Barriers and facilitators of linkage to HIV primary care in New York City

Background: One in five people living with HIV in the U.S. are unaware of their status; they account for 51% of new infections. HIV transmission can be reduced through “test and treat,” which can decrease both viral load and risk behaviors. However, linkage to care has proved challenging. We performed a qualitative study on linkage of HIV testing sites that partnered with the New York City Department of Health and Mental Hygiene (NYCDOHMH) to implement “The Bronx Knows,” a NYCDOHMH borough-wide initiative that tested 607,570 residents over 3 years.

Design/Methods: We interviewed directors and administrators of 24 HIV testing sites to identify linkage problems and successes, and selected 9 for case studies of best linkage practices.

Results: There were three problem domains: (1) system factors (long wait for provider appointments; requirement of a positive confirmatory test before scheduling an appointment; lack of staff respect for patients); (2) social factors (HIV stigma, public, perceived and enacted); (3) stigmatizing patient statuses (e.g., mental illness, homelessness, substance use, immigrant). Best practices for linkage included networking among community organizations; individualized care plans; team approach; and patient peer navigation. No providers cited decreased community viral load as a rationale for prioritizing linkage.

Conclusions: Successful linkage requires a comprehensive individualized approach that reduces the compounded stigma that risk populations face, minimizes delays in seeing a care provider, and provides patient navigation services to address system complexity. Providers defined their role as caring for patients, overlooking the broader public health impact of preventing HIV transmission.