Just a little over a year ago, the ActionAIDS board of directors amended our mission statement to explicitly include our commitment to “creating an AIDS-free generation through a combination of proven strategies.” On World AIDS Day 2014, with its official theme of Focus, Partner, Achieve: An AIDS-free Generation, we can’t think of a better time to explain our focus, how we partner and what we’re achieving to create an AIDS-free generation. Our focus on proven strategies
Among our “proven strategies” is our medical case-management program. Medical case management is our biggest program, with 71 employees involved in providing services to approximately 2,700 clients every year.
Our medical case-management services facilitate access to ongoing medical care, which is crucial to enhance and prolong the lives of our clients. By ensuring continuity of medical care, we also reduce the development of drug-resistant HIV, decrease sexual-risk behaviors and, as our clients in treatment maintain low or non-detectible viral load, we reduce or eliminate the risk of HIV transmission to others. These services are among our most effective means of achieving our mission of creating an AIDS-free generation.
Medical case management: Partnering with clients and their service providers
Medical case-management services link HIV-positive people to medical care; public benefits; behavioral health/substance abuse treatment; medication management; service coordination (housing, employment, education, childcare, emergency financial assistance); and transition to greater health and self-sufficiency. While services are individualized, all clients participate in an intake and assessment process to determine an overview of need. Once a client is assigned to the appropriate service, the medical case manager and client develop an individualized Care Plan, which sets priorities, goals and objectives related to a client’s health and stability. The plan guides intervention and also tracks progress. Clients have contact with their case manager on a minimum of a monthly basis, but often new clients are engaged in services more frequently.
Case management has a cross-coverage system and 24/7 beeper service to ensure that a staff person is always available during times of crisis. Our medical case-management program has grown out of our volunteer Buddy program and has been developed over nearly 28 years, in partnership with HIV-positive clients.
The Philadelphia (Prison) Linkage Program (PLP) works to assist clients in their transition from prison to the community. Clients who have been incarcerated face a myriad of challenges including poverty, homelessness, drug and alcohol and mental-health issues. The stigma of having been incarcerated, coupled with the emotional and physical manifestations of having HIV disease, all contribute to the potential for clients to be lost to care, re-incarcerated or unable to engage in treatment.
Our Prison Case Management model was designed to address the significant challenges we faced in working with this transitioning population. First, we identify potential clients before their release from jail and immediately engage them while they are incarcerated. During this time, the medical case manager has regular face-to-face contact with the client. These face-to-face meetings allow the case manager to establish trust and to build a relationship that enables the case manager to work with the client to facilitate medical care while the client is incarcerated and to remove barriers to primary medical care once the client is released from prison. The model utilizes frequent contact in the first three months of the client’s release from prison, and we have explicit protocols on accessing medications, face-to-face contacts and accompanied primary-care visits. Program staff is heavily involved in ensuring that the client keeps initial primary-care appointments and in working with a pharmacy to ensure that medication regimens are not interrupted during the transition from prison to the community. Additionally, clients establish relationships with the entire prison team staff, allowing for more effective and efficient back-up staff coverage when a client experiences a crisis.
Partnering for outcomes
A key component of our medical case-management model is the delivery of medical case management in partnership with community sites. ActionAIDS’ medical case-management staff are “out-stationed” to provide care at 29 sites in the community, in additional to our own five ActionAIDS offices, including locations in Center City, North Philadelphia, West Philadelphia and Delaware County.
Challenges faced by clients
Our clients with HIV face serious challenges when it comes to accessing health care and keeping up with HIV-treatment schedules — whether they are in the PLP program or not. About 90 percent of our clients are low-income, and 79 percent fall below the Federal Poverty Level. Many clients also are also homeless. In the past year, approximately 55 percent had a history of mental illness or substance abuse. Our clients’ achievements
Despite the challenges they face, our clients are quite successful — with our support — in accessing and staying in treatment for their HIV disease. This treatment can have a significant impact on viral load. Viral load is the amount of HIV in a person’s blood stream — and is thus a crucial indicator of the impact of antiretroviral treatment. If viral load is high, a person’s CD4 count will be low, which results in higher vulnerability to opportunistic infections. Lower viral load, on the other hand, protects the immune system. Ideally, we aim for “undetectable” viral load — a level so low that it can’t be measured.
From the beginning of 2009 to mid-year 2014, our client data shows a strong correlation between the length of time in medical case management and viral load. The initial effect is particularly dramatic: Average viral load drops 76 percent during the first six months during which a client receives medical case-management services. Clients who remained engaged in medical case management for 24 months had an average viral load of just under 3,000, a 93-percent reduction in viral load. On average, clients in medical case management for 48 months have undetectable viral load. At the same time, during 2013 (our most recent period with complete data), 95 percent of our clients were linked to HIV medical care.
These results are particularly impressive when compared to the objectives set forth in President Obama’s 2010 National HIV/AIDS Strategy (NHAS). The NHAS calls for an increase in the proportion of Ryan White HIV/AIDS Program clients who are in continuous care (at least two visits for routine HIV medical care in 12 months, at least three months apart) from 73-80 percent. ActionAIDS exceeds that level, with 95 percent of our clients retained in routine HIV medical care.
To put it quite simply, our medical case-management services out-perform the goals of the president’s HIV/AIDS Strategy. When it comes to our ActionAIDS clients, we expect to create the first AIDS-free generation ahead of schedule.