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HIV, STIs, Viral Hepatitis and LTBI Routine Screening Toolkit: Linkage to care


Step 1: Community outreach | Step 2: Patient intake | Step 3: Initiating standard screening protocols |

Step 4: Testing and diagnosis | Step 5: Patient education and post-test counseling | Step 6: Linkage to care

The routine screening process does not simply end with diagnosis. Care team members must be confident and clear on next steps after result notification. Some clinics may be able to provide treatment directly, while others may link patients to other care providers. Inadequate linkage to care processes and procedures prevent many clinicians from initiating routine screening. It can be a struggle to obtain reliable patient contact information to follow up with result disclosure. 

Without a strong linkage to care infrastructure, positive results fall in the patient’s hands, leaving a huge responsibility on the individual to seek and manage treatment, often resulting in the patient being lost to care.  Routine screening is also critical for re-linking people previously diagnosed back to care.

  • Inconsistent patient contact information 
  • Day-to-day unpredictability with patients in precarious situations 
  • Multiple follow-ups needed to bring patients back into care 
  • Patient resistance to initiating long term treatment
  • Lack of education on current treatment guidelines among health care professionals
  1. Form a strong referral network 

    1. A robust referral list can help connect patients with linkage venues that meet their needs including both treatment for a positive diagnosis as well as support for other wrap around services.
    2. Related resources

    3. Linkage to care administrative resources:

    • Partnership Mapping Template (PDF): This template provides a framework to help your organization keep track of relationships with non-clinical services and outpatient clinics that will support both community outreach and a sustainable linkage to care program.
    • Tool for Tracking Partners and Partnership Activities: Pages 81-88 from HRSA’s Integrating HIV Care, Treatment & Prevention Services into Primary Care–A Toolkit for Health Centers guide includes a Partnership Toolkit that provides a comprehensive list of key considerations, steps, and Partnership-Focused Templates to help guide organizations’ relationship building and tracking.
    1. Providing or linking to care treatment and prevention resources:

      • Effective Interventions to Treat HIV: This webpage from the CDC outlines resources that are available for the HIV prevention workforce to increase their capacity to link, retain, and re-engage people for HIV care and treatment.
      • Learn About PrEP: This CDC webpage provides an overview of clinical practice and prescribing guidelines for PrEP for clinicians.  
      • Ready, Set, PrEP: Healthcare professionals and individuals can use this website to learn more about the Ready, Set, PrEP program which provides free PrEP HIV-prevention medications to thousands of people living in the United States, including tribal lands and territories, who qualify.
      • Sexually Transmitted Infections Treatment Guidelines: CDC’s Sexually Transmitted Infections (STI) Treatment Guidelines, 2021 provides current evidence-based prevention, diagnostic and treatment recommendations that replace the 2015 guidance.
      • HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C: To provide healthcare professionals with timely guidance, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) developed this website to facilitate the dissemination of evidence-based, expert-developed recommendations for hepatitis C management.
      • The Case for Behavioral Health Settings in HIV Care Settings: This report from Substance Abuse and Mental Health Services Administration (SAHMSA) and HRSA highlights the need for HIV treatment providers to address behavioral health concerns with HIV and offers strategies for clinicians to implement screening practices for mental health and substance use disorders.
      • Behavioral Health Treatment Services Locator: This resource from SAHMSA helps connect persons seeking treatment facilities in the United States for substance use and addiction as well as mental health problems.
      • AMA telementoring session video clip: During this telementoring session focused on linkage to care, Katie Conner, MPH discusses key facilitators success for CrescentCare's rapid linkage to care program for HIV.

  2. Hire or assign current staff as patient navigators

    1. Patient navigators take on the labor-intensive responsibility of delivering patient education following a positive diagnosis, making multiple follow-up calls and arranging treatment appointments so health care professionals can focus on clinical duties. Hiring a dedicated staff person to take on this role or assigning existing staff to assist with these responsibilities increases the likelihood that patients with a positive diagnosis initiate the appropriate follow up care and treatment.

    2. Related resources

    • HIV Navigation Services – STEPS to Care: This resource from the CDC provides links to trainings designed to improve navigation skills for those delivering prevention services to persons with HIV and HIV-negative persons at risk.
    • STEPS to Care: Staffing and Supervision: This resource from the CDC outlines key roles and responsibilities for the patient navigation team including adaptable job description templates and videos that discuss key skills and strengths needed to be a patient navigator.
    • HIV Navigation Services Section of the Rapid Antiretroviral Therapy Toolkit: Section 2 (beginning on page 19) of this toolkit developed in partnership by Primary Care Development Corporation, My Brother’s Keeper, the San Francisco Community Health Center, and the Denver Prevention Training Center provides an overview of the essential role of HIV navigation services in rapid ART services. It also includes a review of staffing needs and considerations for resource-limited settings, suggested protocols, and real-world examples of how to provide services in resource variable settings.

Disclaimer: This page contains resources supplied by third party organizations. Inclusion of these materials on this page does not imply endorsement of these resources or corresponding organization.

The HIV, STIs, Viral Hepatitis and LTBI Routine Screening Toolkit is organized across the screening continuum and offers helpful resources and best practices for the care team.