After many months of consultations with representatives of regional health authorities in BC, as well as the First Nations Health Authority, the BC-CfE is proud to announce the publication of the Provincial Best Practice in HIV Case Management.
This document aims to provide a practice standard which has arisen through the Re-engagement and Engagement in Treatment for Antiretroviral Interrupted and Naïve populations (RETAIN) Initiative. Launched in 2016, RETAIN is a partnership with regional health authorities to improve upon the previous system for identifying and re-engaging people living with HIV (PLWH) in BC who may have interrupted treatment. Anyone involved in case-management for persons living with HIV can consult this newly published document for detailed methods and resources used to help those who have become disengaged from care, or have delayed engagement in HIV care following diagnosis.
The BC-CfE’s Hayden Kremer, the RETAIN Coordinator, and Dr. David M. Moore, a physician with the BC-CfE’s Epidemiology and Population Health Program coordinated the development of this document along with Nancy Chow, a public health nurse and Valerie Martin, a social worker, both from Vancouver Coastal Health. Dr. Rolando Barrios, the BC-CfE’s Senior Medical Director, is the Medical Lead of the RETAIN program.
Besides pioneering the Treatment as Prevention (TasP) strategy, adopted by the United Nations in 2011, the BC-CfE and its Executive Director and Physician-in-Chief Dr. Julio Montaner also played a pivotal role in the creation of antiretroviral therapy (ART). ART significantly improves the health and longevity of PLWH, to the point where PLWH on consistent ART can achieve a suppressed viral load and have no possibility of transmitting HIV to others.
However, ART interruptions remain a challenge to improving health outcomes and reduced transmission. Furthermore, delayed ART initiation for newly diagnosed PLWH remains prevalent.
The crucial element of the RETAIN Initiative involves creating clear communication pathways between clinical teams and coordinating case management teams so both sets of teams can work together to bring people living with HIV into care.
With this aim of the project in mind, two phases of the RETAIN Initiative have been implemented. This first is a Clinician Alert which includes Public Health contact information. The BC-CfE sends alerts to the HIV Care Provider most recently linked to the patient. Alerts are sent for people who are either HIV positive and ART naive (never been treated with ART) or those who have interrupted ART for two months and have not yet resumed.
After this initial alert, the next step is Routine Coordination of Case Management Support. This is the core component of RETAIN: ensuring province-wide, public health directed support for all PLWH who have interrupted ART or who have yet to initiate therapy. This support may include case management, outreach, or other client-specific interventions at the discretion of Medical Health Officers in each Regional Health Authority.
As part of the process in creating the best practices document, a RETAIN working group representative of teams from each Health Authority identified five intervention stages to help guide the coordination for outreaching and engaging clients to care and treatment. These five stages are:
- 1 – Receive and Review
- 2 – Investigation
- 3 – Establish Relationship
- 4 – Facilitate the Connection to Care
- 5 – Monitor the Connection to Care.
As the document makes clear, members of teams responsible for RETAIN clients should work with the priorities of the client. As it states, “In many circumstances, re-engaging in HIV care may not be their highest priority. Housing, dealing with mental health and/or substance use issues, applying for disability benefits and obtaining ID and/or status card may be more of a priority for clients.” RETAIN teams are advised to build relationships with clients which may eventually lead to re-engagement in HIV care by helping them to navigate such services.
Beyond these five core stages, each Health Authority has specific structures which dictate roles and responsibilities of their HIV Case Management teams, key members and/or agencies for collaboration, community partnerships, documentation processes, referral services, and information access.
Thanks to the Provincial RETAIN network and Provincial Best Practice in HIV Case Management, BC now has an official and standard process of routine coordination to support a public health response in reaching individuals with HIV who are not accessing or have interrupted treatment. This consensus-based document can now be used as a provincial, national, and international resource.