A brief description of TLC+
HIV policy makers in the United States are seeking new evidence-based approaches to addressing persistent challenges in the epidemic. These include the following:
An estimated 448,000 thousand of 1.1 million HIV-positive people are not engaged in care and treatment that could prolong their lives and help to prevent additional infections. 21% of HIV-positive people in the US are unaware of their HIV status. Because they test so late, 38% of newly tested HIV-positives receive an AIDS diagnosis within one year; 25% of HIV-positive people who know their status are not engaged in care and treatment that could prolong their lives
56,300 individuals become newly infected with HIV each year, a number that has remained constant for over a decade
People of color and women experience significantly poorer HIV health outcomes than other groups.
In December 2009, a multi-disciplinary group of HIV/AIDS experts met to consider whether implementing a Test & Treat strategy could help the United States accomplish three important goals: 1) to increase the percentage of HIV-positive Americans who know their serostatus, 2) to improve the health outcomes of individuals who are HIV-positive, and 3) to reduce HIV incidence. These, as well as reducing health disparities, are also the goals President Obama has set for the National HIV/AIDS Strategy.
The Think Tank resulted in a recommendation to establish a national program called “Testing & Linkage to Care Plus,” or “TLC+” (the Plus referring to Treatment) as an element of the National HIV/AIDS Strategy. This program would have significant potential to help the US meet the three goals described above. (A review of scientific literature on this subject is available at www.projectinform.org/TLC+.)
The Think Tank concluded that, in addition to the demonstrated benefits to the individual of HIV treatment, a substantial body of evidence indicates that viral suppression resulting from effective antiretroviral therapy makes it less likely that an HIV-positive person will transmit HIV to an HIV-negative partner during sex, even in the absence of condom use. Statistical models have come to differing conclusions about the extent to which programs to increase the diagnosis and treatment of HIV-positive people might reduce HIV transmission on a population-wide basis, but various models have concluded that they could have beneficial impact.
Predicated on the need for strengthened efforts to assure that nearly all HIV-positive Americans know their serostatus, TLC+ would establish a national standard of care in which all public and private testing providers work intensively with HIV-positive people as soon as possible after diagnosis. It would include linkage to a spectrum of care and support services including, but not limited to, primary medical care; social services to support entry to care, retention in care, and successful adherence to HIV treatment (when treatment is appropriate); and prevention with positives counseling. Its components are designed to benefit people newly diagnosed with HIV, those who have not previously been ready or able to engage in care and treatment, and those who have been lost to systems of care and treatment. Its elements are also the same ones that would be used whether the goal is to assure individual health or to reduce HIV transmission.
The elements of TLC+ include:
Expanding both routine, population-wide HIV screening and targeted testing of individuals in groups at high risk for HIV;
Effective and immediate linkage of newly diagnosed HIV-positive people to primary medical care to assess HIV health. This includes screening and treatment for sexually transmitted infections (STIs), viral hepatitis and other health issues;
Effective and immediate linkage to social services, including housing, mental health, substance abuse and other services that will support HIV-positive people to remain in care; as well as innovative efforts to re-engage individuals who have been lost to systems of care;
Evaluation of eligibility for HIV treatment, counseling about treatment options, and assessment of services that might help a patient prepare to be in treatment, when and if they so choose;
Ongoing support for retention in care and adherence to anti-HIV treatment for maintenance of viral suppression; and
HIV prevention counseling and linkage to additional services that will support reductions in risk behaviors.
TLC+ would promote a much-needed integration of existing testing, care and treatment, support services and prevention programs at all levels of government and create specific and measurable outcomes for those efforts. While some medical providers and local jurisdictions are taking steps to implement TLC+, there is substantial need for a national program delivered through intensive collaborations of state and local health departments, medical providers, social services agencies, and AIDS service organizations, including advocacy, social justice and prevention-focused agencies.
TLC+ seeks to distinguish itself from the much discussed Granich model of “Test & Treat” in that it emphasizes the voluntary nature of participation in testing, care and treatment as well as the importance of providing an array of social services to support linkage to and retention in care and treatment.
A more extensive description of TLC+ is available at www.projectinform.org/TLC+, as is a document of frequently asked questions and answers about TLC+. For more information, contact Matt Sharp.