Nurse-led hospital-to-community care, clinical outcomes for people living with HIV and health-related social needs

AIMS: To evaluate whether patients with HIV enrolled in Linkage to Care (hospital-based only) or Linkage to Care Plus (nurse-led hospital-to-community transitional care) programmes fare better on clinical outcomes; and to investigate how factors such as substance use, mental health or health-related social needs contribute to these outcomes. BACKGROUND: Social determinants of health contribute to poor HIV outcomes such that only 57% of people living with HIV have achieved the goal of viral suppression nationally, and 50% are retained in clinical care. The programmes evaluated here aimed to increase HIV appointment attendance, retention in care, viral suppression and decrease acute care utilization and mitigate social needs via hospital-to-community transitional support. DESIGN: A retrospective observational cohort study. METHODS: We conducted a retrospective patient chart review abstracting data over three time periods between 2017 and 2020 to conduct this longitudinal programme evaluation. RESULTS: Both programmes had meaningful effects on increasing HIV appointment attendance and viral suppression; Linkage to Care Plus experienced the largest gains. Older age was associated with viral suppression, and housing insecurity and mental health conditions were associated with increased emergency department utilization. CONCLUSION: Hospital-only and nurse-led hospital-to-community transitional care programmes can positively influence HIV care outcomes. There is a need for enhanced attention and accountability related to health-related social needs, especially housing, and mental and behavioural health, to end the HIV epidemic. IMPACT: Globally, we are striving to end the HIV epidemic with evidence-informed interventions. The nurse-led hospital-to-community and the hospital-only interventions evaluated here improved HIV outcomes with most gains realized by the nurse-led transitional care model. Integrating lessons from these programmes, with increased attention and accountability for addressing social needs, can improve practice and policies to achieve programmatic and national goals related to HIV and other diseases, and more critically, to meet the goals of the people we serve. PATIENT OR PUBLIC CONTRIBUTION: Patients, staff and leadership at the University of Maryland Institute of Human Virology JACQUES Initiative and University of Maryland Medical Center THRIVE clinic contributed to the design and implementation of the programmes and informed the programme evaluation study.