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Status Neutral Linkage to Care: Firm Foundations in HIV Screening, Prevention, and Treatment
CME/CE Information

Activity

Progress
1 2 3
Course Completed
Activity Information

Pharmacists: 0.25 contact hour (0.025 CEUs)

Physicians: maximum of 0.25 AMA PRA Category 1 Credit™

Nurse Practitioners/Nurses: 0.25 Nursing contact hour

Released: January 08, 2026

Expiration: January 07, 2027

Joyce L. Jones
Joyce L. Jones, MD, MS

Thank you for joining - thank you - thank you for joining this module on status neutral linkage to care, looking at HIV screening, prevention, and treatment.

 

[00:30:39]

 

Faculty

 

I'm Joyce Jones. I am an Assistant Professor of Medicine in the division of infectious diseases at the Johns Hopkins University School of Medicine in Baltimore, Maryland. And I have no relevant financial relationships to disclose.

 

[00:30:56]

 

Learning Objective          

 

So our learning objective today is to implement status-neutral HIV screening and linkage to rapid PrEP or rapid HIV treatment antiretroviral therapy services in diverse clinical settings.

 

[00:31:14]

 

Status-neutral HIV Linkage

 

Dr. Jones: Status-neutral linkage to care is the concept that regardless of an HIV test result, when a person gets tested for HIV, if they test and the test is positive, that we rapidly link them to HIV treatment services. And if the test is HIV negative and they're at risk for HIV, we rapidly link them to HIV prevention services. This way, we are making sure that people who could benefit from HIV treatment or HIV prevention are getting access to those services as quickly as possible. The idea is that we also should be focusing on wellness in general and addressing any social determinants of health and other issues that may impact people's linkage to HIV treatment or HIV prevention. 

 

HIV linkage to care is an approach to maximize supportive care and access to HIV treatment and HIV prevention, regardless of the test result. It is an important aspect of HIV prevention and treatment services, and our goal is to support optimal health for people regardless of the results of their HIV test. So when we do the test if the test is positive and the person has HIV infection, we want to quickly link them to HIV treatment. And if their test is negative, that's also very important to know about, and also very important that if they're at risk for HIV, we're rapidly linking them into HIV prevention, all the while maximum - maximally supporting the person with their health and well-being and addressing any social determinants of health that may impede linkage to care.

 

[00:33:43]

 

It is important for providers to make sure they're thinking about testing everyone irrespective of their status. And I say that because the onus of HIV prevention cannot rest solely in the hands of people who are living with HIV. Some other ways we can think about improving HIV education, HIV awareness, and HIV prevention is making sure we know what PrEP is and we're communicating to women that PrEP is available to them.

 

We don't tell cisgender women very often that PrEP is something that they can take. We don't normalize that as part of the experience. So if a patient is coming in and that person has a broken toe or a broken finger or something else is going on and our goal is to provide them with holistic care, their sexual health is an important dimension of that holistic care.

 

So how do we do that? We slide a sentence in that says something like, "Hey, have you thought about your HIV prevention options?" Or, "In this office, we test everyone when we haven't seen them for at least six months for HIV. Are you okay with having an HIV test today?" And opening up the conversation so that patient feels respected, they feel safe, and they feel like they have a provider who cares about them holistically in the context of the issue for which they came, but also for their broader health.”

 

There are many factors that have been shown to predict and can delay linkage to care and impede consistent engagement in HIV care and HIV prevention. These include structural barriers such as the healthcare infrastructure, insurance barriers, operating hours of the clinic, and ease of access to the clinic, including access to public transportation, parking, and then there are individual factors such as substance use disorder, mental health issues, financial strain stigma can negatively impact linkage and engagement and in care. And then fear of medication, fear of adverse side effects to medications have also been shown to impede linkage and engagement in care. And then, in terms of being able to facilitate linkage to address these different issues, lack of resources for medical teams can also impede linkage and engagement in care.

 

[00:39:37]

 

Patient Case 

 

So here's a patient case a 29-year-old man presents to a community clinic for screening for sexually transmitted infections. He reports that he is sexually active and has multiple partners, and has inconsistent condom use. And he's never been tested for HIV. And he is interested in options for HIV prevention.

 

[00:41:07]

 

How Should The Patient Be Managed If The HIV Test Is Positive?

 

So if we do the test, the correct answer is to do the test. And ideally, if we're doing point-of-care testing. If the test is positive, again we have that status-neutral pathway. So if the test is positive then we want to offer standard of care, which is rapid HIV treatment initiation. So that's offering HIV treatment as soon as possible, we make sure the person has labs that will give baseline information about their HIV status, their HIV genotype, their HIV viral load, and then we want to provide counseling as well about what it means to have HIV. People with HIV have a life expectancy near that of - of someone who is HIV negative. And then how it's important to - take antiretroviral therapy continuously, and then it is a lifelong treatment.

 

And then you know, that our goal is to establish and maintain viral suppression. That with HIV people with HIV, the virus can be very well treated. The medications are excellent. And with a sustained, suppressed viral load and adherence to medication, people with HIV do not have a risk of transmitting HIV to HIV negative sex partners. It's also important that if you did a rapid test that confirmatory testing is conducted, if you have somebody who is at low risk for HIV, it is possible that that test is a false positive test.

 

This individual in this case has many risk factors for HIV infection. So pretest probability is high that he has HIV so providing rapid HIV treatment initiation is appropriate for this individual, with the caveat that it is possible that it's a false positive, in which case the person could be converted to - to PrEP or pre-exposure prophylaxis.

 

[00:43:21]

 

Same-day ART Initiation

 

So again, same-day rapid initiation is the standard of care for people with new HIV infection. It helps make sure that we're reducing barriers to ART initiation. It accelerates the time to viral suppression. And again, by achieving viral suppression quickly and then with the sustained viral suppression, people with HIV will not transmit HIV to HIV negative sex partners.

 

So sex partners should be tested. Same scenario for those sex partners. Status neutral approach if they're positive. Rapid HIV treatment initiation if they're HIV negative prevention. People newly diagnosed with HIV if they do have sex partners who are HIV negative, those partners should be offered PrEP to prevent transmission of HIV from the person newly diagnosed with HIV.

 

[00:44:33]

 

How Should the Patient Be Managed If the HIV Test Is Negative?

 

If that person's test is negative, he is at risk for HIV infection. And so we have really excellent HIV prevention therapies available. Please do refer to the other modules in this series about PrEP - really excellent options. And this individual should be rapidly connected to HIV prevention. Condom use is also important to discuss as - as there is a risk for other sexually transmitted infections. And the PrEP will not protect against those such as gonorrhea, chlamydia, and syphilis.

 

And then again, a harm reduction approach should be used when we're counseling people around HIV prevention. So, you know, with - with prevention, we have both pharmaceutical approaches to HIV prevention. So use of pre-exposure prophylaxis, post-exposure prophylaxis. And then for people with HIV, treatment sustained suppression and adherence to medication that also prevents HIV transmission. And then there are non-pharmaceutical approaches, including identifying and treating sexually transmitted infections, condom use, addressing risk factors related to sex behavior. Offering treatment for substance use disorder. And then we have really excellent interventions for people who are pregnant and at risk for - or have HIV to prevent perinatal transmission.

 

[00:46:35]

 

The PrEP Gap in the United States

 

So when we think about HIV prevention, there is a gap when it comes to pre-exposure prophylaxis. So that's - that's the emphasis on status neutral. So appropriately, we have had a focus on people who test positive for HIV to get them connected to care. We should have a similar focus on people who could benefit from pre-exposure prophylaxis to connect them to PrEP. So it's estimated that about 1.2 million people in the United States are likely to benefit from PrEP.

 

But in a 2022, there was a - there were studies that showed that very few people who could benefit were actually prescribed PrEP. So only 41% of men who could benefit, 14.5% of women, and only 23.5% of adolescents and young adults who could benefit from PrEP were prescribed PrEP. So we have a large way to go in terms of making PrEP available - available to people who could benefit. And there are definitely race and ethnicity disparities in terms of PrEP being offered to - to these groups that could definitely benefit from HIV prevention.

 

[00:48:03]

 

Expanding PrEP Uptake by Expanding HCPs Who Prescribe

 

So offering pre-exposure prophylaxis does not require HIV expertise. So again, as with HIV screening, pre-exposure prophylaxis really should be part of good primary care. What we do in primary care is we identify and we address health conditions that we want to prevent. So we want to prevent heart attack, stroke, cancer. And we have a lot of interventions that we know decrease people's risk of these conditions.

 

Similarly, we have really excellent prevention for HIV infection. Some of the - the interventions are over 90% effective to prevent HIV infection and up to 100% effective, as was demonstrated recently with lenacapavir to prevent HIV. So please again, refer to those PrEP modules available through this series. But I encourage all primary care providers to integrate HIV screening and prevention status-neutral approaches to their primary care. So contraception is a lesson that we can learn from in the - in the US there is an expansion of prescription of contraceptives beyond these specialists, beyond OB-GYN. And so again, we all should be comfortable in now incorporating PrEP, which is a newer intervention to prevent HIV infection.

 

[00:50:02]

 

Patient Case

 

So we have this 29-year-old man who presents to a community clinic for screening for sexually transmitted infections. He reports he's sexually active with multiple partners and uses condoms intermittently. And he's never been tested for HIV and is interested in HIV prevention.

 

[00:50:24]

 

Question 1

 

So in terms of the options of what we should do we should have status-neutral approach to HIV prevention and treatment for this patient. Perform HIV testing immediately and offer PrEP if negative. And if they test positive, then offer same-day ART initiation if they're positive. You know, I just spoke about primary care, being able to incorporate PrEP into primary care practice. Rapid HIV treatment initiation may or may not be important to incorporate into your primary care setting, depending on where you practice.

 

So if you have or in a setting where there are many new HIV diagnoses and/or you're offering HIV treatment in your primary care setting then rapid art should definitely be part of that practice that might not be feasible for your practice, but linking connecting to a clinic or a health department where rapid access to HIV treatment is available should be part of - part of the practice around HIV testing.

 

[00:51:41]

 

Comprehensive Care for Vulnerable Populations

 

Thinking about this status-neutral approach, we want to offer comprehensive care for vulnerable populations. So for all of our patients, we want to make sure that we're addressing social drivers of health, offering social support - support for housing, financial strain, transportation, mental health counseling, treatment for substance use disorders, and comprehensive care for comorbidities. We're incorporating status-neutral language as - we're incorporating HIV screening and status-neutral linkage to care for people, so that if they test negative, rapid access to PrEP, condoms harm reduction, and then if they test positive, either offering same-day ART or linking them to a clinical setting where same-day rapid HIV treatment initiation is available.

 

[00:52:52]

 

Overall Key Points

 

So the key points I'd like you to take home today are that a status-neutral approach to HIV care involves embedding HIV testing and prevention and access to rapid HIV treatment in the overall care model. HIV testing again acts as a pathway to engagement in HIV treatment and preventive services. It improves connection to care and allows for continuous, comprehensive health services. And integral to this model is an evaluation of the whole patient, and it relies on partnerships between health care providers, local health agencies, and health departments. Thank you so much.

 

[00:53:45]

 

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[END OF TRANSCRIPT]