care. Data-sharing regulations vary from location to location, which may affect replicability and sustainability.
- Many of the client navigation and outreach and linkage activities that were part of this intervention are eligible for support with RWHAP funding.
- Surveillance supported data-to-care programs help to find people that the health care system has failed and link them to much needed, more appropriate medical care, services, and support. While the data-to-care program led to improvements in viral suppression and reengagement in care, there continue to be disparities in viral suppression outcomes, especially among Black men and women.
- Updating the data-to-care lists frequently, (daily/weekly) is essential for limiting the amount of clients misclassified as out of care. Louisiana found that the number of people on the data-to-care lists that are confirmed out of care or with high viral load decreased over time.
- Engagement in HIV care could be addressed only after other immediate challenges for clients were addressed; clients were offered referrals or navigation services to meet other needs, such as transportation and housing).
- Anderson S, Henley C, Lass K, Burgess S, Jenner E. Improving engagement in HIV care using a data-to-care and patient navigation system in Louisiana, United States. J Assoc Nurses AIDS Care. 2020;31(5):553-565. doi:10.1097/JNC.0000000000000150
- Sweeney P, Hoyte T, Mulatu MS, et al. Implementing a data to care strategy to improve health outcomes for people with HIV: A report From the Care and Prevention in the United States Demonstration Project. Public Health Rep. 2018;133(2_suppl):60S–74S. doi:10.1177/0033354918805987
