Participants signed a release before taking the 6-month survey to permit study staff to obtain copies of medical records from HIV medical care locations in the community. If copies of medical records were obtained, study staff then abstracted dates of HIV medical care visits, CD4 T-cell counts, and viral loads covering the entire period between the baseline and 6-month surveys. Case manager summary reports for each participant covered the first 90 days after the baseline survey and indicated whether or not the participant had attended at least 1 HIV medical care visit. The summary reports also documented the number of face-to-face case management sessions attended by the client, the duration and location of the sessions, and all referrals resulting from each contact.
After participants completed the baseline ACASI survey, they received the ARTAS Linkage Case Management (ALCM) intervention that provided intensive short-term assistance to facilitate the process of linking HIV-infected individuals to HIV medical care. The ALCM intervention draws on the strengths-based approach to case management (developed at the University of Kansas School of Social Welfare) that has been used successfully in linking and retaining substance users in drug treatment,16-19 reducing levels of drug use and criminal justice involvement,20,21 and providing psychosocial services to homeless and mentally ill populations.22,23 The strengths-based approach calls on clients to identify internal strengths and abilities and to develop a personal plan to acquire needed resources. Case management sessions focused on building a relationship with the client, identifying and addressing client strengths and needs, identifying and discussing ways to overcome personal or system barriers to health care, and encouraging contact with an HIV medical care provider. The intervention consisted of up to 5 sessions with the case manager over a 90-day period. The ALCM intervention was discontinued once the participant had completed 5 sessions with the case manager, 90 days had elapsed since being enrolled, or the participant had attended an HIV medical care visit. Once the ALCM intervention was completed, participants were offered ongoing case management services (eg, Ryan White or Medicaid case managers).
ARTAS-II case managers and study staff received training in strengths-based case management from the Center for Interventions, Treatment, and Addictions Research (CITAR) at Wright State University (Dayton, OH). Two days of didactic and experiential training were followed by a preceptorship period, during which ALCM case managers shadowed mentor case managers who were experienced in strengths-based care. CITAR trainers conducted 2 follow-up visits to each ARTAS-II site to assess the fidelity with which the intervention was being delivered.
The primary outcome was whether or not participants had attended at least 1 HIV medical care visit in the 6 months after enrollment. A hierarchic system drawing from multiple sources of data was used to determine whether or not each participant had received HIV medical care. The order of priority for determining whether care had been received was participant self-report on the 6-month survey, followed by information abstracted from the medical record, and, finally, case manager summary reports. In other words, if a participant did not complete a 6-month survey, medical record information was used, if available. If medical records were not available, case manager summary reports were used. Self-report was used as the primary indicator of HIV medical care, because the ACASI survey was obtained more uniformly across the 10 sites than were medical records; furthermore, there was 88% agreement between self-report of care received and information obtained directly from medical records among 408 participants with data available from both sources. Medical record abstractions were given priority over case manager summary reports, because the abstraction period covered at least 6 months after baseline (matching the survey recall period), whereas the case manager summary report covered only the first 90 days after baseline.
Descriptive statistics were generated for a variety of demographic, structural, behavioral, and psychologic measures collected at baseline. Bivariate χ2 tests were conducted to assess the relation between predictor variables and whether or not the participant received HIV medical care. All variables that reached P < 0.20 in the χ2 tests were eligible for inclusion in the multivariate logistic regression analysis. Logistic regression diagnostics were performed to assess model fit, collinearity, and outlying values. All analyses were conducted using SAS statistical software version 9.1 (SAS, Inc., Cary, NC).
Enrollment and Sample Characteristics
Of 778 candidates eligible to participate, 646 (83%) enrolled. Ten participants died before follow-up, and 10 were removed by local study staff because of invalid eligibility screening data. The remaining 626 participants comprised the analytic sample for the 6-month longitudinal assessment. Ninety-six percent were diagnosed as HIV-positive within the past 6 months, and 89% had no previous HIV medical care encounters. Baseline characteristics of these 626 participants are shown in Table 1. Most were male (73%) and black non-Hispanic (70%). Approximately 62% had a total annual household income of <$10,000, and 65% reported not having medical insurance. More than half of participants (59%) reported living in their own home or apartment during the past 3 months. Six percent reported injection drug use and 14% reported noninjection drug use (crack, cocaine, or methamphetamine/speed) in the past 3 months.
Percentage of Participants Who Received HIV Medical Care
Seventy-one percent (442 of 626) of participants completed the 6-month survey. Of these, 86% (382 of 442) self-reported having received medical care from an HIV care provider in the past 6 months (Fig. 1). Of the 184 participants who did not complete the 6-month survey, 65 had medical record data available; of these, 85% (55 of 65) had at least 1 HIV medical care visit in the past 6 months. For the remaining 119 participants without a 6-month survey or medical record data, the case manager summary reports confirmed that 60 (50%) of the 119 had seen an HIV medical care provider at least once during the 90-day intervention period. Combining all 3 data sources, 79% (497 of 626) of participants received HIV medical care within 6 months of enrollment. On excluding from analysis the 66 participants (11%) who had reported 1 prior HIV medical care visit at enrollment, the overall linkage rate remained stable at 79% (440 of 560) of participants.
Baseline Predictors of Receiving HIV Medical Care
Table 1 displays the bivariate associations between baseline variables and HIV medical care at 6 months. The following variables qualified for inclusion in the multivariate model (P < 0.20 in bivariate χ2 tests): age, race/ethnicity, gender, study site, whether or not HIV medical care was colocated at the same agency where participants received the intervention, medical insurance, number of case management sessions, housing/living arrangements, jailed/incarcerated, traded sex for money/drugs/food/shelter, injection drug use, noninjection drug use (crack, cocaine, or methamphetamine/speed), alcohol use, and unprotected vaginal or anal intercourse. A median split was used to create a dichotomous variable for the number of case management sessions (0 to 1 vs. 2+), because the percentage receiving care within 6 months was similar for individuals with 2, 3, 4, or 5 sessions and the major discontinuity in the outcome variable occurred between 1 and 2 sessions.
There was a strong association (χ2 = 545.4; P < 0.0001) between study site and colocated HIV medical care. In other words, most of the sites that had HIV care providers located in the same building or complex where the case management intervention was being delivered had the highest percentage of participants entering into care within 6 months. This association precluded entering both of these variables in the regression model. We included the colocated HIV medical care variable in the model rather than the study site because it was more conceptually informative. No collinearity issues were detected among the remaining variables; thus, all were included in the multivariate logistic regression model.
The findings from the multivariate analysis are shown in Table 2. Participants who were 40 years of age or older were twice as likely to have received HIV medical care compared with the youngest group, aged 18 to 25 years (adjusted odds ratio [ORadj] = 2.0, 95% confidence interval [CI]: 1.1 to 3.5). Similarly, participants who were 26 to 39 years old were nearly twice as likely to have received care compared with those 18 to 25 years old (ORadj = 1.8, 95% CI: 1.1 to 3.1). Hispanic participants were approximately twice as likely as black non-Hispanic participants to have received HIV medical care (ORadj = 2.1, 95% CI: 1.03 to 4.4). Participants who were stably housed (ie, lived in their own home or apartment) were more than 2 times as likely to have received HIV medical care as those who were unstably housed (ORadj = 2.4, 95% CI: 1.2 to 4.7). Persons classified as unstably housed included those who reported that during the past 3 months they had mostly lived on the street, in temporary housing (eg, motel/hotel, boarding house, shelter, multiple people's homes), or in an institution (eg, jail/prison, hospital, nursing home, drug treatment center). Only 1 of 3 substance use variables was significant in the multivariate model. Participants who had not used noninjection drugs (crack, cocaine, or methamphetamine/speed) in the past 3 months were nearly twice as likely to have received HIV medical care compared with those who had used noninjection drugs (ORadj = 1.9, 95% CI: 1.04 to 3.6). The number of case management sessions was also a significant correlate. Participants who had 2 or more face-to-face sessions with the case manager were almost 3 times as likely to have received HIV medical care compared with participants who had fewer than 2 sessions (ORadj = 2.9, 95% CI: 1.9 to 4.6). Finally, participants who received the case management intervention at study sites where HIV medical care was colocated were approximately 3 times as likely to have received care compared with participants who received the intervention at study sites where care was not colocated (ORadj = 3.0, 95% CI: 1.9 to 4.9).
Level of Effort Required in Delivering the Case Management Intervention
The median number of face-to-face sessions clients spent with ARTAS case managers was 2, and the mean was 2.3 (range: 0 to 5 sessions). Data were also collected to calculate the amount of time spent per client on all case management activities (face-to-face sessions, telephone calls with client, referrals on behalf of client, transporting client, and efforts to locate client). The median time spent per client on all case management activities was 5.8 hours, and the mean time spent was 7.2 hours (range: 0 to 36.7 hours).
Self-Reported Barriers to Receiving HIV Medical Care
Table 3 displays responses to 19 items assessing barriers to HIV medical care reported by 177 participants on the 6-month survey. These items were asked only of participants who self-reported not receiving any HIV medical care in the past 6 months (n = 60, 34%) or who had received care but missed 1 or more scheduled HIV medical care appointments in the past 6 months (n = 117, 66%). “I felt well or had no symptoms” was the most common barrier; this was reported by 70% of those who had not received any HIV medical care and by 58% of those who entered into care but had missed 1 or more scheduled appointments. Other frequently cited barriers among those who had not entered into HIV medical care were lack of transportation to get to the clinic, not ready to start taking HIV medications, and not having insurance or a way to pay for the cost of care. The median number of self-reported barriers per client was 3, and the mean was 4.5 (range: 0 to 15 self-reported barriers).
The ARTAS strengths-based case management intervention delivered at CBOs and health departments in 10 sites across the United States resulted in 79% of recently diagnosed HIV-infected persons receiving HIV medical care within 6 months of enrolling in the study. Our findings demonstrate that this intervention can be implemented effectively in real-world settings by service-oriented organizations in collaboration with community partners. The 79% linkage rate replicates the 78% finding from the intervention arm of the ARTAS-I trial. Furthermore, the ARTAS-II linkage rate exceeds a recent US surveillance estimate from 33 states indicating that 56% of HIV-infected persons were in care within 12 months of their diagnosis.24
One structural factor that facilitated entry into care was having HIV medical care providers colocated at the agency providing the case management intervention. This finding suggests that the accessibility of medical services during initial case management or referral activities is an important structural factor that promotes entry into care. In those instances in which colocated services are not available, case managers should consider arranging transportation or accompanying clients to their first medical appointment to facilitate the linkage process. Accompanying clients to their first HIV medical care encounter might be an effective technique to help clients learn how to navigate the health care system.
Stable housing was another structural factor independently associated with receiving HIV medical care. Participants who reported stable housing were more likely to have received HIV medical care than those in unstable living situations. Existing studies of unstable housing and HIV medical care utilization are limited and have revealed mixed results.25-27 Those with data comparing stably and unstably housed persons have indicated no difference or slightly more outpatient visits among the unstably housed,25,26 although, at the same time, showing fewer regular medical care visits and lack of HIV medical care provider continuity among the unstably housed.25 Once unstably housed persons are affiliated with an HIV care provider, concerns other than housing are likely determining the frequency of HIV care utilization. Because unstably housed persons may be less likely to focus on health care when other concerns are more pressing, linkage case managers need to acknowledge and address the client's housing situation while continuing to motivate the client to enter into care.
Another factor that was associated with receiving HIV medical care was the number of case management sessions that participants attended. Participants were significantly more likely to have received HIV medical care when they had 2 or more sessions with the case manager as opposed to fewer than 2. This result is consistent with findings from the ARTAS-I study indicating that clients not linked to care spent significantly less time and had fewer face-to-face visits with case managers.28 Most clients probably require multiple sessions to initiate care, because it takes time to help clients cope with their HIV diagnosis, discuss the importance of receiving regular HIV medical care, and address specific barriers to entering care.
Use of noninjection drugs (crack, cocaine, or methamphetamine) in the past 3 months was associated with a decreased likelihood of initiating HIV medical care. This finding confirms similar results from the ARTAS-I study14,29 and suggests that there may be some aspect of the case management intervention or the HIV medical care system that has not been responsive to the specific needs of persons with substance use problems. Noninjection and injection drug users often face many challenging life issues or have conflicting priorities that interfere with seeking HIV medical care. Nevertheless, studies of substance users have demonstrated that case management can be effective in facilitating entry into care, albeit with concurrent substance abuse treatment.30-32 Efforts to identify and treat substance abuse should begin during the first encounter with the client.
Additionally, our results confirm earlier findings14,33 indicating that younger age is associated with a decreased likelihood of initiating HIV medical care. The lower linkage rate among younger ARTAS-II participants cannot be attributed to drug use, housing, insurance, or other covariates that were controlled for in the multivariate model. Neither can it be explained by age differences in self-reported barriers to care (data not shown). It is possible that there are other barriers faced by young persons (eg, denial about HIV-positive diagnosis, sense of invulnerability, lack of knowledge about HIV, lack of family support, inexperience navigating the health care system) that our study did not capture, however, which may account for them being less likely to enter into care. Because new infections are more likely to occur among the young,34 it is important for future studies to identify the factors contributing to their lower linkage rate.
Finally, Hispanic participants were approximately twice as likely to have received care as black participants. This result was statistically significant despite controlling for 12 other potentially confounding variables. Our finding may be the result of clinic-based variables we did not measure, such as having Spanish-speaking providers or clinic staff, which was true at some of the care facilities. Attitudinal and behavioral barrier measures were not collected at baseline, and race or ethnic differences in these factors are possible. Because this is the second ARTAS linkage study to report a relative advantage for Hispanic compared with black participants,14 better measures of clinic features and attitudinal or behavioral variables should be collected in future studies.
Several of the barriers to receiving HIV medical care can be addressed directly by participants and their case managers. For example, many participants reported “I felt well or I had no symptoms” as a reason for never receiving care or missing some of their medical care appointments. Increased emphasis on educating clients about HIV disease and the importance of having their disease status regularly monitored is needed to reinforce the importance of routine medical care, even when feeling well. The ARTAS case management intervention is also designed to address several of the structural/system barriers encountered by clients, such as insurance/cost of HIV medical care and transportation to medical appointments. Linkage case managers can help clients to complete applications for entitlement programs (eg, Medicare, Medicaid) or Ryan White intake and eligibility paperwork and can assist those who already have health insurance coverage to navigate the care system. Case managers can also assist in arranging transportation to case management sessions and the first clinic visit.
The study was not without limitations. The primary outcome measure is based, in part, on participant self-report of HIV medical care received. Although a previous study found poor agreement between self-report and medical records,35 our study had a high rate of agreement (88%) between self-reported care received and medical records among those with both types of data. Also, the privacy and confidentiality afforded by the ACASI survey have been shown to promote more accurate reporting of behavior.36,37 A second limitation is that little is known about those persons who were eligible but declined to participate. Even though only 17% of those eligible to participate declined, those who participated may have done so because they were already interested in receiving assistance, and thus were more likely to enter into care. Another limitation was the lack of a randomized control arm or comparable group with which to evaluate differences in linkage rates between those receiving the case management intervention versus standard-of-care referral at each site. The primary goal of the ARTAS-II study was to demonstrate replicability of the case management intervention in community-based settings, however, outside of a controlled trial. Nonetheless, any comparison of findings between the ARTAS-I and ARTAS-II studies is limited by the lack of control data in the ARTAS-II study and differences in the characteristics of each study population. Finally, although no definitive conclusions can be drawn about generalizability from this nonprobability sample, it is encouraging that a high percentage of clients were linked to care at sites representing racially and ethnically diverse populations from rural and urban areas in several regions of the United States.
With increasing efforts to make individuals aware of their HIV serostatus38 through rapid testing, health departments and CBOs should evaluate how they plan to link newly diagnosed persons to HIV medical care providers effectively. The new CDC recommendations for routine HIV testing in health care settings39 may present opportunities for collaboration between agencies offering linkage-assistance case management services and medical settings that have recently implemented routine HIV testing. Health departments and CBOs may be able to bridge the gap and coordinate linkage services to ensure that there are reliable methods in place to connect persons with HIV medical care. The ARTAS strengths-based case management intervention provides a model that can be used to ensure that HIV-infected persons attend an initial HIV medical care encounter soon after diagnosis.
The authors thank the many people involved in this study for their dedicated work and valuable contributions to make this study a success.
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ARTAS-II study members included the following individuals (grouped by agency and site): Christine O'Daniels and Sanjyot Shinde (CDC, Atlanta, GA), and Tim Lane and Carey Carr (CITAR, Wright State University, Dayton, OH). ARTAS-II study members also included the following individuals (grouped by implementation site): (1) Pamela Morse Garland, Greg Smith, Melanie Sovine, and Tracy Bruce (AIDS Survival Project, Atlanta, GA); and Terry Barlow and John Williams (Our Common Welfare, Atlanta, GA); (2) Barbara J. Hanna, Karen Phillips, Chris Phillips, Tawanah Fagan, and Bryan Hobson (Health Services Center, Inc., Anniston, AL); (3) John I. McNeil, Jennifer L. Kunkel, Shalyta Campbell, Taishawan Joyner, and Nathaniel Scruggs (Total Health Care, Inc., Baltimore, MD); (4) Yolanda Smith and Beth Clemitus (Family Service of Greater Baton Rouge, Baton Rouge, LA); Candace Walters and Angie Pitre (Volunteers of America of Greater Baton Rouge, Baton Rouge, LA); and Shawn Johnson (Louisiana Office of Public Health, HIV/AIDS Program, New Orleans, LA); (5) Rhonda Collins, John Davis, and Kim Smith (Alliance for Community Empowerment, Chicago, IL); (6) Kathy Castro, Miguel Lopez, Regina Gee, LaKeshia Clark, and Chrissy Edmonds (Duval County Health Department, Jacksonville, FL); (7) Holly Buckendahl, Marcia Dutcher, Sarah Goodwin, and the Data Management Specialists (Kansas City Free Health Clinic, Kansas City, MO); (8) Migling Cuervo and Kisha Gaines (Florida Department of Health, Tallahassee, FL); Joe Pietrangelo, Julia Rivers, and Jose Castro (Miami-Dade County Health Department, Miami, FL); Richard Kemp, Edgar Rodriguez, Laura Van Sant, and Katrina Young (South Florida AIDS Network, Miami, FL); and Lisa Metsch and Marvin Shika (University of Miami School of Medicine, Miami, FL); (9) Noreen O'Donnell (South Carolina Department of Health and Environmental Control, Columbia, SC); Crystal Lloyd (Palmetto AIDS Life Support Services, Columbia, SC); Mark Sellers (University of South Carolina School of Medicine, Columbia, SC); and Kevin Lancaster (AID Upstate, Greenville, SC); and (10) Diana Jordan and Safere Diawara (Virginia Department of Health, Richmond, VA); and Angela Revercomb, Deborah Williams, and Kim Hunter (Community Health Research Initiative, Virginia Commonwealth University, Richmond, VA).
Keywords:© 2008 Lippincott Williams & Wilkins, Inc.
case management; community-based organizations; entry into care; health departments; HIV medical care; linkage