Strategy 1: Active Referral

Target Population: 

  • Newly identified HIV-positive

 Number of Pilot Sites:

  • 2

 Purpose:  The overarching purpose of the Active Referral (AR) process is to increase the percentage of newly identified HIV-positive persons who are linked to care within 90 days of diagnosis.  The Virginia Department of Health’s Division of Disease Prevention aims to accomplish this objective through:

  •  Implementation of a standardized active referral protocol to allow Disease Intervention Specialists (DIS) to ensure patients are rapidly linked to HIV medical care upon a positive HIV diagnosis; and
  • Implementation of a process that allows DIS to more efficiently and consistently receive confirmation of patient linkage to HIV medical care.


 Activities:  The DIS encourages patients to connect to a health care provider quickly.  Upon completion of the Coordination of Care and Services Agreement, the DIS connects the patient to a local patient navigator or medical provider.  The form provides an important feedback loop, enabling DIS to confirm when a patient has been linked to care. If the patient has not made contact with the referral agency within 30 days, the DIS will follow-up with the patient to facilitate entry to care.

Strategy 2: Care Coordination

Target Population:  

  • Incarcerated HIV-positive 

 Number of Pilot Sites: 

  • 1 Care Coordination site, 18 DOC facilities


The purpose of Care Coordination is to provide a seamless transition for recently incarcerated HIV-positive individuals by facilitating access to HIV medications at the time of release and by providing 12 months of care coordination services to help clients stay in HIV care.

Activities:  The Care Coordinator serves as a liaison between the correctional setting and the care system.  Upon release, a prescription is sent to the local health department near where the client will be living after release. The Care Coordinator follows up with both the local health department and the provider to ensure the medications are picked up and an appointment is scheduled and kept. The Care Coordinator works with the client to access ADAP and other resources.  The client is followed for 12 months to ensure medical appointments are kept and medications are accessed. Clients are linked with Patient Navigators if medical appointments or medication pick-ups are missed.

 Strategy 3: Mental Health Strategy Protocol

Target Population:  

  • Newly identified HIV-positive
  •  New to HIV care
  • Clients with mental health, substance abuse or psychosocial stressors that may cause person to become non-adherent
  • Clients released from corrections within past 6 months

Number of Pilot Sites: 

  • 1


The Mental Health protocol is an intervention designed to deliver comprehensive screening, referral, and treatment services to address the mental health needs of HIV-positive clients.  The intent is to increase retention in HIV care and improve mental health outcomes. 

 Activities:   Mental health professionals, medical case managers (MCMs), and HIV health care providers work together to increase access to mental health services by using standardized and validated depression, anxiety, cognitive functioning, alcohol and substance abuse tools to screen clients for mental health issues. As appropriate, clients are referred to specialty mental health services such as therapy, counseling, neuropsychological testing, and substance abuse treatment. 


 This protocol is based on an in-house model, where a clinic has the internal capacity to screen, refer, and provide mental health counseling and/or therapy, psychiatric and neuropsychiatric services to clients as well as the ability to refer patients out for other specialty services including substance abuse treatment.  


 Strategy 4: Patient Navigation


Target Population:  

  • Newly identified HIV-positive
  • HIV-positive who are lost to care or at risk of falling out of care


 Number of Pilot Sites:

  • 2

Purpose:  The aim of Patient Navigation is to help patients access the healthcare system so they receive the standard of care in a timely and effective way. The goal is to link clients to care within 90 days of diagnosis and support retention in care for up to 12 months. Patient Navigation also facilitates re-engagement in care. 

Activities:   Patient Navigators provide client-entered counseling to assess and address client barriers to linkage and retention in care.  Referrals to community resources and support services and patient education are provided. Motivational Interviewing techniques are employed to engage and empower clients toward self-management.  Patient Navigation also includes the facilitation of HIV testing by means of referrals and home test kits to identify and link positive clients directly to care.


Active Referral

  •  After regional training was conducted, the AR process was implemented across VA through the local health departments and community based organizations that are funded to provide HIV testing, representing a total of 35 sites.
  • In the near future the AR process will also be used to link Hepatitis C (HCV) patients to care, based on testing conducted in participating opioid treatment centers.  Existing data collection tools have already been modified to include HCV.

Care Coordination

  • Approximately 26 Department of Correction facilities interact with the central Care Coordination site.
  • Using the centrally based VDH site, Care Coordination is currently being expanded to target regional and local jails. 

Mental Health Strategy Protocol

  • The protocol depends on a clinic’s capacity to screen, refer and provide mental health services in a timely manner.  Attempts to replicate the model in two other settings have been unsuccessful due to the lack of capacity.

Patient Navigation

  • Patient Navigation has expanded to a 3rd clinical site.
  • Elements of the Patient Navigation model, such as Coordination of Care and Services Agreement, have been used a similar patient navigation model being implemented in other parts of Virginia.