The goals and objectives of Broward County's Test and Treat (T&T) Program are aligned with measures/indicators and targets set forth by the CDC. The CDC's most recent PS-18-1802 Integrated HIV Surveillance and Prevention Programs for Health Departments Evaluation and Performance Measurement Plan is to increase linkage and retention in HIV medical care among people living with HIV (PLWH).
- Increase the percentage of persons linked to care and on ART medications
- Increase the percentage retained in care and percentage with suppressed viral load
The long-term outcome will be a reduction in community viral load; therefore, decreasing transmission of the virus and rates of new HIV infection in Broward County. Under the ICS structure, ICS Chiefs first met daily beginning 2/5/16 where situation reports were prepared to document meeting outcomes. Also starting in February 2017, the Incident Action Plan was reviewed and updated weekly to monitor key processes that included 1.) Training/Outreach, 2.) Social Marketing, 3.) Data Monitoring and Evaluation, 4.) Ryan White Part A Provider Engagement, 5.) T&T Implementation and 6.) Pharmacy.
Steps taken to implement the program
THREE STEPS FOR T&T
- Referral
- ART Initiation
- Linkage to care, retention and re-engagement
Step 1: Referral for Newly Diagnosed Clients
- Newly Diagnosed Client Identified at a Testing Site that does not Provide HIV Primary Care Under the Ryan White Part A Program:
- Each site where HIV testing is conducted will designate a T&T Key Contact.
- T&T Key Contact will inform the DOH-Broward T & T Program Manager or designee about the newly diagnosed client immediately during normal business hours or the next business day.
- The testing counselor will introduce the concept of T&T to the client and determine the preferred T&T provider.
- The T & T Program Manager will determine if HIV+ client is newly diagnosed or lost to care using PRISM (PRISM: DOH data management system for STD surveillance and investigation), eHARS and/or PE.
- If the client is newly diagnosed, the testing counselor should do an oral confirmatory test as a failsafe mechanism in case the client does not follow through with the T&T appointment and therefore does not have blood drawn for a confirmatory test. Otherwise the client with a reactive rapid test will not be counted as a confirmed case.
- If the client is newly diagnosed, an STD DIS and HIV LRS will arrive onsite to initiate partner services and finalize the T&T discussion.
- The HIV LRS will contact the T&T Champion at the selected T&T Provider and make a T&T appointment for that day.
- The HIV LRS will accompany the client to the appointment along with the testing counselor/linkage if applicable.
- Newly Diagnosed Client who is Identified at a Testing Site that Provides HIV Primary Care Under the Ryan White Part A Program:
- Each Ryan White Part A primary care provider site, where HIV testing is conducted, will designate a T&T Champion.
- T&T Champion will inform the DOH-Broward T & T Program Manager or designee about the newly diagnosed client immediately during normal business hours or the next business day.
- The testing counselor will introduce the concept of T&T to the client and determine the preferred T&T provider.
- The T & T Program Manager will determine if HIV+ client is newly diagnosed or lost to care using PRISM, eHARS and/or PE and will inform the provider.
- If the client is newly diagnosed, the testing counselor should do an oral confirmatory test as a failsafe mechanism in case the client does not follow through with the T&T appointment and therefore does not have blood drawn for a confirmatory test. Otherwise the client with a reactive rapid test will not be counted as a confirmed case.
- The T&T Champion will make a T&T appointment for that day and the testing counselor/ HIV LRS will accompany the client.
- The STD DIS will follow up with the client for partner services.
- Newly Diagnosed Client Identified at a Private Physician's Office:
- DOH-Broward STD Program will be notified about the positive HIV test as part of routine surveillance, most likely before the physician is aware.
- The STD Program Manager will notify the T & T Program Manager who will determine if HIV+ client is newly identified or lost to care.
- The STD Surveillance staff will contact private physician to determine who will notify the client of their HIV+ diagnosis.
- Once client is aware of their HIV+ diagnosis, STD DIS will initiate partner services and introduce the T&T Program to the client. STD DIS will notify the HIV LRS.
- The HIV LRS will select a T&T provider based on the client's insurance status.
- If the client's insurance will not cover a visit to a Ryan White Part A T&T provider due to out of network, deductible etc., HIV LRS will attempt to make a T&T appointment with an in network HIV primary care physician.
Step 1: Referral for Lost to Care Clients
- Lost to care clients may be identified in various ways, including but not limited to:
- Reactive rapid test at a testing site (that provides Ryan White Part A primary care or one that does not)
- Contact with an HIV community based organization
- Referral to the T & T Program by Part A providers, CHD Pharmacy and ADAP (ADAP: AIDS Drug Assistance Program administered by States and authorized under Part B of the Ryan White Treatment Modernization Act. Provides FDA-approved medications to low-income individuals with HIV disease who have limited or no coverage from private insurance or Medicaid. ADAP funds may also be used to purchase insurance for uninsured Ryan White HIV/AIDS Program clients as long as the insurance costs do not exceed the cost of drugs through ADAP and the drugs available through the insurance program at least match those offered through ADAP), private physicians, ERs etc.
- Identified by Data to Care Project
- T&T Key Contact/Champion will inform the T & T Program about the lost to care client
- HIV LRS will conduct the appropriate research in the available data systems
- If client is onsite, HIV LRS will arrive onsite and conduct T&T referral as described above.
- If client is not onsite, HIV LRS will locate the client and conduct T&T referral as described above
Step 1: Referral for Newly Diagnosed or Lost to Care Client Identified while Hospitalized
- Social worker/Designated T&T Key Contact: Appointed staff member located at a community testing site that does not provide HIV Primary Care, the Emergency Room (ER), and the Hospital (inpatient) who is responsible for all correspondence of new HIV+ infections to the T & T Program contacts CIED (Centralized Intake and Eligibility Determination program funded by the Broward County Ryan White Part A Program as the entry point for Broward County HIV positive residents accessing Part A medical and support services) to complete eligibility. CIED collects and enters client's eligibility information (proof of residence, proof of income, HIV+ test) into PE (Provide Enterprise (PE): Provide Enterprise developed by Groupware Technologies, Inc. (GTI) is a web-based relational, integrated data system used by Broward County Ryan White Part A program to collect client-level data on sociodemographic and epidemiologic characteristics, intake and eligibility, detailed procedure-level service units, clinical outcomes, invoices, and payments. This software is used system-wide across a network of providers to collect data that is subsequently utilized for electronic reporting as well as synchronized real time care coordination of Broward County Ryan White Part A Clients).
- Social worker/Designated T&T Key Contact informs the T & T Program Manager or designee about the newly diagnosed client immediately during normal business hours or the next business day or DOH-Broward may become aware through routine surveillance.
- The T & T Program Manager will determine if HIV+ client is newly diagnosed or lost to care using PRISM, eHARS and/or PE.
- If the client is newly diagnosed, an STD DIS will initiate partner services and introduce the T&T Program to the client. STD DIS will notify the HIV LRS.
- If the client is lost to care, an HIV LRS will be assigned to the client to initiate the T&T process described below.
Step 1: Referral for Newly Diagnosed or Lost to Care Clients who are identified while in the ER
- T&T Key Contact informs the T & T Program Manager or designee about the newly diagnosed client immediately during normal business hours or the next business day.
- The T & T Program Manager will determine if HIV+ client is newly diagnosed or lost to care using PRISM, eHARS and/or PE.
- If the client is newly diagnosed, an STD DIS and HIV LRS will arrive onsite, if the client is present, or if not, STD DIS will contact the client to initiate partner services and introduce the T&T Program to the client. The HIV LRS make contact and initiate the T&T process.
- If the client is lost to care, an HIV LRS will arrive onsite if the client is present, or if not, contact to initiate the T&T process.
Step 2: T&T Visit with ART Initiation
- Recommended ART Regimens for T&T Program
- Dolutegravir 50 mg once daily (Tivicay®) + tenofovir alafenamide/emtricitabine (Descovy®) one (1) tab once daily or
- Darunavir/cobicistat (Prezcobix®) once daily + tenofovir alafenamide/emtricitabine (Descovy®) one (1) tab once daily or
- Tenofovir alafenamide/emtricitabine/elvitegravir/cobicistat (Genvoya®) one (1) tab once daily with food.
- ART Availability-ART will be available on-site at all of the Ryan White Part A (Ryan White Part A: The part of the Ryan White HIV/AIDS Program (formerly, Title I) that provides emergency assistance to localities (EMAs) disproportionately affected by the HIV/AIDS epidemic. This includes outpatient medical care, AIDS Pharmaceuticals Assistance, Oral Care, Health Insurance premiums and cost sharing assistance, mental health services, Medical Case Management, Outpatient Substance Abuse, Food Bank/home delivered meals, and legal services) primary care providers.
- Uninsured clients
- Broward Health and the AIDS Healthcare Foundation will fill initial 30-day ART prescriptions at their on-site pharmacies and bill Ryan White Part A under Tier 2 of the Ryan White Part A Formulary.
- Memorial Healthcare Systems, Care Resource, Broward Community and Family Health Centers, and Children's Diagnostic & Treatment Center will be provided with a bulk purchase of drugs on their shelves by DOH-Broward and no billing is necessary. DOH-Broward will develop and deploy an inventory tracking system for the drugs they provide.
- Insured clients
- If the client has insurance and is having a T&T visit at a Ryan White Part A provider, the pharmacy should attempt to get a 30-day ART prescription filled. If insurance will not approve immediate fulfillment of ART prescription, Ryan White Part A will cover the cost. Client must provide proof insurance denied ART prescription (insurance statement, prior authorization, or denial of fill).
- If the client has a T&T visit at a private physician's office and receives a prescription, the client should attempt to fill the prescription at a pharmacy that accepts their insurance. If insurance will not approve immediate fulfillment of the ART prescription, the client can fill the prescription at the DOH-Broward pharmacy. Ryan White Part A will cover the cost if the client provides proof of insurance denial.
C. T&T Visit Process at a Ryan White Part A Primary Care Provider Site
1. An expedited eligibility process will be conducted. The site's designated T&T Champion (Designated T&T Champion: A dedicated T&T Program Staff member located at each community testing site that provides HIV Primary Care) will collect and enter client's eligibility information (proof of residence, proof of income (may be self-declaration), HIV+ test) into Provide Enterprise (PE), ensure the client completes the Authorization to Treat” form, and contact CIED to schedule client's appointment within two weeks to complete eligibility.
2. Client will see the on-site HIV Primary Care physician who will perform a history and physical examination, order the necessary laboratory tests, select a T&T regimen (as deemed appropriate by the physician and acceptable by the client) and provide a 30-day ART prescription. The physician may choose from one of the three recommended ART regimens or prescribe a different regimen based on client history and clinical judgment. The ART will be prescribed with laboratory results pending.
3. Client will receive a 30 day ART regimen either through the provider onsite pharmacy or physician dispensing.
4. Ideally, the client will take the first dose of medication in the physician's office.
5. The physician will document the visit in PE.
D. T&T Process for Clients who are Identified at a Private Physician's Office (Assumption is that client has insurance) (May be Newly Diagnosed or Lost to Care)
- The physician should provide a 30-day ART prescription.
- If the prescription is provided, the HIV LRS will assess the client's insurance status. The client will be referred to a pharmacy that accepts their insurance and linked to HIV primary care with an in network physician. If insurance will not approve immediate fulfillment of the ART prescription, the client can fill the prescription at the DOH-Broward pharmacy. Ryan White Part A will cover the cost if the client provides proof of insurance denial.
- If the prescription is not provided, the HIV LRS will assess the client's insurance coverage and select a T&T provider based on the client's insurance coverage and preference.
- If the client's insurance will allow, the HIV LRS will implement the T&T referral and visit process described above at a Ryan White Part A Primary Care Provider.
- If the client's insurance will not cover a visit to a Ryan White Part A T&T provider due to out of network, deductible etc., HIV LRS will attempt to make a T&T appointment with an in network HIV primary care physician. If the patient receives a prescription from the private physician, they will be referred to a pharmacy that accepts their insurance. If insurance will not approve immediate fulfillment of the ART prescription, the client can fill the prescription at the DOH-Broward pharmacy. Ryan White Part A will cover the cost if the client provides proof of insurance denial
E. T&T Process for Clients who are Identified while Hospitalized (Newly Diagnosed or Lost to Care)
- The hospital physician should provide a 30-day ART prescription at discharge.
- If the prescription is provided, the HIV LRS will assess the client's insurance status.
- Insured clients will be referred to a pharmacy that accepts their insurance and linked to HIV primary care with an in network physician. If insurance will not approve immediate fulfillment of the ART prescription, the client can fill the prescription at the DOH-Broward pharmacy. Ryan White Part A will cover the cost if the client provides proof of insurance denial.
- Uninsured clients will have their prescription filled at the DOH-Broward pharmacy under the Ryan White Part A Program. The client will be linked to care at a Ryan White Part A primary care provider and given a CIED appointment for full eligibility determination.
- If the prescription is not provided, the HIV LRS will assess the client's insurance status.
- If the client is insured, the HIV LRS will select a T&T provider based on the client's insurance status. If the client's insurance will not cover a visit to a Ryan White Part A T&T provider due to out of network, deductible etc., HIV LRS will attempt to make a T&T appointment with an in network HIV primary care physician.
- Uninsured clients will be entered into the T&T process outlined above at the Ryan White Primary Care Provider of their choice.
F. T&T Process for Clients who are identified while in the ER (Newly Diagnosed or Lost to Care)
- The ER physician should provide a 30-day ART prescription at discharge.
- If the prescription is provided, the HIV LRS will assess the client's insurance status.
- Insured clients will be referred to a pharmacy that accepts their insurance and linked to HIV primary care with an in network physician. If insurance will not approve immediate fulfillment of the ART prescription, the client can fill the prescription at the DOH-Broward pharmacy. Ryan White Part A will cover the cost if the client provides proof of insurance denial.
- Uninsured clients will have their prescription filled at the DOH-Broward pharmacy under the Ryan White Part A Program. The client will be linked to care at a Ryan White Part A primary care provider and given a CIED appointment for full eligibility determination.
- If the prescription is not provided, the HIV LRS will assess the client's insurance status.
- If the client is insured, the HIV LRS will select a T&T provider based on the client's insurance coverage and preference.
- If the client's insurance will allow, the HIV LRS will implement the T&T referral and visit process described above at a Ryan White Part A Primary Care Provider.
- If the client's insurance will not cover a visit to a Ryan White Part A T&T provider due to out of network, deductible etc., HIV LRS will attempt to make a T&T appointment with an in network HIV primary care physician. If the patient receives a prescription from the private physician, they will be referred to a pharmacy that accepts their insurance and linked to HIV primary care with an in network physician. If insurance will not approve immediate fulfillment of the ART prescription, the client can fill the prescription at the DOH-Broward pharmacy. Ryan White Part A will cover the cost if the client provides proof of insurance denial.
- Uninsured clients will be entered into the T&T process described above at the Ryan White Part A Primary Care Provider of their choice.
Notes:
1. For all of the above scenarios, DOH-Broward will work with clients who are non-Broward and/or non-Florida residents on a case by case basis.
2. Any client who refuses the T&T appointment or the initiation of ART will be followed by the HIV LRS.
3. Any T&T client who cannot obtain medication following the completion of the initial 30 day supply because they could not complete the RW Part A and/or ADAP eligibility process or due to private insurance or other barriers should receive a second 30 day supply of medication from the T&T provider.
STEP THREE: LINKAGE TO CARE, RETENTION and RE-ENGAGEMENT
A. Day 1 to 3 after ART initiation:
- If the client was newly diagnosed and initially managed by the STD DIS, the STD DIS will transition the client to the HIV LRS. Lost to care clients managed by the HIV LRS will remain as part of their caseload.
- The HIV LRS will document the information in PE.
- If the client is in the RW Part A system of care, the information will be documented in the T&T module of PE.
- If the client is not in the RW Part A system of care, the information will be documented in the T&T module of PE only accessible by DOH-Broward.
- The HIV LRS will contact the client to ask about any medical symptoms or questions and convey those to the HIV primary care provider for appropriate follow up.
- The HIV LRS will also confirm that the client has a CIED and Ryan White Part B (Ryan White Part B: The part of the Ryan White HIV/AIDS Program (formerly, Title II) that provides funds to States and territories for primary health care (including HIV treatments through the AIDS Drug Assistance Program, ADAP) and support services that enhance access to care to PLWHA and their families. This includes ADAP, Health Insurance Premium and cost sharing assistance, Home and Community Based Health Services, and Medical Transportation Services) and ADAP appointment, if appropriate, and the date of their next primary care appointment. The HIV LRS will assess and address any barriers to compliance with ART or those appointments. If the client will be following up with a primary care provide other than the one that initiated T&T, the HIV LRS will assist in making the appointment. The HIV LRS will accompany the patient to those appointments if necessary and acceptable to the client.
B. Day 5 to 14 after ART initiation:
- The client will have a visit with the medical provider to follow up on clinical care and laboratory tests. At that visit, lab results will be reviewed with the client. Any symptoms or medication side effects will be assessed. Treatment may be adjusted as appropriate. The client will make the necessary follow up appointments.
- The client will complete their eligibility appointments as appropriate.
- If the client is RW Part A and B eligible, the client will access other services as necessary and appropriate including RW Part A case management.
- The client may be assigned a HIV Client Navigator as necessary and appropriate.
ELIGIBILITY FOR T&T
- Newly diagnosed HIV clients defined as:
- Acute Infection: antibody (-)/RNA (+)
- Recent Infection: antibody (+) with last documented antibody (-) within last six months
- The client may be identified as a consequence to a reactive rapid test or a routine HIV test (blood draw).
- Previously diagnosed HIV clients lost to care defined clients who have had any interruption in their ART.
T&T implementation began May 1st, 2017. However, additional planning milestones are as follows:
- February 2017: T&T ICS commenced
- February 2017: T&T Protocol was completed
- March – April 2017: All trainings with stakeholders and DOH-Broward staff were completed
- November 2017: T&T six-month process evaluation conducted
Training/Outreach: Training and outreach on T&T protocols were conducted for HIV testing sites, primary care and infectious disease providers, Hospital and Emergency Department staff, STD Disease Intervention Specialists (STD DIS), and HIV Linkage and Re-engagement Specialists ( HIV LRS). T&T Navigators will also be developed and trained to support clients in accessing HIV care, medical care and other essential support services. All STD DIS and HIV LRS were trained in the month of April, 2017. As of October, a total of 9 HIV LRS and 3 STD DIS have been hired and 3 additional HIV LRS, 1 HIV LRS Supervisor, and 1 T & T Data Analyst are being requested to sustain the T&T program. Training and outreach will be an activity that is ongoing and will be sustained throughout the implementation of the T&T program.
Social Marketing: Implementation of a T&T social marketing campaign included the development of a T&T campaign, then implementation of TV, bus, and retail frame advertisements, also the exploration of implementing gas station sign advertisements. The T&T Campaign was developed and implemented on TV in April 2017, implemented on bus advertisements in May 2017, and implemented in retail frames and gas station signs in August 2017. In addition, a debriefing on this current campaign will occur in December 2017 that will focus on discussing best campaign practices.
Ryan White Part A Provider Engagement: The engagement of the Ryan White providers in T&T involved developing a T&T training protocol, identifying insurance plans accepted by Ryan White Care providers, documenting which providers and pharmacies are in network for each insurance plan, creating a directory of insurance plans, identifying Ryan White T&T Champions, ongoing contact with Ryan White Part A providers and Infectious Disease practitioners, and monthly updates of insurance status. T&T Implementation: Implementation encompassed finalizing the T&T protocol, presenting the protocol to Ryan White Part A, Broward County HIV Health Services Planning Council, South Florida AIDS Network, and the Broward County HIV Prevention Planning Council. The identification of insurance plans accepted by Ryan White Care providers, documentation of providers and pharmacies that are in network for each insurance plan, creation of a directory of insurance plans, and identification of Ryan White T&T Champions were completed in April 2017. All of these activities for this Key process will be ongoing and continuous.
For Fiscal year 17-18, the allocation for Test and Treat is $2,856,250. (Below is the budget). 2 months prior to Fiscal Period 17-18, when Test and Treat began, there was an allocation of $260,000 for prescription drugs.
Employee salaries and benefits = $630,600
Prescription Drugs expenses = $2,000,000
Other expenses = $38,100
Vehicles - $180,094
Collocated, Risk Management and HR Expenses = $7,456
Total for FY 17-18 = $2,856,250
Total for FY 16-17 (May 2017 to June 2017) = $260,000 for prescription drugs.
Total = 3,116,250
Pharmacy: The provision of pharmaceuticals for the T&T Program required an initial bulk purchase, working with each Ryan White Provider receiving bulk purchase to determine the most effective dispensing (pharmacy versus physician) and developing a procedure and toll for inventory monitoring and reporting. The T&T Protocol was completed in February 2017, presented to Ryan White Part A in March 2017, Broward County HIV Prevention Planning Council in April 2017, HIV Health Services Planning Council in May 2017, and South Florida AIDS Network in June 2017. Implementation of T&T in Broward County began May 1st 2017. Since Implementation, total pharmacy expenditures for medications have been $644,040.64.