INTRODUCTION:
The Beyond AIDS Foundation recommends that the following services be routinely and consistently provided by public health departments upon receipt of a new HIV diagnosis (a positive laboratory test report or a report by a provider). These recommendations are consistent with CDC surveillance and prevention grant expectations, but currently adherence is not monitored as a condition for continued CDC funding. They both serve the interests of the patient and help to fulfill the public health goal of preventing further infections.
A published survey of state and territorial HIV/AIDS directors conducted by our Foundation (https://guilfordjournals.com/doi/abs/10.1521/aeap.2019.31.1.82) demonstrated wide discrepancies in actual practices among U.S. states and territories and gaps in services in many locations. Such discrepancies and gaps, and the lack of monitoring for adherence to national guidelines by CDC, highlight the need for this policy.
We encourage concurrence with this policy by state and territorial HIV/AIDS directors and epidemiologists, city and county public health officials, federal, state, and local communicable disease-related agencies, local HIV/AIDS projects, state conferences of local health officers and of communicable disease controllers, and others.
On another page of our Website, below this policy statement, we have provided more detailed guidelines as a reference to public health departments for developing their HIV outreach services after new HIV diagnoses are reported (https://www.beyondaids.org/articles/ApprovedPolicies032023.pdf).
POLICY:
When a new HIV diagnosis is reported by a laboratory or a provider, surveillance by public health departments should either include or be seamlessly integrated with outreach and “case management” services to prevent further transmission:
- Initiation and facilitation of the HIV Care Continuum (linkage to care, and encouragement of maintenance of treatment to reach undetectable viral loads). The achievement of undetectable viral loads both eliminates sexual transmission and achieves the best clinical outcomes, and is therefore a major public health objective.
- Partner services (contact tracing and partner notification) with referrals of contacts for testing and counseling; best conducted by public health personnel 2 with or without the presence of the patient. Trusting the patient to notify partners is not consistently reliable, and should only be used as a last resort and when adherence can be verified
- Referrals to other needed services (substance abuse or mental health treatment, housing, etc.)
- Counseling/education on HIV infection and its prevention and treatment. This should include information that the patient does not yet have and is interested in receiving. Safe behaviors, protection of partners (e.g., condoms and PrEP), and the benefits of rapid treatment initiation are priority topics.
- Obtaining information to accurately complete the morbidity reporting form. This is important to the local jurisdiction, state, and CDC for monitoring the epidemic, but does not in itself interrupt transmission or result in treatment, and therefore should not be the sole objective when following up on new reported diagnoses.
These services can be provided by communicable disease investigators if they receive adequate training. Some jurisdictions may assign other staff, such as public health nurses or health educators. These staff may be assigned as case managers, so that there is consistent follow-up by a worker who has already established rapport and knows the patient.
When a public health department receives a new positive HIV test result, there should be immediate outreach. If the test was ordered by a medical provider, there are advantages to contacting the provider first. The provider’s office can frequently provide information regarding reaching the patient, completing the morbidity reporting form, known partners, acute transmission risks such as history of needle sharing, comorbidities including mental illness and substance abuse, homelessness, and whether the provider can offer immediate initiation of therapy, has already made arrangements for referral or consultation regarding HIV care, or is willing to delegate referral for treatment initiation to the public health department or designee.
Following the communication with the provider, or if there is no provider associated with the test, the public health department should make every possible effort to contact the patient directly. In-person meetings have the advantage of establishing trust and rapport. Virtual meetings may be next best, and in some cases, the only opportunity to see each other.
The same four bulleted priorities listed above should be discussed with the patient, emphasizing rapid linkage to care and partner services. A follow-up contact a few weeks later, should help verify that linkage actually occurred. Subsequently, monitoring of periodic lab reports, particularly of viral load, should be done to determine whether the patient is maintaining treatment and that the viral load is approaching undetectable levels. The patient, medical provider, and in some cases the laboratory should be contacted if these test results are not being regularly reported.
If a patient is found to live outside of the jurisdiction of the public health department, the appropriate department in the jurisdiction of residence should be informed of the case, so that services can be initiated.
