Standard 3
Access to Care - Clinical Services
Range of Services
The full range of clinical, specialty and supportive services appropriate for the care of patients in the AIDS Center, as described in the AIDS Institute Adult, Pediatric and Adolescent HIV Guidelines and Policies published on www.hivguidelines.org and the AI Standards for HIV/AIDS Case Management 2006, shall be provided directly by AIDS Center staff or arranged and coordinated through formal referral agreements at sites accessible to the patient population served.
All services must be delivered in a manner that ensures compliance with HIPAA and State Public Health Law with regard to patient confidentiality.
AIDS Centers shall have policies and procedures in place that ensure the medical care coordination of all patients.
Discussion
All hospitals designated as AIDS Centers must provide the core clinical and subspecialty services. Subspecialty services not available through the hospital must be provided through formal referral agreements to assure the timely delivery of these services in a patient-centered model. AIDS Centers should have an integrated network of providers to address the full range of the patient's medical and psycho-social needs.
The AIDS Center must have policies in compliance with HIPAA and Article 27F of the New York State Public Health Law (HIV Confidentiality Law) protecting the confidentiality of all protected and HIV-related information shared or received in the course of providing services, or in conjunction with community based providers and others involved with the patient's care outside of the AIDS Center.
Medical care coordination is an essential component of HIV primary care. Medical care coordination focuses on the clinical services of HIV primary and specialty care as well as supportive services including case management. Core functions include coordination of inpatient and outpatient care; referrals to and coordination with specialists; referrals to community services not available in the Center; follow-up o referrals and missed appointments; and conferencing between clinical and community-based case managers.
Emergency Department Services
A Designated AIDS Center should have protocols for the Emergency Department to make HIV testing available, conduct timely assessment and management of HIV exposures, and offer post-exposure prophylaxis, if indicated. These protocols can be found at Clinical Guidelines.
Emergency Service staff should provide needed services to AIDS Center patients, including HIV-positive children and pregnant women, during the times out-patient staff are not available (weekends and evenings). A routine system of communicating emergency service reports on AIDS Center patients should be established.
Discussion
HIV testing shall include the availability of rapid testing and other tests able to identify acute HIV infection (AHI) in symptomatic, high risk patients.
The Emergency Department of the AIDS Center hospital should effectively promote: a) the continuity of care of all patients being managed by the AIDS Center program, including the Pediatric Maternal HIV Service (PMHS), who are seen on an episodic basis in the emergency service; and b) linking persons newly diagnosed with HIV in the ED, in-patient or other hospital services to the AIDS Center's program of comprehensive services.
Post-exposure prophylaxis shall be available for patients with non-occupational exposures, including rape and sexual assault survivors.
Non-occupational post-exposure prophylaxis (n-PEP) shall be offered, provided and tracked. Once n-PEP is given, referrals for follow-up shall be made.
In the event of an occupational exposure to HIV, all AIDS Centers must be able to provide immediate post-exposure prophylaxis medication and follow-up for the exposed staff, when appropriate.
Pediatric Maternal HIV Services
A) Range of Services for HIV-Positive Pregnant Women and Mothers
All HIV-positive pregnant women should be co-managed by an experienced HIV specialist and obstetrical provider, both of whom should have current experience in caring for pregnant women with HIV.
Discussion
The management of HIV-positive pregnant women should be in accordance with State clinical guidelines and policies posted on www.hivguidelines.org and federal guidelines posted on http://AIDSinfo.nih.gov.
When the obstetrical provider does not have experience in caring for HIV-positive pregnant women, the provider should seek consultation from an AIDS Center that has obstetrical staff with this experience.
In order to facilitate care for women and their children, services should be family-centered, with coordination of care among the HIV specialist, pediatrician and obstetrician/gynecologist caring for the mother/child.
B) Range of Services for HIV-Exposed Infants and HIV-Infected Infants, Children and Adolescents
Care for HIV-exposed infants and HIV-infected infants, children and adolescents, should be in accordance with State clinical guidelines and policies posted on www.hivguidelines.org and federal guidelines posted on http://AIDSinfo.nih.gov.
Discussion
Care for an HIV-exposed infant should be provided by a pediatric HIV specialist until the infant's HIV status has been determined.
All exposed infants should have complete diagnostic HIV testing to determine infection status.
All HIV-infected infants, children and adolescents should be cared for by a pediatric or adolescent HIV specialist, following state or federal guidelines.
Where an HIV Specialist is not available, the child's pediatrician should provide care in consultation with a pediatric or adolescent HIV Specialist.
Infants, children and youth with HIV need comprehensive HIV-related services provided by an experienced team including the minimum of a pediatric/adolescent HIV specialist, nurse, social worker and case manager. If the AIDS Center does not have these comprehensive services onsite, referral to a center that provides these services should be offered to the family.
The exposed newborn's medical record, including maternal ARV use, should be shared with the infant's ongoing pediatrician.
Programs caring for HIV infected children/youth must have services in place to transition the child from pediatric to adolescent to adult services. Transition activities should involved staff from pediatric, adolescent and adult HIV services.
Substance Use Services
The AIDS Center Hospital should offer directly or by referral the full spectrum of alcohol and substance use treatment methodologies as part of the Center's inter-disciplinary team planning. Where provided by referral, formal agreements must be in place.
Discussion
The AIDS Center hospital is expedited to provide on-site, comprehensive substance use assessment, including laboratory screening. This should include addressing the impact of substance use on the family unit.
Programs should address the full spectrum of both licit and illicit substances and incorporate sexual harm reduction services and information. AIDS Center staff should be trained to understand the effect and impact of substance use (illicit and prescribed) on the patient's ability to remain in care and engage in treatment adherence and harm reduction activities.
The AIDS Center must have collaborative relationships and/or referral arrangements for the full spectrum of alcohol and substance use treatment methodologies including syringe exchange programs (where available) and Expanded Syringe Access Program (ESAP) provider listings.
Oral Health Services
Oral health services, including periodontics and oral surgery, shall be provided directly or arranged and coordinated through formal referral agreements.
Discussion
At a minimum, routine dentistry should be provided on-site to the extent that they are currently offered to all other patients in the hospital. All hospitals designated as AIDS Centers shall provide emergency and urgent oral health services to HIV-infected patients. Formal referral agreements should be developed when services are not available on site.
Mental Health Services
Mental health services are an integral component of HIV care, a psychiatrist or a licensed clinical psychologist must be a participating member of the HIV treatment team.
Discussion
The HIV-infected population in the State of New York, as our general citizenry, is aging; eventual cognitive and neurological deteriorations should be anticipated.
Mental health conditions impact care and retention activities for individuals infected with HIV. All staff should be trained to understand the relationship between mental health conditions and the patient's ability to remain in care, engage in treatment, adherence and harm reduction activities.
An initial cognitive and neuropsychological assessment should be conducted for all patients. Assessment components include: cognitive function, screening for depression and anxiety, including PTSD, psychiatric and medical history and psychosocial evaluation.
Periodic updates of each patient's cognitive function and psychological status should be conducted and recorded annually in the patient's medical record. Referrals to the team psychiatrist or psychologist should be made as needed.
Psychiatric, neurological and radiological services should be coordinated with primary care HIV services for appropriate diagnosis and symptomatic treatment of developing neurological impairments.
HIV Testing
Confidential HIV testing services, including the use of rapid testing technologies, should be readily available in all appropriate hospital inpatient and outpatient settings.
The AIDS Center hospital shall ensure that HIV counseling and testing services are provided to all pregnant/delivering patients served at the hospital.
Designated AIDS Centers should ensure that new and existing patients receive partner services as appropriate.
Discussion
The AIDS Center should facilitate integration of routine HIV screening activities throughout the hospital. This includes the use of rapid testing technologies in other hospital departments, including the emergency department, inpatient units, walk-in clinics and family health centers and the coordination of follow-up care for persons testing positive. Policies and procedures must detail the coordination of follow-up care for evaluation and assessment of individuals testing positive.
The DAC shall ensure that HIV counseling with testing recommended is provided to all pregnant patients, and that repeat HIV testing is offered in the third trimester (see www.hivguidelines.org).
- Health care providers of all pregnant women should encourage repeat testing in the third trimester (recommended by the CDC, USPHS, ACOG and the NYSDOH)
- All prenatal care providers should be knowledgeable about the signs and symptoms of acute HIV infection, as well as the diagnosis and treatment of pregnant/delivering women with acute HIV infection and their infants.
Partner services are essential tools to identify new cases of HIV disease and engage these patients in care. Ideally, arrangements with the City/County or State health departments should be in place to maximize these efforts. Partner services should be available throughout the time the patient remains in care.
All hospital staff should be made aware that confidential HIV testing is available on-site and be trained to routinely offer it to patients. All hospital staff conducting HIV testing shall be trained in accordance with Article 27F of the Public Health Law to ensure that confidential practices are maintained in accordance with Public Health Law in testing programs.
Management of Co-morbidities
The AIDS Center shall implement specific protocols to assure the appropriate management of HIV-infected patients with co-morbidities. At a minimum these should address Hepatitis A, B and C; STIs; and any other conditions detailed in Clinical Guidelines.
Discussion
The effective management of diseases that are not necessarily HIV-related, but common among HIV-infected patients, is critical to assure positive outcomes. While there are numerous co-morbidities, the prevention and management of the Hepatides, TB and STIs are of primary importance.
The AIDS Center must have specific protocols for the clinical screening, diagnosis, management and when appropriate, treatment, of co-morbid conditions, such as Hepatitis A, B, C, TB, STIs, and other conditions detailed in Clinical Guidelines.
Clinical Research Programs
The AIDS Center shall facilitate access to clinical research programs, including those for investigational new drugs.
Discussion
The treatments for HIV infection and AIDS are dynamic and evolving processes; it is essential that AIDS Centers be linked to state-of-the-art clinical treatments and that AIDS Center staff be knowledgeable about up-to-date HIV treatments guidelines, investigational protocols and agents for the treatment of HIV and its associated co-morbidities. Patients should have full access to these treatments when appropriate for their care, and should be educated on this options.
Physicians in AIDS Centers should be aware of the HIV/AIDS clinical trial networks funded by the Division of AIDS (DAIDS) of the National Institutes of Health (NIH):
- AIDS Clinical Trial Groups (ACTG)
- HIV Prevention Trials Network (HPTN)
- HIV Vaccine Trials Network (HVTN)
- International Maternal Pediatric and Adolescent AIDS Clinical Trial group (IMPAACT)
- Microbicide Trials Network (MTN)
These NIH funded networks offer research protocols, including those for drugs for compassionate use, both at their sites and other venues for which many patients may be eligible. Those hospitals that do not offer clinical trials should have close professional linkages with institutions in which treatment protocols and agents are available. Appropriate referrals for access to investigational agents should be made if indicated.
