Promoting Linkage to Care among HIV population: Utilizing ... · Web viewThe grey literature, editorials, comments, congress abstracts, and letters were excluded. PubMed revealed

Running head: PROMOTING LINKAGE TO CARE AMONG THE HIV POPULATION: 1

Promoting Linkage to Care among the HIV population: Utilizing the Same- Day Access Clinic

for a Initiating Antiretroviral TherapyTest and Treat Initiative in Hillsborough County

Digy Paul

NGR 7974

University of South Florida

Patty McCabe-Remmell, 07/31/18,

You are dealing with a local population – your title should reflect that.

Running head: PROMOTING LINKAGE TO CARE AMONG THE HIV POPULATION 2

Abstract

Promoting Linkage to Care among the HIV population: Utilizing the Same Day Access

Clinic for Initiating Antiretroviral Therapy

Abstract

In an attempt to answer the question “Does implementation of a Same Day Access clinic with

ART initiation improve access to care among newly diagnosed HIV Patients?”, I have

endeavored to prove that tTreatment for Human Immunodeficiency Viral infection (HIV)

through Same Day Access clinics, coupled with Same Day Antiretroviral Therapy (ART) has

dramatically improved the quality of life and life expectancy of people living with HIVthe

disease. Initiation of sameSame D day Antiretroviral Therapy ART is an evidence-based

intervention that facilitates the care for HIV- positive patients. The guidelines published by the

Centers for Disease Control and Prevention (CDC) have issued guidelines that emphasize a on

“tTest and tTreat” initiative for HIV prevention, which . This approach emphasizes on universal

HIV testing, followed by Antiretroviral treatment to improve linkage and retention in care.

Improving patients’ access to care is very crucial in the HIV care continuum. The overriding

concept of the Same D Day Access Clinic concept is that a change in practice that can be

implemented in any HIV clinic for an early initiation of Antiretroviral Therapy (ART). This

quality improvement project proposes that the initiation of same- day ART (Test & Treat

Initiate) through a Same D Day Access Clinic will have a positive impact on accessibility to

care.e.

PROMOTING LINKAGE TO CARE AMONG THE HIV POPULATION 3

Promoting Linkage to Care among the HIV population: Utilizing the Same Day Access

clinic for Initiating Same Day Antiretroviral Therapy

for Initiating Same Day Antiretroviral Therapy.

Early initiation of an Antiretroviral Therapy (ART) reduces the morbidity and mortality

of patients with HIV infection. As per the HIV/AIDS Clinical Care guidelines, the five key

components to eliminate HIV transmission and related deaths are as follows:

1. 1. Implement routine HIV screening in healthcare and non-healthcare settings.

2. 2 Increase access to antiretroviral therapyART

3. 3. Ensure retention in care.

4. 4. Improve access to antiretroviral pre-exposure prophylaxis (PreP)

5. 5. Increase the HIV awareness through community outreach programs (AIDS info,

2017).

In 2010, the San Francisco Department of Public Health offered ART to all patients with

human immunodeficiency virus (HIV) regardless of their CD4 count. In 2013, San Francisco

General Hospital have launched a clinical health system intervention, the entitled Rapid ART

Program Initiative for HIV Diagnoses (Rapid RAPID) ART program for HIV patients, by

initiating same- day antiretroviral therapyART. The results of the program report reveal that

repeated HIV testing, followed by immediate ART, could substantially decrease the incidence

incidents of HIV (“SFGH Rapid RAPID ART program,””, 2013). The HIV Treatment Cascade

recommends that same day ART initiation and early accessibility to care could reduce the

prevalence of HIV infection (CDC, 2017). The primary objective of the Hillsborough County,

FL, Department of Health in of implementing the Same Day Access Clinic in Hillsborough


County Health Department is to increase the accessibility to of care among newly- diagnosed

HIV patients.


Description of the Problem (Background & Significance)

According to the Centers for Disease Control and Prevention (CDC), as of 2016, more

than 1.1 million people in the United States are were living with HIVV according to US

government data as of 2016. . The year before that, In 2015, an estimated 38,500 new patients

people were diagnosed with new HIV. infection in this country. While there was an overall eight

percent decline in annual HIV infections in the United States from 2010 to 2015 (from 41,800 to

38,500), in 2016, 39,782 people were diagnosed with HIV (CDC, 2017).

Despite impressive advances in antiretroviral therapy (ART) for HIV-infected

individuals, only around one-third of the 1.1 million individuals who are eligible for treatment

are currently receiving it. As perof the 2011 US Ccensus, it was estimated that only 21% of HIV-

infected individuals in the United States are were aware of their HIV status. The data also shows

that 31% of newly- diagnosed HIV patients delay the linkage to care for about six months or

longer, (“Guide for HIV/AIDS,”, 2011). Missed appointments are often common and are

associated with the delayed initiation of ART. According to the CDC’s (2011) data collection,

480,000 (40%) out of 1.2 million people with HIV in the US infection, 40% (480,000) were

engaged in any form of HIV medical care. Only 92% (444,000) of tthose hose 480,000 were

prescribed ART, and 82% (360,000) were withpresented a suppressed Viral Lload (VL) below

200 copies/ml. (CDC, 2011).

In 2016, Florida was ranked ranked the third in the United States for HIV cases in 2016.

As perThe Florida Department of Health reports that there were 4,972 people were diagnosed

with HIV in that year. With 114,772 persons living with HIV in Florida, antiretroviral

Antiretroviral (ARV) drug use is very essential in the treatment of HIV Florida’s population

(114,772 people) living with HIV (CDC, 2016).


Make sure this is cited in reference section


The US Department of Health and Human Service (DHHS) guidelines recommend s

universal ART to all patients with HIV as the early as possible. In 2016, DHHS identified the

strategic directions to achieve this outcome, including are encouraging people to know their

HIV status, accelerating the scale-up of HIV/AIDS treatment, maximizing the health sector’s

contribution to HIV prevention, and investing in obtaining strategic information’s to guide the

patient’s outcome (DHHS, 2016).

One of the issues currently facing being faced today in the Hillsborough County Health

Department’s (HCHD) , Specialty Care Clinic is the lack of accessibility to immediate HIV care

among HIV- positive individuals. Initiating ART at the early stage of HIV diagnosis, as well

asnd connecting patients to care, are necessary to keep the viral load under control. Patients were

seen in this Specialty Care Clinic as an 80/20 mix of scheduled and walk-in patients respectively.

The current practice of initiating ART takes three to four3-4 months, to initiate an Antiretroviral

Therapy, and the system was is currently not capable of accommodating the newly- diagnosed

HIV patients. As a result,This prompted the HCHD to initiate a Same Day Access Clinic

mModel was identified to initiatefor Antiretroviral TherapyART therapy among this newly-

diagnosed HIV population.


“This” is a vague subject – make it clear what “this” is. You could say “The HCHD initiated a Same Day Access Clinic model for ART therapy among this newly-diagnosed HIV population because the current practice takes three to four months and the system is not capable …” etc.


I feel that this should be addressed in your abstract also, since your premise is location-specific.


Review of LiteratureReview of Literature

Introduction

The review of literature provides the relevant information for validating the necessity of

initiating ART at the early stages of HIV diagnosis. The HIV/AIDS tTreatment guidelines

support the initiation of same day antiretroviralSame Day ART therapy on a newly diagnosed

HIV patient. I have also reviewed Same Day ART initiation and its impact on linkage to care,

along with and its effect on viral load suppression are reviewed. Furthermore, I have appraised a

synopsis of related themes found in supportive literature. are appraised.

Search Strategy

A systematic literature search was done in theI have utilized the literature database

PubMed, ; the search engine Google Scholar, and Research Gate for my systematic literature

search. The search terms used are “Test and Treat initiative;”’’; “Same -Day Antiretroviral

Therapy;”’’; “Early viral load suppression;””, and “linkage to care among the HIV population.””.

Additionally, the eligibility criteria were set as follows: the publication period from

January 1, 2013, to June 1, 2018;, however interventional, non-interventional; multiple design

studies and randomized control trials were included. The grey literature, editorials, comments,

congress abstracts, and letters were excluded. The search in PubMed revealed seventy suitable

records; ten duplicates were removed, resulting in sixty records for screening. The first hundred

hits for each of the search terms in Google Scholar were considered, resulting in two additional

records after removing duplicates. Each title of the article was read and evaluated. Sixty-two


non- duplicate citations were screened. Thirty-two articles were excluded after title/abstract

screening, fifteen articles were excluded after full text screening, and ten articles were excluded

during data extraction. After the entire search process were was completed, five were selected.

For a depiction of the search, see the Prisma Diagram in Appendix A.

PRISMA DIAGRAM

Patient Problem, Intervention, Comparison, Outcome and Time (PICOT) and tThe Johns

Hopkins Nursing Evidence-Based Practice (JHNEBP) tools were used to develop the practice

question, evidence and translation. After using PICOT to formulate the practice question, “Does

implementation of a Same Day Access Clinic with ART initiation improve access to care among


newly diagnosed HIV Patients?”, was determined, a search for an evidence was conducted on

selected articles regarding the impact of same day ART on access to care among HIV population.

As per the Poe & White (2010), I propose afollowing evidences, a practice change of

implementing the Same Day Access Clinic model as a means of achieving virology suppression

in newly-diagnosed patients. is proposed. (Poe &White, 2010).

Literature Appraisal

Research has shown that prioritizing immediate ART initiation can reduce the time

needed to achieve virology suppression in newly- diagnosed patients. Pilcher, et al. (2015)

performed a quantitative study (“Providing Same Day, Observed ART to newly diagnosed

HIV+ out patients are associated with improved virology suppression” and published in the

Journal of Acquired Deficiency Syndrome) in 86 patients, out of which; 39 were eligible. & 37

(94.9%) of those patients out of 39 began ART within 24 hours. VThe virology suppression was

faster (within 1.8 months) in comparison to universal ART treatment in a standard clinic (within

4.3 months). This study agreed that same Same day Day ART shortens the time- to- virology

suppression.

One limitation of the study, however, identified that ART was begun without some

baseline laboratory results, yet n. No safety or ART resistance issues were identified. As a result,

there were intensified demands on clinical providers to consider early regimen modifications on

follow- up visits were intensified. Furthermore, Aa second limitation of this study is that the

RCT was performed with a small sample size; h. However, the data provided was substantial and

evidence-based (Pilcher et al., 2015).

A randomized control trial, performed by Rosen et al. (2016), shows There is an evidence

that that offering single-visit -ART initiation to adult patients in South Africa increased the


uptake of ART by 36% and viral suppression by 26 %. The trial A randomized control trial

performed by Rosen et al. (2016) measured the outcome of viral suppression (<400 copies/ml) in

377 patients. In the rapid RAPID group, 119 out of /187patients (64%) initiated same daySame

Day ART treatment and were virally suppressed at 10 months compared to 96/190 (51%) in the

standard group. This study demonstrated a strong relationship between sameSame dDay ART

initiation and early linkage to care. However, the long-term effect of reducing the number of

clinic visits prior to ART initiation remains unclear. The results could not be generalized as the

trialit was conducted only in two clinics (Rosen et al., 2016).

A randomized control trial performed by Michael, et al (2012), concluded that higher

rates of early retention in HIV care are associated with same same-dday ay initiation of ART, as

well as helping . It also helps to attain early viral load suppression. The study identified that,

aAmong 676 HIV patients that were included in the trial, the study identified that 63% achieved

VL<50 copies/ml within three hundred and eight308 days. These findings validated the

importance of same- day ART initiation on a newly diagnosed HIV patient (Michael et al.,

2012).

Same- –day HIV testing, and ART initiation is feasible, beneficial, and improves

retention in care with virology suppression among patients with early clinical HIV disease. As

per Serena et al. (2017), a randomized control trial in Haiti enrolled 762 patients, out of which ; a

356 standard group initiated ART (standard group) in 3 weeks after HIV testing vs 347 in the

same- day ART group. In the standard group, the 156 (44 %) participants who were retained in

care with 12-month HIV RNA <50 copies/ml; 184 (52%), had <1000 copies/ ml. In the Same

DSame Day ART group, 184 (53%) participants were retained with HIV RNA below 50

copies/ml, and 212 (61%) had <1,000 copies/ml (Serena et al., 2017).


CASCADE trial, an RCT by Labhardt, et al. (2016), concluded that the same- day home-

based ART initiation after a positive HIV test is a feasible approach to improve linkage to care,

retention in care, and e & viral load suppression. The study points out that there was a

significant increase in linkage to care at three months and viral suppression at twelve months

(Labhardt et al., 2016). Among these evidences, five level- one high- quality quantitative control

trials were appraised. All of these studies concluded that Same Day ARTnti-Retroviral Treatment

improves access to care, retention in care, and faster viral load suppression among HIV-positive+

patients.

Literature Synthesis

Throughout the review of multiple literature,The multiple sources I

have reviewed agree that Same day Day HIV testing and combined with ART

initiation has been shown to improve the virology suppression among

patients with an HIV. Pilcher, et.al., and disease (Pilcher et al.2015). Serena, et. al,

agree that Same day Day ART will shorten the time to virology suppression

and support the fact that . Hhigher rates of early retention in HIV care are

associated with achieving VL suppression and lower VL burden (Serena et al.

2017). Labhardt, et. al., agree that Same day Day Anti-Retroviral Treatment

improves access to care, ; retention in care, and faster HIV viral suppression

among newly diagnosed HIV patients (Labhardt et al. 2016). Overall, the

literature supported thatsupporting Same daySame Day ART initiation is

rigorous, feasible, and beneficial.

Patient, Implementation, Outcome, Time (PICOT)


PICOT (Patient Problem, Intervention, Comparison, Outcome and Time) was utilized to

develop a proper quality improvement question. The “P” addressed in thine PICOT represents

the number of Adult HIV patients of all ethnicities and genders that could benefit from linkage to

care in the Same Day Access Clinic. The “I,” for Intervention recommended, includes same- day

ART initiation as per “Test & Treat” guidelines. The “C” “represents comparison of access to

care through a Same Day Clinic versus a Standard Clinic. Outcome is measured by the number

of days it took to initiate ART through au Same Day Clinic, while . “T” represents time, which

includesand represents a four- a four-month retrospective chart review. Utilizing the PICOT

development tool, a formal PICOT question was established: “Does implementation of a Same

Day Access clinic with ART initiation improve access to care among newly diagnosed HIV

Patients?” (Poe & W white, 2010).

Goals/ & Objectives

The primary objective of this quality improvement project is to increase the accessibility

of care among the HIV population through a “Same Day Access Clinic” that minimizes the time

to initiate an Anti-Retroviral Therapy on a newly diagnosed HIV+ patient.

Theoretical or conceptual Conceptual models Models that guide Guide the project Project

designDesign

The HIV Treatment Cascade (Appendix B) is a powerful model that

represents a quantitative depiction of discrete steps in the HIV Care

Continuumcontinuum. This model is consistent with the National HIV/AIDS

Strategy and its specific national goals for testing, linkage, retention, and

viral suppression (CDC, 2017). By applying this Eevidence-based Based

practice Practice (EBP) model, a Same Day Access Clinic concept was


introduced to initiate ART on newlyto newly- diagnosed HIV patients in order

to promote early linkage to care. This concept was created specifically by

using the latest research findings as well as incorporating the best practices

in patient care.

HIV Treatment Cascade

{Retrieved from Clinical Infectious Diseases., 57(8), 2013.}

Early initiation of ART will benefit individuals from in their pathophysiological

progression to AIDS. In broad sense, ART initiation has various types of impact such as: It

reducesimpacts, such as reducing the opportunity of secondary transmission by suppressing

the viral load to an undetectable level. It impacts an individual’s life expectancy by


reducing the risk of AIDs and AIDS- related death. The ultimate aim for an HIV treatment

program is for people living with HIV to be virally suppressed. For this to happen, people

living with HIV need to be diagnosed promptly, quickly receive antiretroviral treatment

(ART), continuously engage with medical services, and adhere to medication. Their c, and

the care also needs to be managed appropriately. If any of these steps are missed, the

benefits of treatment for the individual and their sexual partners can be lost. (Mugavero,

etal. 2017). The Joint United Nations program on HIV/AIDS (UNAIDS) has introduced the

concept of an HIV Treatment Cascade to fill the gaps in the continuum of services for

testing, care and effective treatment (UNAID, 2018).

Implementation Plan

Setting

The study will be conducted at Specialty Care Clinic, in Hillsborough County,; Florida.

This clinic is operated by the Hillsborough County Health Department (HCHD) in , Tampa and.

This clinic provides services to the local population of patients with HIV/AIDS population. An

estimated of 2000 HIV patients were as established with this clinic, and & 2300 unduplicated

services were provided in the year 2017. Six nurse practitioners and two physicians are

provideing various services, including to this population. This clinic provides medical, ; dental, ;

laboratory,; pharmaceutical, and ART assistance programs for all patients with HIV/AIDS.

Target Population

All newly- diagnosed HIV patients are included, irrespective of age, gender, or ethnicity.

Patients who will be excluded from this project are:

1. Patients with HIV+ diagnosis for more than two years,


2. Patients who would not be safe to start therapy on the same day,

3. Patients transferring HIV care from other clinics or already on ART at the time of

initial visit to Same Day Access Clinic.

Procedure or Intervention

The HIV Treatment Cascade model will guide administrators who wish to facilitate a

practice change at Specialty Care Clinic. The review of evidence-based literature supports that

early initiation of ART on newly diagnosed HIV patients helps not only the accessibility to care

but also helps to attain early viral load suppression. Same Day ART on newly diagnosed HIV

patients will improve the linkage to care and will reduce the time span from diagnosis to the

initiation of treatment.

To achieve this outcome, the Same Day Access Clinic will be utilized to implement the

Test & Treat Initiative. The Same Day Access clinic will see all newly diagnosed HIV patients

who walk in any day (Monday to Friday) from 7 am to 3 pm. The purpose of this clinic is to

offer same- day healthcare evaluation and treatment to three types of HIV infected patients on a

walk-in basis. They include newly diagnosed HIV patients, previous patients that are being

readmitted to the clinic who are fallen out of care for more than a year, and established patients

who are sick and need to be seen before their next scheduled appointment. At the initial visit,

prescribing provider offers mental health screening, risk assessment, discuss sexual health,

education regarding HIV infection, and benefits of initiating antiretroviral therapyART. Options

will be given to patients for declining the treatment or initiation of ART on the same day. To

those who are willing to start the ART, all baseline laboratory tests (CD4 count, HIV RNA level,

renal and liver function tests, hepatitis serology, HLA B 5701 testing and HIV resistance


genotyping) will be obtained. Pre-approved ART regimen (Tivicay & Descovy or Prezista &

Descovy or Genvoya) will be initiated and the patient will be given a 30-day supply of ART with

a 2 two-weeks follow up appointment in a regular clinic. Also, Drug assistance Assistance

program Program(ADAP) / Ryan White funding appointments for unfunded patients will be

arranged on the same day so that these patients will be eligible to get free medication through

these funding. The Same Day Access Clinic will increase the number of patients added to the

practice and thereby access to care for newly diagnosed HIV patients as well as those who want

to get re-established with the services.

Measurement & Evaluation Plan

Measures

After the implementation of Same Day Access Clinic, the quantitative data will be collected

related to patient metrics and no show rates. Also, the qualitative data pertaining to the referral

process and clinic flow will be evaluated using a quality assessment questionnaire developed

from the Agency for Healthcare Research and Quality (AHRQ, 2017).

Data collection Procedure

Upon IRB approval, the data will be collected for a period of four months after

implementation of the project. Indicators are as follows :1. The percentage of newly diagnosed

HIV patients who initiated ART through the Same Day Access Clinic for a period of four months

2. The time frame from the date of diagnosis to ART initiation in each individual cases. 3.

Percentage of no-show rates will be assessed for a period of four months status post

implementation of the project. To measure the no show rate, the total number of referrals will be

collected from various referral units such as HIV screening, Disease Intervention Specialists

(DIS) and the Health Department Business Center. Data will be compared with the number of


patients who are not showing up for their initiation of ART. The student researcher will create a

form and will answer six series of open-ended questions after analyzing the data and will record

the results in narrative text format. The researcher will be using a series of tables and graphs to

summarize the information gathered. To have an easy understanding of the process a flow chart

will be developed that will guide other Health Department Clinics who would like to implement

Test & Treat initiative in their practice settings. A minimum of thirty newly diagnosed HIV

patients will be included for the study. However, sample size may vary according to the

availability of new cases, plan is to include all the newly diagnosed HIV patients for a period of

four months post implementation of the project.

Data Management

Data analysis will be done on an Excel spreadsheet. A flow chart will be created to show

the comparative analysis of patients who initiated ART on the same day versus those not

initiated same day antiretroviral therapy. The researcher will collect the data by reviewing the

patient chart from Electronic Health Record (EHR) for a period of four months upon IRB

approval. The data will be stored in health department computer with a protected password. Once

the project is completed, the hardcopy of files will be destroyed by shredding, and the researcher

will delete the computer files permanently.

Data Analysis Plan

The author will evaluate both quantitative and qualitative data from Same Day Access

clinic to see if the goals and objectives of the project have been met and intervention is

beneficial. It is assumed that initiation of an ART on the same day of HIV diagnosis will not

only increase the access to care but also improves the patient metrics of the facility. The

Researcher also will evaluate whether this Same Day Access Clinic process will reduce time


frame to initiate ART on a newly diagnosed patient. In addition, it will serve as a practice model

for other county health departments to increase the accessibility of care for their HIV population.

The process of referrals and barriers will be analyzed. Based on the results, the recommendations

for a process improvement will be given.

Measurement & Evaluation Plan

Measures

After the implementation of the Test & Treat Initiative through the Same Day Access

Clinic, this researcher will evaluate the process of outcome by looking into four steps in the

process (see Appendix C)

1. S creening for HIV

2. L inkage to care

3. I nitiating Same Day ART

4. T ransition to care.

Data collection Procedure

Upon IRB approval, the qualitative outcome pertaining to the Test and Treat initiative

will be assessed by using a checklist, and the data will be collected every month for a period of

four months after implementation of the project. The outcome will be evaluated are as follows:

1. Percentage of patients who had screening and tested positive for HIV

2. Linkage to care as measured by the percentage of patients who were registered at the

Same Day Access Clinic, are seen by the provider on same day, and who were issued a

prescription for Same Day ART

3. Percentage of patients who initiated Same Day ART and those who got their first dose of

medication in the clinic


4. Transition to care as measured by the percentage of patients who had shown up for

follow-up appointments in two weeks.

This researcher will utilize a series of tables and graphs to summarize the information

gathered. To facilitate easy understanding of the process, a flow chart will be developed that

will also serve as a guide for other Health Department Clinics that would like to implement the

Test and Treat initiative in their practice settings. A minimum of thirty newly-diagnosed HIV

patients will be included in the study; however, sample size may vary according to the

availability of new cases.

Data Management

A checklist will be created in questionnaire format, and adherence to each step of the

Test and Treat Initiative will be marked by answering “Yes” or “No.” The data will be collected

each month, and the results of the analysis will be marked on an Excel™ spreadsheet. There will

also be a monthly comparative analysis of patients who initiated ART on the same day versus

those who did not. This researcher will collect the data by a retrospective review of the patient

chart from Electronic Health Record (EHR) for a period of four months upon IRB approval. The

data will be stored in health department computer with a protected password. Once the project is

completed, any hard copies of files will be destroyed by shredding, and this researcher will

delete the computer files permanently.

Data Analysis Plan

The author will evaluate quantitative as well as qualitative data from the Same Day

Access Clinic to see if the goals and objectives of the project have been met and intervention is

beneficial. It is assumed that the Test and Treat initiative through the Same Day Access clinic

will increase the access to care, an early initiation of ART and the transition to care. A flow chart


will be created to show the Same Day Access Clinic process of implementing the Test and Treat

Initiative. In addition, it will serve as a practice model for other county health departments that

wish to increase the accessibility of care for their HIV+ population, where the process and

barriers can be analyzed and recommendations for process improvement can be made based on

those results.

Protection of Human Subjects

As Because this study focuses on practice improvement, it will have pose a low risk for

human subjects. There are no known or anticipated risks associated with participation in this

study. Volunteers who agreed to participate in the practice improvement project will be provided

an with all information pertaining to informed consent prior to the implementation of the project.

. There is no compensation; cost or conflict of interest because of participation. Records

and data will remain private and confidential. Outcomes from this study may be published,; in

which case no information that would allow for patient identification will be includedpatient

identification will be impossible. No names or patient identifiers will be included in the data

collection process. A pPatient’s health information will remain private and their human rights

will be protected.

Project Approval approval was obtained from Mr. Carlos Mercado, the Director of

Hillsborough County Health Department, Mr. Carlos Mercado. (See Appendix D.)

The Same Day Access Clinic model will be submitted to the IRB for review and

approval.

Dissemination Plan


Meetings will be held weeklyto keep to inform the Same Day Access Clinic staff

(Registered registered Nursesnurses; Nursing nursing supervisors & Medical medical assistants)

up to date on the process who are working in the Same Day Access Clinic will be held

weeklyabout the process.

D. The daily data regarding the number of newly diagnosed HIV patients who initiated

ART through Same Day Access Clinic will be reported to the data analyzer. After

implementation, the all data will be collected, analyzed, and compared by the researcher. The

dissemination Dissemination Pplan involves the internal stakeholders, manuscript, poster,

conferences and meetings. The final report will be submitted to the Program Manager of the

Specialty Care Clinic Health Department, and the results will be shared with Dr. Catherine Ling,

USF faculty supervisor. AThere will be a poster presentation will be made accessible to staff and

students at the University of South Florida, while t. The data will also be shared with internal

stakeholders, providers, nurse practitioners, and nurses who work in the Health Department. A

manuscript will be submitted for publication to the peer- reviewed -journal of the Association of

Nurses in AIDS Care.

Conclusion

The United States Centers for Disease Control and Prevention (CDC) estimates that HIV

has not been diagnosed in about 13% of the people living with this virus (CDC 2017). Review of

the literature shows that only 57% of patients are retained in care since the diagnosis of HIV.

Among this group only 55% are virally suppressed because of poor linkage to care and retention

in care (CDC, 2015). Implementation of Same Day Access Clinic is an evidenced-based

intervention that aims to facilitate linkage to care. Previous quality improvement projects suggest


that initiation of same daySame Day ART on newly diagnosed HIV patients improves early viral

load suppression as well as keeps them in care. Implementing the proposed changes not only

minimizes the days from HIV diagnosis to initiation of antiretroviral therapyART but is also

proven to suppress the viral load at the earliest. This proposed project investigates the promoting

factors and gaps in the literature, and uses that combined information to implement the Same

Day Access Clinic in the Specialty Care Clinic setting at Hillsborough County Health

Department. This will ultimately promote quality priorities of the FLDH, and improve healthcare

outcomes for its HIV population.


Appendix A.

PRISMA Diagram


Appendix B

HIV Treatment Cascade

Retrieved from Clinical Infectious Diseases., 57(8), 2013.


Make sure to include this in your Reference section


Appendix CLetter from Mr. Mercado


Appendix D

Same Day Access Clinic Process in Initiating Same Day ART on

Newly-diagnosed HIV+ Patients


References

Dearholt, S.L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and

Guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.

FDOH HIV/ AIDS section Test and Treat Protocol. (Sep 2016) retrieved from

hhttp://www.flheath.gov.

1.Screening Test

Positive

Screening Test Positive for HIV

New HIV + Patients

2.Linkage to Care new HIV+

Patients.

Register to same day Acess clinicSeen By Providers

Medical/ Psychosocial EvaluationMedical history/ Physical Exam

Education/ counselling on HIV & its treatment

Prescribe ART

3.Start Same Day ART

Clinician /nurse VisitObtain Baseline labs.

Counselling on risks & benefits of ART

ART dispensed as per provider recomendations.

Educational Hand outs givenEligibility AssessmentCounselling by Ryanwhite/ ADAP funding staff

4.Transition to Care

Monitor/ assure compliance by RN within 7 days

Follow up labs and appointments in 2 weeks

Transition to long term Primary HIV care.


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Koeing, S. P., Dorvil, N. De Vieaux, J. G., Hedtgautheir, BL, Riviera. C., & Faustin; M. (2017)

same day HIV testing with initiation of antiretroviral therapy versus standard care for persons

living with HIV. PLoSMed,14(7).doi.org/10.1371/journal.pmed.10002357.

Rosen, S., Maskew, M., Fox, M.P., Nyonic, C., Mallet, G., Sannel, L., Bokaba, D., Saul, C., &

Long, L. (2016). Initiating Antiretroviral Therapy for HIV at a Patients First Clinical Visit: The

Rapid IT Randomized Control Trial. PLoS Med. 13(5), e1002015.doi:10.1371.

National Institutes of Health, U.S. Department of Health and Human Services. (2017). Retrieved

July 2, 2018, from http://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/30/

adherenc.


Pathways of resistance in subjects failing dolutegravir monotherapy (2017).CROI Conference,

Retrieved from http://www.croiconference.org/sessions/initiating-art-patient%C2%92s-first-

clinic-visit-rapit-randomized-trial.

World Health Organization. “Towards Universal Access: Scaling up Priority HIV/AIDS

Interventions in the Health Sector. Progress Report (2008).” Retrieved June 30, 2018 from

http://www.who.int/hiv/pub/towards universal access report 2008.pdf.

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents,

AIDS info, (2017). Department of Health and Human Services. Retrieved July 2, 2018 from

https://aidsinfo.nih.gov/guidelines.

Appendix E

Evaluation Questionnaires Developed as per Agency for Healthcare Research and

Quality’s (AHRQ), 2017 Tool

Does the Same Day Access Clinic help to reduce the number of days to ART initiation on a newly diagnosed Patients?

Once Implemented the process of Same Day Access Clinic Model, are we able to get zero percent no show rate.

Does the process flow for referrals are executed smoothly and patients get to the provider within recommended time frame.?

What are the benefits of implementing the project?

What are the barriers for implementation of the process?

https://aidsinfo.nih.gov/guidelines

http://www.who.int/hiv/pub/towards%20universal%20access%20report%202008.pdf


Does Same Day Access Clinic will be a model for other health department clinics to follow in providing efficient care for HIV population?

Center for Disease Control and Prevention, Guidelines for Using Antiretroviral Agents Among

HIV-Infected Adults and Adolescents, (2014). Atlanta, GA:US Department of Health and

Human Services, CDC, (2014). Retrieved from https://stacks.cdc.gov/view/cdc/2603.

Mugavero ,M.J., Amico, K. R., K., Horn, T., & Thompson, M.A. (2013).The State of

Engagement in HIV Care in the United States: From Cascade to Continuum to Control. Clinical

Infectious Diseases, 53(8),1164-1171.Retrieved from

https://doi.org/10.1093/cid/cit420.

San Francisco Program for Rapid ART Initiation and Linkage to Care,

Standard Operating Procedures (2016). Retrieved June 28, 2018, from

https://www.gettingtozerosf.org/wp-content/uploads/2016/09/20160822 citywide rapid

protocolv2.pdf.

Guide for HIV/AIDS Clinical Care. (2011). Retrieved June 30, 2018, from

https://www.scribd.com/document/68035987/AIDS-Clinical-Guide-Jan2011.

Labhardt, N.D., Ringera, I., ThaboI.Lejone, T.I., Klimkait, T., Muhairwe, J.,

Amstutz, A., & Glass, T.A. (2018). Effect of offering Same-Day ART VS Usual

Health Facility Referral During Home Based HIV testing on Linkage to Care

and Viral Suppression among Adults with HIV, The CASCADE Randomized

Clinical Trial. JAMA,319(11),1103-1112. doi:10.1001/jama.2018.1818.

https://www.scribd.com/document/68035987/AIDS-Clinical-Guide-Jan2011

https://www.gettingtozerosf.org/wp-content/uploads/2016/09/20160822%20citywide%20rapid%20protocolv2.pdf

https://www.gettingtozerosf.org/wp-content/uploads/2016/09/20160822%20citywide%20rapid%20protocolv2.pdf

https://stacks.cdc.gov/view/cdc/2603


Appendix A

Mission:

To protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.

Vision: To be the Healthiest State in the Nation

June 6, 2018

Rick Scott

Governor

Celeste Philip, MD,

MPH

State Surgeon General and Secret

Digy Paul, MSN, ARNP-c

Florida Department of Health in Hillsborough County 1105 E. Kennedy Boulevard

Tampa, FL 33602-3511

Dear Ms. Paul:

The purpose of this letter is to confirm administrative support and approval for implementation of the proposed quality improvement project, under protocol title "HIV Same Day Access Clinic Model Initiative & Implications on a Practice" at the Florida Department of Health in Hillsborough County in the Specialty Care Center facility. The goals of this quality improvement project are consistent with the Department's commitment to a culture of continuous quality improvement and of our agency's strategic goal to increase healthy life expectancy, including the reduction of health disparities by reducing the number of new HIV infections and fulfill our mission to promote, protect and improve the health of all people in Florida through integrated state, county & community efforts. We welcome this opportunity to support this endeavor and to further achieve our mutual goals and objectives.

,

Director, Disease Control Division

Florida Department of Health - Hillsborough County

cc:

HEALTH


Charurut Samboonvit, MD, Senior Medical Director, Florida Department of Health in Hillsborough County

Michael Wagner, Health Center Administrator, Special Care Center, Florida Department of Health in Hillsborough County

Nadine Connor, DNP, MSN, ARNP-c, Administrative Director for HIV Services, Specialty Care Center, Florida Department of Health in Hillsborough County

Maritza Acosta, Office Manager, Specialty Care Center, Florida Department of Health in Hillsborough County.

Florida Department of Health - Hillsborough County

Division of Disease Control; P. O Box 5135. Tampa, FL 33675-5135. Phone (813) 307-8008. Fax:813-272-6984.

PROMOTING LINKAGE TO CARE AMONG HIV POPULATION: 33

Appendix B

Same Day Access Clinic Process in Initiating Same Day ART on Newly Diagnosed HIV+ Patients.

1.Screening Test

Positive

Screening Test Positive for HIV

New HIV + Patients

2.Linkage to Care new

HIV+ Patients.

Register to same day Acess clinicSeen By Providers

Medical/ Psychosocial valuationMedical history/ Physical Exam

Education/ counselling on HIV & its treatment

Prescribe ART

3.Start Same Day ART

Clinician /nurse VisitObtain Baseline labs.

Counselling on risks & benefits of ART

ART dispensed as per provider recomendations.

Educational Hand outs givenEligibility AssessmentCounselling by Ryanwhite/ ADAP funding staff

4.Transition to Care

Monitor/ assure compliance by RN within 7 days

Follow up labs and appointments in 2 weeks

Transition to long term Primary HIV care.


Appendix C

Evaluation Questionnaires Developed as per Agency for Healthcare Research and

Quality’s (AHRQ), 2017 Tool

Does the Same Day Access Clinic help to reduce the number of days to ART initiation on a

newly diagnosed Patients?

Once Implemented the process of Same Day Access Clinic Model, are we able to get zero

percent no show rate.

Does the process flow for referrals are executed smoothly and patients get to the provider

within recommended time frame.?

What are the benefits of implementing the project?

What are the barriers for implementation of the process?

Does Same Day Access Clinic will be a model for other health department clinics to follow in providing efficient care for HIV population?


References


Center for Disease Control and Prevention, Guidelines for Using Antiretroviral Agents Among

HIV-Infected Adults and Adolescents, (2014). Atlanta, GA:US Department of Health and

Human Services, CDC, (2014). Retrieved from https://stacks.cdc.gov/view/cdc/2603.

Clinical Infectious Diseases (2013). Volume 57, Issue 8, 15 October 2013.

https://doi.org/10.1093/cid/cit420

Dearholt, S.L., & Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and

Guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.

FDOH HIV/ AIDS section Test and Treat Protocol. (Sep 2016) retrieved from

hhttp://www.flheath.gov.

Guide for HIV/AIDS Clinical Care. (2011). Retrieved June 30, 2018, from

https://www.scribd.com/document/68035987/AIDS-Clinical-Guide-Jan2011.

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents,

AIDS info, (2017). Department of Health and Human Services. Retrieved July 2, 2018

from https://aidsinfo.nih.gov/guidelines.

Koeing, S. P., Dorvil, N. De Vieaux, J. G., Hedtgautheir, BL, Riviera. C., & Faustin; M. (2017)

same day HIV testing with initiation of antiretroviral therapy versus standard care for

persons living with HIV. PLoSMed,14(7).doi.org/10.1371/journal.pmed.10002357.

Labhardt, N.D., Ringera, I., ThaboI.Lejone, T.I., Klimkait, T., Muhairwe, J., Amstutz, A., &

Glass, T.A. (2018). Effect of offering Same-Day ART VS Usual Health Facility Referral

During Home Based HIV testing on Linkage to Care and Viral Suppression among Adults

with HIV, The CASCADE Randomized Clinical Trial. JAMA,319(11),1103-1112.

doi:10.1001/jama.2018.1818.


Mugavero ,M.J., Amico, K. R., K., Horn, T., & Thompson, M.A. (2013).The State of

Engagement in HIV Care in the United States: From Cascade to Continuum to Control.

Clinical Infectious Diseases, 53(8),1164-1171.Retrieved from

https://doi.org/10.1093/cid/cit420.Melnyk, B.M., & Fineout-Overholt, E. (2015). Evidence-

based practice in nursing & healthcare: A guide to best practice (3rd ed.). Philadelphia,

PA: Wolters Kluwer Health.

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National Institutes of Health, U.S. Department of Health and Human Services. (2017). Retrieved

July 2, 2018, from http://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/30/

adherenc.

Pathways of resistance in subjects failing dolutegravir monotherapy (2017).CROI Conference,

Retrieved from http://www.croiconference.org/sessions/initiating-art-patient%C2%92s-

first-clinic-visit-rapit-randomized-trial

Pilcher, C.D., Ospina-Norvell, C., Dasgupta A., Jones, D., Hatrogenesis, W., Torres,

S., Calderon, F., Demico, E., Geng, E., Gandhi, M., Havir, D.V., & Hatano, H (2015)

Providing Same Day, Observed ART to newly diagnosed HIV+ out patients are associated

with improved virology suppression. Journal of Acquired Deficiency Syndrome,59(1), 86-

93.doi:10.1097/QAI.0000000000001134


Poe, S. S., & White, K. M. (2010). Johns Hopkins nursing evidence-based

practice: Implementation and Transition. Indianapolis, IN: Sigma Theta

Tau International.

Rosen, S., Maskew, M., Fox, M.P., Nyonic, C., Mallet, G., Sannel, L., Bokaba, D., Saul, C., &

Long, L. (2016). Initiating Antiretroviral Therapy for HIV at a Patients First Clinical Visit:

The RAPID IT Randomized Control Trial. PLoS Med. 13(5), e1002015.doi:10.1371.

San Francisco Program for RAPID ART Initiation and Linkage to Care, Standard Operating

Procedures (2016). Retrieved June 28, 2018, from https://www.gettingtozerosf.org/wp-

content/uploads/2016/09/20160822 citywide rapid protocolv2.pdf.

World Health Organization. “Towards Universal Access: Scaling up Priority HIV/AIDS

Interventions in the Health Sector. Progress Report (2008).” Retrieved June 30, 2018

from http://www.who.int/hiv/pub/towards universal access report 2008.pdf.

http://www.who.int/hiv/pub/towards%20universal%20access%20report%202008.pdf

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