Our Work

North Carolina Systems Linkage

Project Objectives

The NC-LINK project receives funding from a HRSA Ryan White SPNS grant, as part of the Systems Linkages and Access to Care for Populations at High Risk of HIV Infection Initiative. The grant was provided to the NC DHHS, Communicable Disease Branch (NCDHHS, CDB), and represents a partnership between the NC DHHS, Duke University and UNC Chapel Hill, with participation from two pilot intervention sites: Wake Forest University Health Sciences and East Carolina University, among other sites throughout the State. CHIPR's role in NC-LINK is to serve as the local evaluation site and to manage the data systems of the project.

The primary goal of NC-LINK: Systems Linkage and Access to HIV Care in North Carolina, part of the Special Projects of National Significance (SPNS), is to increase the number of people living with HIV/AIDS (PLWHA) engaged in consistent care by creating a system of linkages along the HIV Continuum of Care in North Carolina. This will be accomplished through improved coordination between HIV testing and HIV care providers; creating integrated NC HIV data sources and regional data repositories; testing and linkage within the sexual networks of high risk persons; and a new statewide nurse-led team of bridge counselors whose role is to rapidly link newly-diagnosed HIV patients into care and reengage patients who fall out of care.

NC-LINK has the following aims:

Increase viral load and CD4 count reporting across the state by linking the surveillance system (NCEDSS), care system (CAREWare) and other HIV/AIDS related databases

Target testing toward the most high-risk patients and settings to decrease the number of persons living with HIV/AIDS (PLWHA) who are unaware of their HIV status

Reduce the number of PLWHA who do not enter care for more than 3 months after receiving a positive HIV test via improved state bridge counseling

Increase care communication and coordination within regions of HIV care and across the state

Re-engage HIV patients who are out-of-care through improved regional and state bridge counseling efforts

Project Outcomes

During the first two years of the grant, sites piloted interventions for HIV testing of hard-to-reach populations and client linkage/retention/re-engagement in consistent HIV care. During the third and fourth years of the grant, additional intervention sites have joined the project, as part of wider-scale implementation, to adopt the final NC-LINK strategies:

1. Clinic-Based HIV Testing: This strategy offers an individual who accompanies an HIV-positive patient to a clinic appointment with the opportunity to receive free and confidential rapid HIV testing at the clinic.
2. Retention Protocol: This strategy focuses on improving the capacity of regional and clinic-based retention staff to retain persons who are PLWHA in HIV care and to engage PLWHA who are lost-to-care back into quality and consistent HIV care.
3. State Bridge Counseling Linkage: This strategy focuses on State Bridge Counselors linking newly-diagnosed PLWHA to quality care via streamlined processes, enhanced communication, coordination of efforts and improved electronic methods for tracking patients.
4. State Bridge Counseling Re-engagement: This strategy focuses on standardizing the work of the State Bridge Counselors to locate out-of-care PLWHA and re-engage them in care, once local re-engagement efforts by clinics/regions are exhausted.

Data Collection and Analysis
The Duke evaluation team works with all intervention sites to design, implement and monitor intervention tracking data collection. This process data is being combined with NC DHHS surveillance data to evaluate intervention outcomes; these analyses are ongoing.

In 2014, the Duke evaluation team collaborated with the cross-site evaluation team at the University of California, San Francisco (UCSF) to conduct a qualitative evaluation of the State Bridge Counseling (SBC) intervention by interviewing clients who had interacted with SBCs in order to re-engage in HIV care.

Data Systems
The Duke evaluation team continued their work with RDE Systems - a technical company with HIV experience — and other project partners, to further the efforts to create a State HIV Data Warehouse, called NC ECHO (NC Engagement in Care for HIV Outreach). NC ECHO would allow a more efficient and streamlined approach to combine the data from the disparate HIV surveillance and care databases throughout the state. This would help providers to engage and retain their patients in quality and consistent HIV care.
The Duke evaluation team also worked with project partners to continue the work of the NC-LINK CAREWare Policies and Procedures Workgroup in order to standardize the use of the State CAREWare server and to create CAREWare user/training manuals; this work complements the Data Warehouse activities as well as intervention data collection through CAREWare.


• Keller, J., Sullivan, K., Schafer, K., Cox, M.B., Heine, A., Clymore, J., Seña-Soberano, A., & Wilkin, A. (2014, June). Bridging the gaps: The use of health information technology and bridge counseling to improve retention in care in North Carolina. Paper presented at the 9th International Conference on HIV Treatment and Prevention Adherence, Miami, FL.

• Berger, M., Sullivan, K., Perry, K., Ramaiya, M., Parnell, H., & Quinlivan, E.B. (2014, November). One size does not fit all: An assessment of HIV linkage, retention and re-engagement programs in southern states. Paper presented at the 142nd annual meeting of the American Public Health Association, New Orleans, LA.

• Parnell, H., Cox, M.B., Sullivan, K., Quinlivan, E.B., Jensen, R., Berger, M., Thomas, J., & Dayananda, A. (2014, November). Building a statewide HIV surveillance and care data warehouse in North Carolina: A collaborative approach. Poster presented at the 142nd annual meeting of the American Public Health Association, New Orleans, LA.


• Presentation at SPNS Grantee Meeti

Project Policy Impact Description

NC-LINK has several statewide policy/practice implications. The interventions supported through the NC-LINK partnerships are being rigorously evaluated and will contribute to the evidence base of approaches to promote testing, linkage to HIV care, and the retention of HIV individuals in care. These interventions include partner testing, a regional retention protocol, and a state bridge counselor retention protocol. These protocols are being rolled out by NC-LINK partners and are helping to standardize retention and re-engagement efforts throughout the State.

Another policy implication is the opportunity to improve HIV-related data systems housed at the North Carolina Department of Health and Human Services. Through working with State organizations to improve the links between HIV surveillance and care data, we aim to increase access to quality data, improve communication among providers, increase retention in quality HIV care, and ultimately improve the health outcomes of people living with HIV/AIDS in NC.



  • Health Resources and Services Administration


  • Institute for Global Health and Infectious Diseases, UNC Chapel Hill
  • Communicable Disease Branch, NC Department of Health and Human Services
  • Infectious Diseases Specialty Clinic, Wake Forest Baptist Health

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