Acute Care Visit

Per visit

CD-4 T-Cell Count

Per test

Dermatology

Per visit

Developmental Assessment for Infants/Children

Per visit

Developmental Intervention for Infants/Children

Per visit

Infectious Disease

Per visit

Intravenous (IV) Administration

Per visit

Laboratory Service

Per test

Neurology

Per visit

Obstetrics/Gynecology

Per visit

Oncology

Per visit

Ophthalmology

Per visit

Other Specialty

Per visit

Outpatient/Ambulatory Health Services

Per visit

Radiology

Per test

Telemedicine Services

Vaccine Administration

Viral Load Test

Per test

Comprehensive HIV-related History: Providers will conduct a comprehensive health history that includes detailed HIV-related information and relevant medical, psychosocial, and family history. Providers can complete this during the initial visit or divide it over two or three early visits. Providers will request and review medical records from previous treatment to supplement self-reported history and update the medical record accordingly. At a minimum, this health history will include:

• History of present illness and HIV-specific history, including:
  • Diagnosis and testing history
  • Prior HIV care, including current and past ART
  • CD4 and viral load history
  • History of HIV-related illness
• Past medical and surgical history, including:
  • Chronic conditions and comorbidities
  • Gynecological and obstetric history, as applicable
  • Immunizations
  • Current medications
  • Allergies and medication hypersensitivities
• Psychosocial history, including:
  • Mental health history
  • Sexual health history
  • Social history
  • Current and past use of substances, including tobacco use
  • Current and past experiences of interpersonal violence, including physical and sexual abuse and domestic violence
  • Housing status
  • Travel history, if applicable
• Family history
  • Diabetes
  • Early heart disease
  • Hypertension
  • Hyperlipidemia
  • Cancer

Sources:
Baseline Evaluation: Adults and Adolescents with HIV | NIH
Section II, Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America (idsociety.org)

1. Percentage of clients with a documented comprehensive HIV-related history, inclusive of all the components listed in the OAHS Standard.

Physical examination: Providers will perform a baseline and annual comprehensive physical examination, with attention to the areas potentially affected by HIV. 

Sources:
Section II, Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America (idsociety.org)

2. Percentage of clients with a documented annual physical examination.

Laboratory Tests: Providers will follow the most recent HHS guidelines, which contain detailed recommendations on laboratory tests for an initial assessment and treatment monitoring, including the appropriate testing intervals. A licensed provider must order all tests.

Initial laboratory testing will include:

• Confirmatory HIV testing, if not documented previously.
• CD4 count and CD4 percentage.
• Quantitative plasma HIV RNA (HIV viral load).
• Genotypic drug-resistance testing before or at the time of initiation of antiretroviral therapy (refer to HHS guidelines for guidance on other scenarios where experts recommend resistance testing). Providers will not delay ART initiation pending the results of resistance testing.
• Complete blood count (CBC) with differential.
• Complete metabolic panel (CMP) or a basic metabolic panel (BMP) and liver function tests, including alanine transaminase (ALT), aspartate transaminase (AST), and total bilirubin.
• Lipid profile (random or fasting).
• Urinalysis (UA).
• Hepatitis A antibody, hepatitis B serology (surface antigen, core antibody, and surface antibody), and hepatitis C antibody screens at the initial intake and when otherwise clinically indicated.
• Syphilis screening.
• Gonorrhea (GC) and chlamydia (CT) testing at all applicable sites

Providers will order the following tests as part of initial labs when appropriate:

• Pregnancy test for clients of childbearing potential.
• Human leukocyte antigen (HLA) B*5701 when the provider is considering an abacavir-containing regimen.
• Coreceptor tropism testing when the provider is considering a CCR5 antagonist.
• Glucose-6-phosphate dehydrogenase (G6PD) for clients in certain racial or ethnic groups when the provider is considering oxidant drugs.
• Trichomonas for clients practicing receptive vaginal sex.
• Varicella and measles immunity testing in clients without documented immunity.

Routine laboratory monitoring will include:

• CD4 count annually and more frequently as indicated.
• HIV viral load every six months, and more frequently as indicated.
• CMP or BMP and liver function tests (including ALT, AST, and total bilirubin) annually, and more frequently as indicated.
• CBC with differential annually, and more frequently as indicated.
• Lipid profile in accordance with cardiovascular risk.
• Syphilis screening annually and more frequently as indicated.
• Gonorrhea (GC) and chlamydia (CT) testing at all applicable sites annually and more frequently as indicated.
• Trichomonas testing for clients practicing receptive vaginal sex annually and more frequently as indicated.

Sources:
Adult and adolescent laboratory monitoring: Tests for Initial Assessment and Follow- up | NIH (hiv.gov)
Pediatric laboratory monitoring: Clinical and laboratory monitoring of pediatric HIV infection | NIH
Drug resistance testing: Drug-Resistance Testing | NIH (hiv.gov)
STI testing recommendations: STI Screening Recommendations (cdc.gov)

3. Percentage of clients with documentation for all lab tests performed, to include: (Pilot measure)
   1. The laboratory performing the test.
   2. The credentials of the individual ordering the test.
       
4. Percentage of clients who had an HIV drug resistance test performed before or at the time of initiation of antiretroviral therapy, if therapy started during the measurement year.
    
5. Percentage of clients with a documented CD4 count (absolute) within the measurement year.
    
6. Percentage of clients with a documented HIV viral load within the measurement year.
    
7. Percentage of clients with a documented complete blood count (CBC) with differential and platelets within the measurement year.
    
8. Percentage of clients with either a documented comprehensive metabolic panel (CMP) or a basic metabolic panel (BMP) and liver function testing, during the measurement year.
    
9. Percentage of clients who were prescribed ART and who had a random or fasting lipid panel at least once since the diagnosis of HIV.
    
10. Percentage of clients at risk for sexually transmitted infections (STIs) who had gonorrhea testing at all applicable sites within the measurement year.
     
11. Percentage of clients at risk for STIs who had chlamydia testing at all applicable sites within the measurement year.
     
12. Percentage of adult clients who had a test for syphilis performed within the measurement year.
     
13. Percentage of clients, regardless of age, for whom hepatitis A total antibody screening was performed at least once since the diagnosis of HIV or for whom there is documented infection or immunity.
     
14. Percentage of clients, regardless of age, for whom hepatitis B screening was performed at least once since the diagnosis of HIV or for whom there is a documented infection or immunity.
     
15. Percentage of clients for whom a hepatitis C screening was performed at least once since the diagnosis of HIV.

Screenings and Assessments: People living with HIV are at increased risk for developing cardiovascular disease, certain cancers, metabolic disorders, loss of bone mineral density, and neurocognitive disorders. Providers will conduct routine preventative health services, screening for opportunistic infections as applicable, and an assessment of psychosocial needs as appropriate. For detailed information on screening modalities and timelines, refer to the United States Preventative Taskforce (see source list). 

Screening will include, at a minimum:

• Mental health assessment at least annually with an age-appropriate, standardized screening for clinical depression. Validated tools include the Patient Health Questionnaire (PHQ)-2, PHQ-9, Edinburgh Postnatal Depression Score, and the Geriatric Depression Score.
  • Clients with a positive clinical depression screen must have a follow-up plan documented by the provider on the date of the assessment.
• Housing status assessment to determine if the client is experiencing housing instability or homelessness, as applicable.
• Domestic violence screening, as applicable.
• Substance use screening.
• Oral health exam and assessment by a dentist.
• Tuberculosis (TB) screening at the time of diagnosis and when clinically indicated.
  • Providers will order a chest x-ray for a client with a newly positive tuberculin skin test or interferon-gamma release assay (IGRA) test, or with a clinical concern for tuberculosis.
• Cervical cancer screen for clients who have a cervix. Providers who do not conduct screenings on-site will refer clients to an outside provider for screening:
  • Clients Ages 21-29 Years:
    • Clients ages 21-29 will have a Pap test at the time of initial HIV diagnosis. Providers will perform a Pap at baseline and every 12 months. If the results of three consecutive Pap tests are normal, providers can perform follow-up Pap tests every 3 years.
  • Clients Aged 30 Years or Older:
    • Providers will perform a Pap test or Pap test with human papillomavirus (HPV) co-testing at baseline and every 12 months. If results of three consecutive Pap tests are normal, providers can perform follow-up Pap tests every 3 years.
• Anal cancer screening for adult clients, following the most recent HHS Guidelines.
• Atherosclerotic cardiovascular disease (ASCVD) risk estimation using a validated calculator for clients aged 40-75.
  • For clients with a 10-year ASCVD risk of 5 percent to <20 percent, the HHS Clinical Guidelines recommend initiating at least a moderate-intensity statin therapy. 

Sources: 
Preventative care: United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)
Tuberculosis screening: Mycobacterium tuberculosis Infection and Disease | NIH (hiv.gov)
Depression screening: Depression: Screening and Diagnosis (aafp.org)
Cervical cancer screening: Human Papillomavirus Disease | NIH (hiv.gov)
Anal dysplasia and cancer screening: Human Papillomavirus Disease | NIH (hiv.gov)
Statin therapy: Statin Therapy in People With HIV | NIH
 

16. Percentage of clients with a cervix, ages 21 or older, who were screened for cervical cancer in the last three years or who received a referral for cervical cancer screening, if the screening was not available onsite. 
     
17. Percentage of clients aged 12 years and older screened for clinical depression within the measurement year using an age- appropriate standardized depression screening tool. 
     
18. Percentage of clients aged 12 years and older with positive clinical depression screen with follow-up plan documented on the date of the positive screen.
     
19. Percentage of clients who have been screened for substance use (alcohol and drugs) in the measurement year.
     
20. Percentage of clients aged 3 months and older for whom there was documentation that a tuberculosis (TB) screening test was performed (and results interpreted for TB skin tests) at least once since the diagnosis of HIV.

Immunizations: Providers will give both adult and pediatric immunizations according to the most current HHS and CDC recommendations. The CDC maintains specific immunization schedules for both adults and children with HIV, which include modifications based on CD4 count: 

• Adult Immunization Schedule, By Medical Indications | CDC
• Birth-18 Years Immunization Schedule, By Medical Condition | CDC

The HHS HIV/AIDS Clinical Guidelines also provide vaccination guidance for adults, adolescents, and children:

• Immunizations for Preventable Diseases in Adults and Adolescents with HIV | NIH
• Preventing Vaccine-Preventable Diseases in Children and Adolescents with HIV Infection | NIH

Providers will ensure clients receive all vaccinations with specific recommendations based on HIV status. These include the Covid-19 vaccine series; the hepatitis A vaccine series; the hepatitis B vaccine series; the recombinant zoster vaccine series (RZV); the meningococcus serogroup A, C, W, Y (MenACWY) vaccine series; and at least one dose of a pneumococcal vaccine.

When clients self-report a history of vaccination but medical records are not available, providers should use clinical judgement to determine whether to repeat vaccination, order serologic testing to determine immunity status, or accept the client’s self-report. The Advisory Committee on Immunization Practices (ACIP) recommends that in most circumstances, providers order vaccine doses for adults with unknown vaccine status (except for influenza vaccines and pneumococcal polysaccharide vaccines).

Sources: 
COVID-19 vaccination: Clinical Care Considerations for COVID-19 Vaccination | CDC
Adult immunizations: Immunizations for Preventable Diseases in Adults and Adolescents Living with HIV | NIH
Vaccines Indicated for Adults Based on Medical Indications | CDC
Pediatric immunizations: Preventing Vaccine-Preventable Diseases in Children and Adolescents with HIV Infection | NIH
Vaccines Indicated for Persons Aged 0 through 18 years Based on Medical Indications
| CDC
Zoster vaccination: Clinical Considerations for Use of Recombinant Zoster Vaccine
(RZV, Shingrix) in Immunocompromised Adults Aged ≥19 Years | CDC
Considerations for Mpox Vaccination | CDC

21. Percentage of clients with documentation of immunizations with special recommendations related to HIV status (including client self-report), or documentation of refusals: (Pilot measure)
    1. At least one dose of a Covid-19 vaccine for clients 6 months or older
    2. Hepatitis A vaccine series for clients without evidence of immunity
    3. Hepatitis B vaccine series for clients without evidence of immunity
    4. Recombinant zoster vaccine series for clients 18 years or older
    5. Meningococcus serogroup A, C, W, Y vaccine series for clients 2 years or older
    6. At least one dose of a pneumococcal vaccine for clients 2 months or older

Antiretroviral Therapy: Primary medical care for HIV includes prompt initiation of ART. Providers will offer and prescribe ART for all clients in accordance with current HHS Guidelines for the Use of Antiretroviral Agents.

Providers will initiate prophylaxis for specific opportunistic infections (OIs) in clients who meet CD4 thresholds or have other risk factors for OI. Providers will provide both prophylaxis and treatment for opportunistic infections in accordance with the HHS Guidelines for the Prevention and Treatment of Opportunistic Infection.

Sources:
ART: Guidelines for the Use of Antiretroviral Agents for Adults and Adolescents with HIV | NIH (hiv.gov)
OI prophylaxis: Guidelines for the Prevention and Treatment of Opportunistic Infection in Adults and Adolescents | NIH (hiv.gov)

22. Percentage of clients, regardless of age, who were prescribed antiretroviral therapy (ART) for the treatment of HIV during the measurement year.

Health Education and Risk Reduction: Providers or other members of the interdisciplinary team will provide routine risk-reduction counseling, sexual health promotion, and behavioral health counseling for clients living with HIV. Since clients’ behaviors and social situations may change over time, staff will tailor health education to the individual client. Providers or other members of the interdisciplinary team will conduct the following education and counseling:

• Providers or members of the interdisciplinary team will inform clients that maintaining a plasma HIV RNA (viral load) of <200 copies per mL with antiretroviral therapy prevents sexual transmission of HIV to their partners. Clients may recognize this concept as Undetectable = Untransmittable or U=U.
• Providers or members of the interdisciplinary team will discuss safer sexual practices that decrease risk of transmitting HIV, such as treatment as prevention, condom use, preexposure prophylaxis (PrEP) for partners, and reducing or abstaining from sexual activity.
• Providers or members of the interdisciplinary team will counsel clients regarding behaviors that transmit HIV, including anal and vaginal sex, shared injection equipment, and during pregnancy, birth, and breastfeeding.
• Medical providers will discuss family planning with clients of childbearing potential. Clients of childbearing potential includes all premenopausal clients who are capable of becoming pregnant, regardless of contraceptive use or sexual practices. Family planning counseling will be consistent with the HHS Clinical Guidelines and include, as applicable, information about contraceptive methods, safer sex, interventions to prevent perinatal HIV transmission, and potential interactions of ART regimens with pregnancy and contraceptives.
• When providers identify current alcohol or other substance use, medical providers will discuss the possible effects of such use on the client’s general health and HIV medications, as well as options for treatment if indicated.
• Providers or members of the interdisciplinary team will routinely discuss with clients the importance of disclosure to partners and educate clients about the options for voluntary partner notification.
• Providers or members of the interdisciplinary team will counsel clients about the risk of acquiring syphilis and other STIs from sex, including all applicable sites of transmission (anus, cervix, vagina, urethra, and oropharynx) and risk reduction strategies.
• Providers or members of the interdisciplinary team will educate clients on nutrition and physical activity, as medically indicated.

Sources:
Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update (idsociety.org)
Treatment as Prevention (TasP): Antiretroviral Therapy to Prevent Sexual Transmission of HIV (Treatment as Prevention) | NIH

23. Percentage of clients who received HIV risk counseling in the measurement year.
     
24. Percentage of clients with documented counseling about the risk of acquiring syphilis and other STIs from unprotected sexual contact, including all applicable routes of transmission (anal, oral, or vaginal sex), within the measurement year.
     
25. Percentage of clients of childbearing potential with documented counseling about family planning methods appropriate to the client’s status, including preconception counseling as applicable, within the measurement year.
     

Treatment Adherence and Retention in Care: Providers and members of the interdisciplinary team will assess and promote adherence and retention in care for clients. Clients who are prescribed ART will receive adherence assessment and counseling at every HIV-related clinical encounter, twice a year at minimum. When another member of the healthcare team identifies an adherence issue, they must notify the prescribing provider of the concern and document counseling and follow-up.

Staff will tailor adherence interventions to the individual client, and may include:

• Prescribing regimens with high barriers to genetic resistance.
• Changing ART to simplify dosing and reduce side effects.
• Addressing underlying cost and medication access concerns.
• Multidisciplinary approaches, including social work, case management, counseling, and mental health care.

To increase retention in HIV care, providers or other members of the interdisciplinary team will:

• Document number of missed client appointments and efforts to bring the client into care.
• Contact clients who have missed appointments, using at least three different forms of contact (phone, mail, emergency contact, referral to DIS) prior to determining they are lost to follow-up.
• Address specific barriers to accessing services.

Sources: 
Adherence to the Continuum of Care | NIH (hiv.gov)
Evidence-based adherence and retention-in-care interventions

26. Percentage of clients with an unsuppressed viral load on antiretroviral therapy who staff assessed for treatment adherence two or more times within the measurement year.
     
27. Percentage of client medical records with documentation of specific barriers and efforts made to address missed appointments.

Referrals: Providers will refer to specialty care or other systems as appropriate in accordance with current HHS guidelines. Providers or clinic staff will follow up on each referral to assess attendance and outcomes. At a minimum, clients will receive referrals to the following specialized services, as needed or medically indicated to augment their medical care:

• AIDS Drug Assistance Program (ADAP)
• Pharmaceutical patient assistance programs (PAPs)
• Care coordination services
  • Medical Case Management (MCM)
  • Non-Medical Case Management (NMCM)
  • Referral for Healthcare and Support Services (RHCS)
• Medical specialties
• Mental health and substance use services
• Adherence counseling
• Partner counseling and referral, including PrEP services
• Annual oral hygiene and intraoral examinations by a dentist
• Medical nutrition therapy (MNT)
• Preventative care, including:
  • Cervical cancer screening
  • Family planning
  • Colorectal cancer screening
  • Breast cancer screening
  • Bone densitometry (DXA) screening
• Disease intervention specialist (DIS)
• Vision care
• Audiology

Providers or staff will follow up on each referral to assess attendance and outcomes. When agencies use OAHS for specialty care, DSHS requires agencies to follow the specialty care service standards and measures.

Sources: 
Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update (idsociety.org)
United States Preventive Services Taskforce (uspreventiveservicestaskforce.org)

28. Percentage of clients with documented referral to dentist for oral healthcare or documentation that client is already seeing a dentist (can be client self-report) within the measurement year.

Documentation in Client Medical Chart: Providers or other members of the interdisciplinary team will develop or update the plan of care at each visit.

Documentation will include the following:

• Current and complete problem list.
• Current and complete medication list.
• Documentation of refused treatment, such as a vaccination.
• Signature of the provider developing the plan; an electronic signature is allowable.

29. Percentage of client medical records with signed clinician entries.

Referrals to Specialty Care:

Clients receiving specialty care services will have documentation of a referral to those services made by a licensed medical provider (except for optometry services, for which a client can self-refer).

Referrals will include documentation of how specialty care is related to HIV diagnosis. Documentation must show that the specialty care is related either to the client’s HIV infection or to conditions arising from HIV treatment, such as adverse effects of medication. If a client self-refers to optometry the client chart will contain documentation that vision services support the goals of HIV treatment.

Documentation from each specialty visit will be present in the client record and include an updated plan of care and the signature of the provider (an electronic signature is allowable).

Agencies may only use OAHS funds may for contact lenses and contact lens-related appointments when there is no other option to correct or ameliorate a visual defect.

See details under ‘Limitations.’

Sources: 
Policy Clarification Notice (PCN) 16-02
Make Referrals Easy | Agency for Healthcare Research and Quality (ahrq.gov)
High Value Care Coordination (HVCC) Toolkit | ACP (acponline.org)

30. Percentage of clients receiving specialty care services (other than optometry) who have a referral for those services and documentation of how specialty care is related to HIV diagnosis.
     
31. Percentage of clients receiving specialty care services with signed clinician documentation for each visit in the measurement year.