A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

A Guide to Primary Care of People with HIV/AIDS
Chapter 16: Clinic Management
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Welcoming environment: Physically comfortable
waiting and examination areas, with linguistically and
culturally appropriate decoration and reading material,
are important for patient retention. A clinic that serves
parents or children should make available toys or
children’s books.
Orientation to clinic systems and rules: New patients
need a brief description of clinic staff and services,
routine and emergency procedures, prescription refill
procedures, and after-hours followup. They must
understand about requirements for referrals from
managed care providers, and new patients may need
help with such requirements. Patients must also be
oriented to what is expected of them (eg, coming on
time, calling to cancel or reschedule appointments) and
the consequences of not fulfilling their responsibilities
(eg, clinic rules regarding late arrivals). A handout or
pamphlet with staff names, clinic hours and phone
numbers, and emergency procedures can be very helpful.
Systems to support attendance: Patients should
receive reminders (by phone or mail) about 48 hours
before each appointment. It is also useful to have
a staff member contact patients who have missed
appointments to find out what prevented them from
attending and offer to reschedule. ASOs may have
funding for transportation (eg, door-to-door taxi service
for selected patients, van service, vouchers for use on
public transportation). Other barriers may require a
coordinated effort by the clinic staff, case manager, and
others. Clinic sessions should be scheduled at times
convenient for the patients; mid-to-late afternoon is
best for school-age children, occasional evenings or
weekends are good for working people.
CLINICAL SERVICES
NEEDED FOR HIV CARE
What is the optimum array of services that an
HIV clinic should provide?
All patients with HIV need a similar array of services
that must be provided either directly or through referral.
Patients need providers knowledgeable in the diagnosis
and treatment of HIV infection and its complications,
including state-of-the-art use of antiretroviral therapy
(ART). Services must address the clinical conditions
associated with patients’ current or prior risk behaviors.
Given improved life expectancy, patients need ageappropriate
general preventive and screening services.
The high rates of premorbid mental health problems in
persons with HIV and mental health problems related
to HIV disease make mental health services a key
component of HIV care. Substance abuse treatment
is crucial. Confronting the epidemic by including HIV
prevention activities in clinical care sites is a new
activity, challenging and critically important (see
Chapter 4).
The HIV/AIDS Bureau of the Health Services and
Resources Administration (HRSA) lists basic services
required for agencies to receive funding through
the RWCA Title III (Early Intervention/Primary Care)
Program (Table 16-1). Some States have produced more
detailed lists for agencies wishing to receive special
State-level funding for HIV care; see the New York State
list for comparison (Table 16-2). Funded programs
generally must demonstrate continuity in primary
care, 24-hour access to emergency care, ongoing
staff training, an administrative apparatus adequate
to manage the program and its funding, a reporting
system to meet the grantors’ requirements, and quality
management. Programs that do not receive explicit
funding for clinical care and/or support services need to
rely more on referral networks.
Table 16-1: HIV/AIDS Bureau
Requirements for Title III-funded Early
Intervention/Primary Care Programs
• HIV counseling, testing, and referral
• Counseling and education on living with HIV disease,
including availability and use of treatment therapies
• Appropriate medical care and monitoring, including CD4
cell monitoring, viral load testing, antiretroviral therapy,
and prophylaxis and treatment of opportunistic infections,
malignancies, and other related conditions
• Oral health care, outpatient mental health care, substance
abuse treatment, nutritional services, and specialty care
either directly or through a formal referral mechanism
• Appropriate referrals for other health services
• Perinatal care including therapy to reduce mother to child
transmission (MTCT)
• Screening/treatment of TB
Source: Adapted from Ryan White C.A.R.E. Act Title III Manual.
Rockville, MD: HIV/AIDS Bureau, Health Resources and
Services Administration. 1999(Section II):5. Available at http:
//www.hab.hrsa.gov/CATIE/ Accessed 2/04.Table 16-2. Comprehensive
Ambulatory HIV Programs from the New York State AIDS Institute
Monitoring and treating the long-term complications
of ART, such as insulin resistance, lipodystrophy
syndromes, dyslipidemia, and osteopenia, are of
increasing importance. Instituting formal activities
to assist patients in behavior change is increasingly
recognized as an essential component of HIV care.
Hepatitis C diagnosis and management are of particular
importance for patients who have had blood product
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U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau