Linkage, Integration, Navigation, and Comprehensive Services (LINCS)

This data-to-care (D2C) initiative, implemented by the San Francisco Department of Public Health (SFDPH) and its affiliated clinics from 2015–2017, used three sources of data to identify people not in care: HIV surveillance data, healthcare provider referrals, and electronic health record (EHR) data. LINCS navigators then used disease intervention searching tools and EHR data to locate clients and connect them to an HIV care provider. LINCS navigators followed up with clients for 90 days to support engagement in care. LINCS participants were more likely to be retained in care and virally suppressed after the intervention than before.

San Francisco, CA

Evidence-Based Intervention
Icon for Intervention Type
Outreach and reengagement activities
Icon for HIV Care Continuum
Linkage to HIV medical care; Viral suppression
Icon for Ending the HIV Epidemic in the U.S. Pillar
Treat
Icon for Focus Population
People with HIV
Icon for Priority Funding
RWHAP Part A; RWHAP Part B
Icon for Setting
City/county health department
Need Addressed

The number of people with a diagnosis of HIV in San Francisco has declined over the years, bringing the city closer to its goal of ending the HIV epidemic.1 In addition, virtually all people with newly diagnosed HIV are linked to a provider within 30 days of diagnosis.1 However, the percentage of people with HIV who are virally suppressed has remained steady with persistent disparities. Women, including transgender women, people who inject drugs, or are Black, Latina(o/x), or experiencing homelessness are less likely to be virally suppressed than the overall population.2 Given that viral suppression helps reduce transmission and improve quality of life, the SFDPH developed and launched the LINCS D2C initiative team to locate people with HIV who were not in care, identify barriers to care, and re-link them to care through short-term case management. D2C leverages HIV surveillance data as a tool to identify clients in need of outreach and linkage, through the absence of reportable lab values.3

Core Elements
Identifying clients in need of reengagement

SFDPH developed a list of clients in need of LINCS navigator support through HIV surveillance data, provider referrals, and EHR data. HIV surveillance data contain dates and values of viral load tests reported by labs to SFPHD for disease monitoring purposes. Clients without indication of a viral load test in 15 months or with a viral load value of >1,500 copies within the previous four months were included on the list. In addition, clinicians within the three participating health department clinics referred clients who had not been adherent to their medications, or had no indication of treatment after diagnosis or a medical appointment in many months. Finally, SFDPH matched a clinic EHR registry with surveillance data and added clients to the list if they met the inclusion criteria and had not moved out of San Francisco, died, or already been assigned to a LINCS navigator in the past year.

Client outreach

This list of clients was sent securely to the LINCS navigators, who were co-located within the clinics, for outreach. LINCS navigators leveraged surveillance data, EHR data, and existing disease investigation tools, such as LexisNexis, to find clients’ most recent contact information. Their goal was to contact clients within 30 days of the referral. LINCS navigators tracked client status (e.g., enrollment into LINCS, program refusal, incarceration) and communicated back to SFDPH epidemiologists if the client had moved or died to incorporate findings into HIV surveillance data.

Reengagement in care

LINCS navigators helped clients schedule an appointment with an HIV care provider, which triggered enrollment into the program. They then worked with clients for 90 days, helping them access benefits, reminding them of appointments, and accompanying them to appointments. They used motivational interviewing techniques and a modified Anti-Retroviral Treatment and Access to Services (ARTAS) approach to support engagement in care.

Outcomes

SFDPH enrolled 233 clients into LINCS from 2015–2017. Clients were eligible if they were not in care or had a high viral load (>1500 copies). Evaluators conducted a pre-post analysis, assessing outcomes during the 12 months before and 12 months after the intervention. Clients were significantly more likely to be retained in care and virally suppressed during the 12 months after the intervention than the 12 months before. Specifically viral suppression increased by 47% among Black people, 34% among Latina(o/x) people, 31% among people who use methamphetamine, and 27% among people experiencing homelessness.

Category Information
Evaluation data
Data collected by LINCS navigators from clients; EHR documentation; HIV surveillance data
Measures

The following measures were calculated for the 12 months prior to the intervention and 12 months after the intervention:

  • Percent retained in care, defined as having two tests (viral load, CD4, or genotype) at least 90 days apart  
  • Percent virally suppressed, defined as having least one viral load <200 copies/mL at any time 
  • Percent with durable viral suppression as defines as having all viral loads suppressed after the first suppressed viral load (clients without at least 12 months of follow up were excluded from this measure)
Results
  • The percent of participants retained in HIV care increased from 35% to 58%*
  • The percent of participants virally suppressed increased from 18% to 53%*
  • 70% of participants who were virally suppressed after LINCS enrollment and had enough follow-up time were durably virally suppressed

* statistically significant

Source: Sachdev DD, Mara E, Hughes AJ, et al. “Is a Bird in the Hand Worth 5 in the Bush?”: A comparison of 3 data-to-care referral strategies on HIV care continuum outcomes in San Francisco. Open Forum Infect Dis. 2020; 7(9):ofaa369

“These data reinforce that public health re-linkage efforts can address health disparities, as we found that Black and Latinx individuals, people who use methamphetamine, and people experiencing homelessness who were enrolled in LINCS experienced improvements in viral suppression.”

Planning & Implementation

Hiring of additional LINCS navigators. When the SFDPH received additional funding, the agency expanded the number of LINCS navigators and embedded them within three public health clinics, instead of just at the SFDPH’s sexual health clinic.    

Generation of client lists. Creating the list of clients for outreach and linkage required the integration of multiple data sources, including HIV surveillance data, EHR data, and a clinic registry. Lists had to be sent securely from SFPHD to LINCS navigators. 

Sustainability

The Centers for Disease Control and Prevention is the primary funding source for HIV surveillance activities, including outreach and linkage by disease intervention specialists. SFDPH funded the additional navigators through an increase in city funding. However, Health Resources & Services Administration HIV/AIDS Bureau Ending the HIV Epidemic funding is being used to support D2C efforts across many jurisdictions, and may be a potential source for providers and jurisdictions interested in implementing similar initiatives.

Lessons Learned
  • Multiple demographic groups experienced statistically significant improvements in health outcomes, indicating that this D2C approach with LINCS navigators can help reduce disparities. 
  • Public health statutes often places restrictions on sharing HIV surveillance data with providers for privacy reasons. SFPHD did not face this hurdle given the agency engaged its own public health clinics. Providers or jurisdictions that wish to implement D2C approaches with external agencies may need to develop data use agreements that meet legal requirements.
  • Over 70% of participants were identified through provider referrals. Providers were the strongest referral source compared to surveillance data or the EHR registry/surveillance match because clients identified by providers were more likely to be eligible for and enroll in the program. 
  • However, participants identified through surveillance data experienced greater gains in viral suppression primarily because they were less likely to be virally suppressed prior to the intervention. Coupling provider referrals with HIV surveillance data analysis can create a robust list for outreach and linkage. 
  • Disease intervention specialists who conduct outreach and linkage typically reside within health department settings. Placing LINCS navigators in clinics allowed them to build trust with clinic staff and strengthened the collaboration between the health department and clinics.
Contact
San Francisco Department of Public Health
Susan Scheer, PhD
Director, HIV Epidemiology and Surveillance

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