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Systems Linkages and Access to Care Initiative

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The Special Projects of National Significance Program’s Systems Linkages and Access to Care for Populations at High Risk of HIV Infection initiative is a multistate demonstration project and evaluation of innovative models of linkage to and retention in HIV care. The initiative is funding six demonstration states for up to four years to design, implement and evaluate innovative strategies to integrate different components of the public health system such as surveillance, counseling and testing, and treatment, to create new and effective systems of linkages and retention in care for hard-to-reach populations who have never been in care, have fallen out of care or are at-risk for falling out of care.  Populations of interest are limited to those persons who at high risk for and/or infected with HIV but are unaware of their HIV status; are aware of their HIV infection but have never been referred to care; or are aware but have refused referral to care.

The University of California at San Francisco, the Evaluation and Technical Assistance Center for this initiative, is coordinating the multistate evaluation and providing programmatic technical assistance to the Demonstration States.



Grants for this initiative were awarded to the six States listed below. The following abstracts provide a brief description of each project.


The Office of Public Health STD/HIV Program in Louisiana is focusing on linkages within two systems that have the potential to access hard-to-reach populations at high risk of HIV infection: the correctional system and the health care system. Louisiana is using a continuum of care model framework to implement a streamlined process through which HIV infected persons will move from testing to linkage and maintenance in HIV care and services.

The state is expanding opt-out rapid HIV testing to jails and prisons in the state and maintain current testing activities. Prison/Jail Linkage Coordinators and Peer Coordinators are utilized to provide pre-release planning services to HIV infected inmates and ensure they are linked with appropriate medical and social services before release. Louisiana also is using new or existing video consultation technology in correctional facilities and case management agencies to virtually connect inmates with HIV medical providers and case managers while incarcerated.

This project also seeks to expand the Louisiana Public Health Information Exchange (LaPHIE) electronic system (developed under an earlier SPNS initiative) to a private non-profit health system and modify its criteria so that PLWHA who are out of care be quickly and easily identified when they receive health services at other health facilities.



The Massachusetts Department of Public Health's MIDDLEMARCH (Massachusetts Initiative for Data-Driven Linkage, Engagement, Management and Retrieval for Continued Health) Project addresses the problem of HIV positive individuals who are not yet linked to or have disconnected from HIV care. The project employs a multi-faceted strategy to be piloted in Boston, Springfield, and Worcester. MA plans to integrate surveillance, lab and service delivery data (client level HIV/AIDS data system, or CHADS) to identify HIV+ patients who have not entered care, fallen out of care, or use services on a sporadic basis. Routine HIV testing has been expanded at hospitals and health centers and through mobile outreach. Peer Linkage Specialists are based at provider agencies to serve as system navigators, counselors and outreach workers, to ensure engagement and maintenance in HIV care.


New York 

The New York State Department of Health is developing innovative and systemic models of linkage to care to improve access to and retention in high quality HIV care, bringing providers and communities together in local collaborative partnerships toward common improvement goals. NY's model implements regional public health collaboratives, which are formed in geographic areas that have been prioritized, based upon surveillance and epidemiology data, to bring together testing and prevention providers, non-traditional providers, and community representatives.


North Carolina 

The Communicable Disease Branch of the North Carolina Department of Public Health is partnering with Duke University and University of North Carolina – Chapel Hill to improve the coordination of HIV care in the state. The NC- LINK project is creating a connection between HIV surveillance and HIV care data systems, developing electronic transfers of data between surveillance, lab reports and CAREWare for regional and state-level assessments and interventions to promote entry and retention in care. NC-LINK is also facilitating dialogue between medical care providers and labs to promote HIV test reporting completeness. Finally, NC-LINK is promoting surveillance and location of PLWHA who are unaware of being HIV positive.



Virginia Department of Health (VDH) has implemented a health care model to utilize active referrals and strengthening of partnerships to improve continuous engagement and retention into primary medical care for people diagnosed with the HIV/AIDS. The overall goals of this project are to increase the percentage of newly-diagnosed clients who engage in care within three months post-diagnosis; to increase the retention rate in care; and to develop a referral system maximizing funding and linkage resources while coordinating and streamlining client services. This project has three distinct components that were piloted in the Central and Southwest health regions. First, an active referral process allows Disease Intervention Specialists (DIS) to ensure client needs are met in a more efficient fashion. Second, Patient Navigators assist clients in the treatment process, keeping them engaged and linking them to all available resources. Finally, a newly-established Central Care Coordinator position coordinates the efforts of staff in both regions, and assists in meeting the needs of clients’ transitioning out Virginia Department of Corrections facilities.



The State of Wisconsin is bridging the service gap between prevention and care through the provision of intensive, time-limited, case management services provided by Linkage to Care Specialists (LTCS). The project  targets African-American men who have sex with men (AAMSM), since this population has seen a 144% increase in HIV diagnoses over the past decade. The project has five overarching goals: 1) Increase engagement in and retention to medical care; 2) Improve health outcomes; 3) Improve linkage to care for newly infected individuals; 4) Increase identification of acute infection; and 5) Decrease percent of individuals who are unaware of their HIV status in the AAMSM target population.



Journal Articles

Sullivan KA, Berger MB, Quinlivan EB, Parnell HE, Sampson LA, Clymore JM, & Wilkin AM.  Perspectives from the Field: HIV Testing and Linkage to Care in North Carolina.  Journal of the International Association of Providers of AIDS Care, E-published ahead of print, November 19, 2015.  PubMed Abstract

Berger MB, Sullivan KA, Parnell HE, Keller J, Pollard A, Cox ME, Clymore JM, & Quinlivan EB. Barriers and Facilitators to Retaining and Reengaging HIV Clients in Care: A Case Study of North Carolina.  Journal of the International Association of Providers of AIDS Care, E-published ahead of print, November 19, 2015.  PubMed Abstract

Broaddus MR, Hanna CR, Schumann C, & Meier A. "She makes me feel that I'm not alone": linkage to Care Specialists provide social support to people living with HIV. AIDS Care, 2015; 27 (9): 1104-7.  PubMed Abstract


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