Counselling / Linkage to care

Linkage to care

Linkage to care ensures newly diagnosed clients receive the full health benefits of treatment as early as possible. The point of diagnosis is key because it may be difficult for a person newly diagnosed with HIV to engage with specialised treatment services if that connection is not made in a supportive fashion.

Linkage to care is one of the most important components of CBVCT operations, and services are judged on their performance on this point. Their role in lowering the testing threshold for key populations must be complemented by linking those with a reactive or HIV positive test result into HIV clinical care. CBVCTs that have been able to obtain follow-up data report successful linkage to care in the 90% – 100% range. It is important to find ways to document this part of the client pathway.

Referral to additional services for other health and social needs may apply to any client, irrespective of the test result.

Item Does your CBCVT have this in place? Is there a documented standard, guideline, plan, policy, procedure, contract or agreement? Is it adapted to local needs and conditions? Is it working as intended? Action
Follow up and referral
Description

Description

Following up includes any further contact the CBVCT makes with the client after the counselling and testing process. Referral means arranging further or additional services for a client through another provider. Methods range from providing information about services to making appointments for the client or even personally accompanying them there.

 

Guidance

Guidance

To make a successful referral, the CBVCT must cover the following steps:

  • Notice, recognise and identify the client’s needs (e.g. during counselling)
  • Discuss needs and referral options with the client
  • Know about relevant services, select the most appropriate and recommend them to the client
  • Connect the client with the referral service(s).

The basic referral sources that a CBVCT service requires include:

  • Confirmatory testing and/or laboratory services (if not performed in-house)
  • Specialised HIV treatment centre
  • Specialised STI treatment centre
  • Specialised viral hepatitis treatment centre
  • General medical care (general practice)
  • Mental health services
  • Drug and alcohol services
  • Social services
  • Legal services.

Referral means more than having information available about where clients can access additional services. Referrals are more likely to be successful if the referral service is aware of the CBVCT and the fact that clients may be referred from there.

It is even better if the referring CBVCT staff know the staff at the referral service personally, can make appointments for their clients and/or even offer to accompany them to their first appointment.

 

Please find main findings and recommendations for Linkage to care in the EURO HIV EDAT WP 6 Practical Guide FINAL.

 

Adaptation

Adaptation

Referral mechanisms need to be adapted to the mode of service delivery of the CBVCT, the needs of the client, the availability of appropriate referral services and the ability of the client to access them.

For example, a CBVCT providing rapid HIV testing at a gay bar with minimal counselling may refer to other services by offering business cards or brochures with the referral information, or by making an appointment at the CBVCT premises for a more in-depth needs assessment and referral process with the client.

A more comprehensive testing service at the CBVCT premises that includes pre-and post-test discussions may be able to make appointments, e.g. with collaborating mental health or drug and alcohol service providers, there and then. If there is a peer-based component to the CBVCT, a trained volunteer may even be able to accompany a client to appointments if they would like this assistance.

 

Quality Improvement

Quality Improvement

Reflecting on the referral sources and mechanisms the CBVCT uses can be part of structured quality improvement, e.g. at a special team meeting on the topic every year, or at least every two years. It is best if all relevant personnel (volunteer/paid counsellors, trainers, managers) participate and if feedback from clients and referral partners is available to inform the process. This kind of reflective discussion can also be used to adapt the referral sources and mechanisms to changes in the key population and its needs, as well as to changes in the services referred to.

The ‘Enquiries and Concerns Register’ method in the PQD (Participatory Quality Development, step-by-step instructions available at www.qualityaction.eu) can be used to collect and analyse information about the referral needs of clients.

The overall quality of the service from clients’ perspective depends not only on the quality of the CBVCT and its referral mechanism, but also on the quality of the services referred to. This can only be addressed as part of a broader quality improvement or planning process with participation of all relevant service providers that respond to a particular key population and its needs.

The Shift tool (available at www.qualityaction.eu) is a comprehensive tool to assess and improve the overall response to HIV in a given region or country. The systems approach used by the W3 project in Melbourne, Australia (available at www.w3project.org.au) offers another option to develop quality in settings where individual ­– especially peer-based – programmes interact with other service providers in a constantly changing and dynamic environment.

 

Action plan

Action plan

This Action Plan helps you to work directly on the items identified as priorities (yellow and/or red fields in the Checklist). Please list actions that are as specific as possible. You can download your finished Action Plans for each section as an xlsx.-document and print it afterwards. The Action Plans form the basis for your further planning, implementation and evaluation.

The Action Plan shows a sequence of steps to be taken, or activities to be performed for a strategy to succeed. The Action Plan has four major elements: (1) what will be done (specific tasks), (2) by whom (responsibility), (3) by when (timeframe), and (4) how the implementation of the task will be monitored.

 


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Linkage to HIV care
Description

Description

Linking a client with a reactive result or new HIV diagnosis to care means ensuring the client receives assessment, advice, and access to treatment and care for HIV infection.

 

Guidance

Guidance

There are internal linkage to care (e.g. in-house confirmatory test, buddy system, follow-up counselling appointments, reminder service for the next test etc.) and external linkage to care (e.g. external confirmatory test, clinical care for HIV infection, referrals to other services), depending on the test result and needs of the client, e.g.:

  • Non-reactive result: offer of reminder service for the next routine test
  • Reactive result: confirmatory testing, linkage to HIV care
  • HIV diagnosis: linkage to HIV care
  • Referrals to additional services, e.g. drug and alcohol services, mental health services (see also the section on follow-up and referral)
  • Connection to community resources, e.g. MSM-friendly general practitioners, community groups and social networks.

Linking clients newly diagnosed with HIV to specialised care is a special form of referral that requires planning and building relationships with clinical services to function well.

Formal agreements, e.g. a Memorandum of Understanding (MOU) between the CBVCT and HIV treatment and care provider(s) can document how this will work and serve as the basis for regular evaluation and re-negotiation. Following up on the outcome of referrals is an important source of information for CBVCTs and helps assess whether the referral system is working. Successful referrals are an important indicator in monitoring and evaluation.

 

Adaptation

Adaptation

Follow-up needs to be adapted to the capacity of the CBVCT and the preferences of the client. If, for example, a reminder service for the next test is available, the client must still consent to it. Any such process needs to take into account national data protection laws and regulations.

Confirmatory testing may be part of referral to clinical services or may be performed in-house. For example, Barcelona Checkpoint uses PCR (viral load) testing as a confirmatory test that can be done in-house on the same day (the test takes approx. 90 minutes). This alleviates the stress of having to go somewhere else and having to wait a week for a result.

Depending on the local availability of specialised HIV care, the CBVCT may work closely with a specific provider to ensure their services are culturally appropriate and accessible to the key population or even provide treatment services at the CBVCT. This may include HIV treatment centre nurses working at the checkpoint, thus providing a direct personal link to clinical services.

Another possibility is showing clients with reactive results a photograph of the personnel at the treatment centre (e.g. “This is the person who will look after you at the HIV clinic. You can say “I’m here to see nurse xxx when you arrive.”) and handing them a business card they can take to their first appointment there.

Some CBVCTs offer services to tourists, some do not. On the one hand, funding may be restricted to locals (especially in low-income settings), and there are issues regarding linkage to care. On the other hand, there is evidence that MSM travel a lot across Europe for sex, and Checkpoint staff being part of a European network of CBVCTs can provide good linkage to care across countries.

 

Quality Improvement

Quality Improvement

Question five of the Euro HIV EDAT Self-evaluation Grids focuses specifically on linkage to care. Reflecting on and improving follow-up and linkage to care can be part of structured quality improvement (more tools available at www.qualityaction.eu), e.g. at a special team meeting on the topic every year or at least every two years. It is best if all relevant personnel (volunteer/paid counsellors, trainers, managers) participate and if feedback from clients and external partners is available to inform the process (use e.g. ‘Rapid Assessment’ or a ‘Focus Group’ from the PQD toolkit, available including step-by-step instructions at www.qualityaction.eu). Reflective discussions can the lead to adapting follow-up and linkage to care.

 

The overall quality of follow-up and linkage to care depends not only on the quality of the CBVCT and its referral mechanism, but also on the quality of the services referred to. This can only be addressed as part of a collaborative quality improvement or planning process with participation of all relevant service providers that respond to a particular key population and its needs.

 

The Shift tool available at www.qualityaction.eu is a comprehensive tool to assess and improve the overall response to HIV in a given region or country, including the pivotal connection of testing and linkage to care. The systems approach used by the W3 project in Melbourne, Australia (available at www.w3project.org.au) offers another option to develop quality in settings where individual ­– especially peer-based – programmes interact with other service providers in a constantly changing and dynamic environment.

 


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Individual support
Description

Description

Support persons, e.g. peers, trained volunteers or staff provide individual support to a client for a limited period and for a specific need.

 

Guidance

Guidance

Support persons understand how factors such as sexuality, gender, migration status, cultural and linguistic diversity, age and disability can increase vulnerability and offer individually tailored support, in particular to clients newly diagnosed with HIV infection.

Trained peers often perform this role as part of a ‘buddy’ system. This means that clients are matched with a support person who has enough in common with the person (e.g. HIV status, sexuality, language, age etc.) to allow them build trust quickly, and who has enough experience to give the client guidance.

Individual support may include:

  • Listening to the concerns of the client
  • Offering examples from their personal history and experience to break isolation and boost confidence
  • Giving practical assistance, e.g. finding services, filling in forms
  • Accompanying the client to appointments
  • Reminding the client of their goals, decisions, appointments
  • Asking the client about their experience (e.g. disclosing their status to others, medical appointments).

Support persons complement the role of the person conducting the testing and counselling conversations where some additional support will ensure the overall goals of the continuum of care are reached, especially linkage to and retention in treatment or follow-up testing for those most at risk.

 

Adaptation

Adaptation

Providing individual support to vulnerable clients is an additional function. Not all CBVCTs have the capacity to train and allocate support persons for vulnerable clients. If an individual client needs additional support, another organisation or service – not necessarily an HIV-specific one – may also be able to assist. A combination of referral and individual support can be matched to the client’s need.

Options for reducing costs:

  • Using the same pool of volunteers to conduct testing and to provide individual support when needed.
  • Negotiate referral links with other suitable community-based services or social service providers to provide support for people with particular vulnerabilities, e.g. regarding sexuality, migration, language, age etc.

 

Quality Improvement

Quality Improvement

The ‘Enquiries and Concerns Register’ method in the PQD (Participatory Quality Development, step-by-step instructions available at www.qualityaction.eu) can be used to collect and analyse information about the support needs of clients.

Reflecting on the individual support system the CBVCT uses can be part of structured quality improvement, e.g. at a special team meeting on the topic every year, or at least every two years. It is best if all relevant personnel (volunteers, counsellors, trainers, managers) participate and if feedback from clients is available to inform the process.

Comprehensive quality improvement tools for prevention and health promotion projects such as Succeed and QIP, both available at www.qualityaction.eu, include sections on needs assessment and the resources available to respond to the needs identified.

 


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Linkage to care data
Description

Description

Support persons, e.g. peers, trained volunteers or staff provide individual support to a client for a limited period and for a specific need.

 

Guidance

Guidance

While it is not always straightforward for the CBVCT as the referring service to obtain feedback on the success of its efforts to link clients to specialised HIV care, having these data is essential for monitoring success. One of the core overall indicators of the COBATEST network is the ‘Proportion of clients who tested HIV positive at CBVCT sites who were linked to health care.’

Including arrangements for how these data are provided back to the CBVCT in agreements with clinical services (e.g. a Memorandum of Understanding) can assist with monitoring this indicator.

The specific indicators suggested by COBATEST are:

  • Entry into health care or follow‐up by an HIV specialist or in an HIV unit within three months after HIV diagnosis at the CBVCT service
  • The linkage was facilitated by the CBVCT service.

 

Adaptation

Adaptation

The exact process of gathering these data needs to be adapted to local factors such as:

  • Systems of unique identifiers at the CBVCT and clinical services (in order to keep personal client information regarding linkage of care confidential)
  • Who monitors linkage to care, clinical services, testing services or both
  • Regional or national data reporting requirements.

To demonstrate successes in linkage to care and to identify gaps, it is important to find a way of monitoring linkage of care for clients first diagnosed at the CBVCT within any existing data collection systems.

Data can be collected from laboratories and hospitals by checking lists of unique identifiers at regular intervals (asking the question ‘how many of this list of unique codes have turned up in your care system in this period?’). It is not necessary to use any names, thus protecting confidentiality.

If the confidentiality arrangements and informed consent from the client allow it, it may be possible to check with treatment centre staff whether a particular client has been linked to care successfully and follow up with the client if necessary. It is possible to ask clients to agree to this kind of follow-up support after a reactive test.

Download: AIDES Linkage to care data form

 

Quality Improvement

Quality Improvement

Reflecting on how linkage to care data are collected, analysed and reported can be part of structured quality improvement (tools available at www.qualityaction.eu), e.g. at a special team meeting on the topic every year, or at least every two years. It is best if all relevant personnel (volunteer/paid testers and counsellors, trainers, managers) participate, and if feedback from external partners (e.g. clinical services) is available to inform the process. Reflective discussions can the lead to adapting follow-up and linkage to care.

The Shift tool available at www.qualityaction.eu is a comprehensive tool to assess and improve the overall response to HIV in a given region or country, including data collection, monitoring and reporting systems. The systems approach used by the W3 project in Melbourne, Australia (available at www.w3project.org.au) offers another option to develop quality in settings where individual ­– especially peer-based – programmes interact with other service providers in a constantly changing and dynamic environment.

 


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