CE / CME
Nurses: 0.75 Nursing contact hour
Pharmacists: 0.75 contact hour (0.075 CEUs)
Physicians: maximum of 0.75 AMA PRA Category 1 Credit™
Released: July 24, 2024
Expiration: July 23, 2025
Creating a Welcoming HIV Care Environment for Reengagement
What are the best practices for creating that welcoming environment? For me, it’s really changing how we consider those who have fallen out of care.
If they are out of care, I really am committed to welcoming them back warmly, like a red carpet. It is about showing that we have missed them, we want to see them, and we are their partners. We need to convey that we’ve got their back and that we are a team.
To achieve this, you really start to ask your patients what some of their struggles are with adherence to medication or appointments.
I have always used a model of asking my patients what brings them joy. Through this, I learn about their lives, their pets, or what they do for fun. This helps keep the conversation going and builds a stronger relationship.
This should not just be a relationship that is built on prescribing a medication, but on a partnership. We know people living with HIV feel so unwelcomed, unfortunately, because of the stigma that continues to exist in our country. We need to go further than just destigmatizing; we need to make our patients feel genuinely welcomed.
I think a lot about this in how I educate my staff. I have taken them to fine dining restaurants to experience and understand how to build a welcoming structure into our clinic operations. It is essential.
Another important aspect is having staff that look and sound like the people we serve. I strongly support peer support workers who are paid living wage. They can work with patients to say, “I’ve been in your shoes before, let me show you what success looks like.”
Click here and here to listen to Marc Thompson, a person living with HIV in London, England, as he describes his perspectives on best practices.
Max Clinic: Key Structural Elements to Low-Barrier HIV Care
The University of Washington has developed a framework called the Max Clinic. Located in Seattle, the clinic aims to implement a referral-based, low-barrier care model.
This approach is distinct because it doesn't seek change from the individual patient but asks how to change the infrastructure to be more welcoming.
They allow for walk-in care, which says to patients, “We are here for you. We understand that there are many competing priorities in life, and when you come see us, we are here with a red carpet welcome.”
For this approach to work, you need high intensity case management, and you need to make sure that case managers have a lower caseload so that they can provide that level of care.
In the Max Clinic, they use incentives including cash, gift cards, and necessities like food, clothing, and hygiene items.
The idea is that these are patients who have struggled with being virally suppressed within the existing health infrastructure. If they are struggling, we have to ask ourselves, what can we change to be of most assistance?
We can't just keep doing the same thing and expect a different result, and we certainly cannot place this burden on our patients. It is our responsibility to think through how we can reach those 10-10-10 goals.9
Click here to listen to audio from Toni Newman, Director of the Coalition for Justice and Equality Across Movements and Director for the Center to End the Epidemic at NMAC.
Max Clinic: Key Process-of-Care Elements to Low-Barrier HIV Care
Having a low barrier to care philosophy in everything that you do is crucial. I commend our harm-reduction colleagues who developed this approach decades ago.
It is about meeting your patients where they are, working with them to encourage behavior change, and standing with them in solidarity, providing the best information and support to minimize harm. This is the essence of harm reduction, which is well incorporated in the low-barrier to care model.
You also need multisector coordination. For example, in New Orleans, partnering with the jail system was very beneficial. We had a case manager who was informed whenever someone living with HIV was released from jail, allowing us to schedule an appointment the next day to welcome them back into our clinic.
Before we established that relationship, many people released from jail felt a lot of embarrassment and shame, which often delayed their reengagement in care by weeks, months, or even indefinitely.
By saying, “We stand with you”, we created a moment of solidarity, similar to how you would welcome home a family member after incarceration.
This same approach applies to understanding and integrating substance use treatment programs and behavioral health programs in the community.
There also needs to be a commitment to modification; when things don't work, we should be willing to change our approach. We need to hear from our patients and staff and be willing to make changes when possible.
For example, we were initially open until 8 pm on weekdays, and all day on Saturday. However, we found that our Saturday clinics had a very high no-show rate. Staff felt that their time at the clinic was less purposeful because of this.
We looked at the data and talked to our patients, and discovered that having the clinic open on Saturday morning was not effective. No patient wanted to come in during the morning hours of a weekend. So, we closed that morning clinic and only opened in the afternoon.
This significantly reduced the no-show rate, and many of my staff were thankful they didn't have to work Saturday mornings. This example shows the importance of getting input from both patients and staff.9
Click here to listen to audio from Toni Newman as she describes her approach to being open to change at the St James Infirmary in San Francisco.
Clinic at DAP Health in California
How can we implement a low barrier to care? Let's go through some best practices.
I now work at DAP Health in California, serving the Coachella Valley and San Diego County. We have considered what we can do for our patients who have consistent viremia.
Following the Max Clinic model, we are giving patients a “golden ticket”, which allows them to walk in any time to one of our sexual wellness clinics. We rapidly restart ART for patients when they return to care and we have dedicated high-intensity case managers.
In addition, we conduct a weekly interdisciplinary review of all cases. This includes our front desk staff, case management, phlebotomists, and, if possible, one of the pharmacy techs. The idea is to work as a holistic team providing comprehensive care to our patients.
It's a reframing process. Often, I would hear that these are the most difficult patients. I think “difficult” is used because, as HIV treatment providers, our goal is to achieve viral suppression. When patients don't achieve this, we may feel like we are failing and project some of that failure onto our patients.
We need to reframe this for both them and ourselves. The golden ticket is a way to signal that this relationship is different. We need to change the structure so that we can both achieve the desired outcome. Both my patient and I want a healthy life. We need to approach this as a team.10
DAP Health: Return to Care With Rapid StART
In terms of our key interventions, you can see that ART should start as soon as possible. We aimed for within 72 hours, but the goal is same-day initiation. By doing this, we saw a 23% higher retention in care at Year 2, demonstrating that rapid start, the idea of starting patients immediately after diagnosis, significantly helps maintain engagement.
However, the rapid start model needs to also incorporate linkage to care interventions, and we need innovations like the Max Clinic to keep patients retained in care.
We had mental health support as part of our rapid protocols, and patients were 4 times more likely to follow up for their second visit if they saw a mental health specialist within 4 weeks of their diagnosis or return to care.
In addition, we have specific peer support for substance use disorder, which has been incredibly helpful. All of our peer support network follows a harm reduction approach.10
Crescent Care: Rapid ReSTART Program
These data come from New Orleans and represent our rapid reentry program. I have been very committed to rapid start, but then we expanded this to include patients who were out of care for 9 months or more.
This idea came from people living with HIV who asked why the red carpet treatment was only for newly diagnosed individuals. They suggested it should also be for those who have been living with HIV for many years but fell out of care and are now ready to return.
You can see from these data that rapid start for newly diagnosed patients—our “low-hanging fruit”—is represented by the blue bar. In New Orleans, we saw 5 to 10 newly diagnosed patients per week.
However, when we expanded to include those returning to care, which you can see in the red bars, the volume increased significantly.
In other words, community leaders living with HIV were absolutely correct in advocating for a red carpet welcome back to the clinic for these individuals. Rapid restart of ART is likely to increase the chances of remaining in HIV care if they are willing to restart and there are no concerns for significant ART resistance. There was no need to wait—no need to hold ART until their social needs were met, or until they had established a consistent pattern of care or met with case managers.
Even if this means a higher volume, we must build the clinic infrastructure to support it. This approach is essential if we are to surpass the 90-90-90 goals and reach the 10-10-10 targets.11
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