Dr. Helena Kwakwa's presentation to the RWPC on Philadelphia Health Centers' health system navigators program, funded through Merck.

1. HEALTH SYSTEM NAVIGATORS:
A NEW RESOURCE FOR PHILADEPHIA’S HIV-POSITIVE POPULATION

2. Overview
 HIV epidemic in Philadelphia
 Snapshot of HIV as seen in the health centers
 Testing
 Priority Clinics
 Tools to manage the HIV epidemic
 Testing
 Treatment
 Importance of linkage to care and retention in care
 Introducing EHPIC, the System Navigator Program

3. HIV/AIDS in Philadelphia at a glance,
2011
29,139
• Cumulative HIV/AIDS cases
• 25.7% female, 64.5% black
19,157
• Living with HIV/AIDS
• 39.6% 50 years or older
888
• New HIV/AIDS diagnoses
• 50% heterosexual

4. Overview
 HIV epidemic in Philadelphia
 Snapshot of HIV as seen in the health centers
 Testing
 Priority Clinics
 Tools to manage the HIV epidemic
 Testing
 Treatment
 Importance of linkage to care and retention in care
 Introducing EHPIC, the System Navigator Program

5. HIV/AIDS: A view from AHS
Rapid
Testing
• 7,000/yr
• 40 positive/yr
Conventional
Testing
• Fam Med Clin
• Women’s
Health
HIV Clinics
• 1,054 in 2012
• 120 new pts
• 115 lost to
care

6. Overview
 HIV epidemic in Philadelphia
 Snapshot of HIV as seen in the health centers
 Testing
 Priority Clinics
 Tools to manage the HIV epidemic
 Testing
 Treatment
 Importance of linkage to care and retention in care
 Introducing EHPIC, the System Navigator Program

7. Improving efficacy of initial HAART regimens
*Values are weighted means 1994 to July 2004 (n=14,264 patients). 90 treatment
arms from 53 trials: NNRTI (n=38); PI (n=32), NRTI (n=12), boosted PI (n=8).
Unboosted PI + 2 NRTIs
Boosted PI + 2 NRTIs
NNRTI + 2 NRTIs
3 to 4 NRTIs
(qid/tid/bid)
Unboosted PI + 2 NRTIs
Boosted PI + 2 NRTIs
NNRTI + 2 NRTIs
(tid/bid)
Boosted PI + 2 NRTIs
NNRTI + 2 NRTIs
(qd/bid)
0
20
40
60
80
100
<1998* 1999-2000* 2001-2002* 2003-2004*
Patients(%)
Bartlett et al
(AIDS. 2006;20:2051-2064)
2006-2010
ACTG 5142, CASTLE,
ALERT, KLEAN,
GEMINI, ARTEMIS,
Study 903 and 934,
STARTMRK
41%
50%
56%
64%
65% to 85%HIV RNA <50 Copies/mL

8. CDC estimates (1996-2005):
life expectancy after HIV diagnosis
 Life expectancy for HIV
patients increased from 10.5
to 22.5 years
 Women: 23.9 years
 Men: 22.0 years
 Average life expectancy
decreased with each
increasing year of age at HIV
diagnosis
0
5
10
15
20
25
30
LifeExpectancy(years)
10.3
White Black Hispanic
20.1
1996
2000
2005
Life Expectancy by
Year of HIV Diagnosis
Harrison KM, et al. JAIDS. 2010;53:124-130.
25.5
9.5
16.4
19.9
10.1
20.4
22.6

9. 0
10
20
30
40
50
NA-ACCORD: temporal changes
in life expectancy (1996-2007)
Age(years)
Life Expectancy at Age 20 Years
Year Range
96-99 00-02 03-05 06-07
34.4
47.1
36.9
43.1
 North America cohort (n=75,148)
 On HAART (49.5%)
 1799 deaths over 89,521 person-years of
follow-up
 Life expectancy at age 20 years
 Increased
 Stepwise with each calendar year
 White and Hispanic versus black
 Decreased
 IDU versus MSM and heterosexuals
 Low baseline CD4 (<100 cells/mm3)
 The need to address disparities in life
expectancy is an ongoing need
Hogg R, et a. 19th CROI. Seattle, 2012. Abstract 137.

10. Overview
 HIV epidemic in Philadelphia
 Snapshot of HIV as seen in the health centers
 Testing
 Priority Clinics
 Tools to manage the HIV epidemic
 Testing
 Treatment
 Importance of linkage to care and retention in care
 Introducing EHPIC, the System Navigator Program

11. Linkage to and retention in care
 3.9 – 8.8 years of life lost due to late initiation of ART as a result
of
 Late diagnosis
 Late linkage to care
 Approximately 1 additional year of life lost due to early
discontinuation of ART
 Among a cohort in TX with no financial barriers to care, compared
to those with visits in all 4 quarters of the first year of care, there
was
 A 42% increase in risk of death with visits in 3 quarters
 A 67% increase in risk of death with visits in 2 quarters
 A 95% increase in risk of death with visit(s) in 1 quarter
Losine E et al, Clin Infect Dis 2009;49(10):1570-1578; Giordano TP et al, Clin Infect
Dis 2007;44:1493-1499

12. “. . . underscores the importance of
developing interventions that are focused
on better linkage to and retention in care,
especially for racial/ethnic minorities.”
- Elena Losina
Losina E et al, Clin Infect Dis 2009;49(10):1570-1578

13. CDC: HIV-infected persons engaged in
selected stages of the continuum of care (2009)
0
20
40
60
80
100
Incidence(%)
Black
(n=510,600)
Hispanic or Latino
(n=220,400)
White
(n=417,200)
CDC and Prevention National HIV Surveillance System
Diagnosed
Linked to care
Retained in care
81%
62%
34%
29%
21%
Hall HI, et al. 19th IAC. Washington, DC, 2012. Abstract FrLBX05.
Prescribed ART
Viral suppression
80%
67%
37%
33%
26%
85%
71%
38%
35%
30%

14. Outreach data, AHS November-December
2012
Lost to care patients
293
116
177
0
50
100
150
200
250
300
350
Lost to care Not reached Pts contacted
Data on file, AHS

15. November-December Outreach findings
40 34
63
21
5 12 2
177
0
50
100
150
200
Relocated
Re-engaged
Change
PCP
Deceased
M
issed
appts
Incarcerated
Other
Total
#ofpatients
Data on file, AHS
Disposition of lost-to-care patients, AHS 2012

16. #ofvisitsforpatientslostto care in 2012 (n=46)
43%
30%
27%
1visit
2visits
>2visits
First visits important for retention, AHS 2012
Data on file, AHS

17. Overview
 HIV epidemic in Philadelphia
 Snapshot of HIV as seen in the health centers
 Testing
 Priority Clinics
 Tools to manage the HIV epidemic
 Testing
 Treatment
 Importance of linkage to care and retention in care
 Introducing EHPIC, the System Navigator Program

18. Introducing EHPIC: a program for linkage to
and retention in care for Priority Clinic
patients
Engaging
HIV-positive
Patients
In
Care
HIV Clinic
accessibility to
community
providers
serving PDPH
patients
Barriers imposed
by system
complexity
(PDPH and other
institutions) and
patient needs
Increase
Decrease

19. EHPIC Program
 Health System Navigators to improve retention by assisting
patients with
 Navigating health center systems
 Navigating other systems to which they are referred
 Health System Navigators to improve retention by better engaging
existing patients
 Health center clinicians
 Improve HIV testing rates to identify and link patients with HIV
 HIV community engagement by identifying key community
partners and improving communication and resource-sharing

20. Pt
HC
AA
HF
AACO

21. Targets for health system navigation
Health
System
Navigators
Newly
diagnosed
patients
Patients lost
to or loosely
engaged in
care
Patients
referred

22. Health system navigation flow chart

23. Health System Navigator referrals
Newly diagnosed
Social workers
Rapid testers
Family Med
Pediatrics
External sources
Previously diagnosed
Community
testing sites
Other care
providers
Other
Lost to care
Outreach worker

24. The loosely engaged patient
 The patient with non-engaged visits
 Forms
 Acute issues
 Walk-in visits
 Often precedes loss to care
 Will be referred by
 Oumar Gaye
 Priority Clinic team

25. Introducing the health system
navigators
Trevor Dantzler
(HC #3, HC #5)
Shelise Henneghan
(HC #9, HC #12)
Richard LaBoy
(HC #6, HC #10)
Donielle Sturgis
(HC #2, HC #4)
Supervisor
CQI Manager

26. And the Health System Navigator
supervision
• Program
• CQI
Oumar Gaye
Clinical Care Coordinator,
AHS
• Personnel
management
• ActionAIDS liaison
Raphiatou
Noumbissi
Case Management
Supervisor, ActionAIDS

27. Additional Navigator duties
 Partner services
 DIS to meet with patients at health centers
 Coordinated by Oumar Gaye
 For patients testing HIV-positive through conventional testing, and
who do not show for follow-up appointments
 Navigators will assist with re-linking patients
 Not Navigator duties
 Adherence counseling
 Case management
 Social work
 Clerical duties

28. Referring to Navigators
 Trevor Dantzler (HC #3, HC #5)
 267-291-4539; tdantzler@actionaids.org
 Shelise Henneghan (HC #9, HC #12)
 267-713-8974; shenneghan@actionaids.org
 Richard LaBoy (HC #6, HC #10)
 267-908-6040; rlaboy@actionaids.org
 Donielle Sturgis (HC #2, HC #4)
 Don’t know which health center? Don’t have time to look it up?
 Call Oumar Gaye (215-869-0721); oumar.gaye@phila.gov
 Call Raphia Noumbissi (215-387-7058); rnoumbissie@actionaids.org

29. HEALTH SYSTEM NAVIGATORS:
A NEW RESOURCE FOR PHILADELPHIA’S HIV-POSITIVE
POPULATION