Strategy 1: Nurse/Peer Team

Target Population: 

  • Newly diagnosed with HIV
  • New to HIV care and has:
    • Been released from corrections within the last 12 months;
    • Immigrated or moved to the US in the past 5 years; or
    • Missed an intake appointment or 1st medical appointment
    • Has been receiving HIV care and has:
      • Missed 2 or more consecutive appointments
      • Not had CD4 or viral load drawn in more than 6 mos.
      • Detectable viral load while on HIV treatment
      • Moderate-to-high level of need as determined by the SPECTRuM Acuity Tool in 1 or more of the following areas: 1) medical/adherence/insurance; 2) housing; 3) mental health; or 4) alcohol and drug use

 Number of Pilot Sites:  3

 Purpose:  The linkage and retention services are intended to help individuals with significant service needs access supports that will help them engage and stay retained in HIV medical care and treatment. Nurse/peer teams provide short-term services (6-12 mos) to a small caseload and prepare clients for transition to routine HIV/AIDS Medical Case Management (MCM) or self-management.

 Activities:  The nurse/peer team assesses the acuity of the client’s needs at pre-determined points of service provision (2-weeks, 3 mos. & 6 mos.) to determine the priorities.  Working in tandem, the nurse and peer identify and minimize potential barriers to care and help support the client as they link to and engage in care. Reminders about appointments, education, medication adherence, coaching, and follow-up on missed appointments are key activities undertaken. Services are provided in both the clinic setting and the community. 

 Strategy 2:  Communication between Surveillance & Clinical Sites

Target Population:

  • Clients without a CD4 count or viral load reported to Surveillance > 6 mos.
  • Clients with a detectable viral load

 Number of Pilot Sites:  3

 Purpose:  The purpose of the enhanced communication is to routinize the use of laboratory data to promote linkage to care, retention in care and adherence to HIV medication with viral suppression as the goal.

 Activities:  Using a list of clinicians that order HIV labs from each site and a dataset that includes all living HIV–positive persons receiving care in MA, a list is generated for each site that identifies  1) individuals whose most recent lab was submitted by an ordering clinician from that site who have not had a CD4 count or viral load reported in 6 months or longer, and 2) individuals who have a detectable viral load. The agency-specific lists are shared with the respective sites every month.  The list includes: 1) patient name; 2) date of birth; 3) physician name; 4) for those with a detectable viral load, date of the lab result; and 5) for “out of care” individuals, the date of the last lab. The agencies review the list and take appropriate action to engage the client in care.


 Nurse/Peer Team

  • After testing out the protocols, the model of care was expanded to one additional clinical site, and a modified model of care with a social worker/peer team was implemented at two additional clinical site.  
  • For consideration in use with all medical case management services, the acuity scale is currently being piloted with 25 clinical and non-clinical agencies funded by MDPH for medical case management, and an additional 14 clinical and non-clinical agencies funded by the Boston Public Health Commission (administers Part A dollars for the Boston EMA) for medical case management.

Communication between Surveillance & Clinical Sites

  • Five additional sites have begun receiving and using the list to assist in identifying and engaging clients in care.