An American randomized trial1 showed that short-term, intensive support for hospitalized HIV-positive people who use substances to navigate the health system does not have an impact on rates of viral load suppression.
The study: Project HOPE
This health navigation program was designed for HIV-positive people who use drugs. Participants were recruited only from inpatient units in hospitals. Health navigation services were provided by hospital staff with experience in social work, case management, discharge planning, or delivering health or prevention services.
The intervention had three arms:
- Six months of health navigation with financial incentives
- Six months of health navigation without financial incentives
- Treatment as usual
Participants who received the health navigation intervention (with and without financial incentives) received up to 11 sessions with a navigator over a six-month period. Navigators worked with clients’ strengths and helped coordinate care with clinicians; reviewed their health information; helped them overcome any personal barriers to care, including transportation and child care; provided psychosocial support; and made referrals. Navigators accompanied clients to their first substance use treatment and HIV care appointments.
Participants who received financial incentives had the opportunity to earn as much as US$1,160 over the six-month period. Incentives were given for attending all 11 navigation sessions, attending HIV clinic and substance use treatment appointments, submitting negative alcohol and substance use tests, having blood drawn, and having an active prescription for HIV treatment. Incentives were also given for participants whose viral load decreased and who had an undetectable viral load at the six-month follow-up appointment.
Participants in the treatment-as-usual arm were linked to HIV care and substance use treatment using the standard protocols in each hospital. A designated staff member was responsible for scheduling an outpatient HIV care appointment, and participants received a written referral for substance use treatment.
Viral load and other measures were taken when participants enrolled, at six months (at the end of the intervention) and a year after enrollment.
Participants were recruited from 11 American hospitals between July 2012 and January 2014. A total of 801 participants were randomized into one of the three arms. Participants were eligible for the study if they:
- were inpatients at the hospital and were living with HIV
- provided information on where and how to be located
- reported or had medical records documenting any opioid, stimulant or heavy alcohol use
- had an AIDS-defining illness; or CD4 cell count of less than 350 cells/μL and viral load more than 200 copies/ml within the last six months; or CD4 cell count of less than 500 cell/μL in the last 12 months; or a viral load of less than 200 copies/mL in the last twelve months
- at least 18 years old and could communicate in English
A third of the participants were women, 78% were black and 38% had been unstably housed in the previous six months. Three-quarters had been in jail or prison at some point in their lives. Most participants reported using stimulants (71%) and alcohol (59%). A minority of participants reported using marijuana (45%), opioids (22%), and club drugs (8%).
The primary outcome of the study was undetectable viral load. The study found no difference in rates of undetectability across the three arms of the study at 12 months (six months after the end of the intervention):
- navigation arm – 36%
- navigation-plus-incentive arm – 39%
- treatment-as-usual arm – 35%
The study also included a number of secondary outcomes. At six months, but not 12 months, the study found that, compared to the treatment-as-usual group, the navigation-plus-incentives group was significantly more likely to:
- have an undetectable viral load (46% vs. 35%)
- report attending HIV care appointments (87% vs. 67%)
- report using HIV medications (91% vs. 84%)
- engage in professional substance use treatment (31% vs. 18%)
The study also found that (at six months, but not 12 months), compared to the treatment-as-usual group, the navigation-only group was significantly more likely to:
- report attending HIV care appointments (79% vs. 67%)
- report using HIV medications (84% vs. 77%)
- engage in professional substance use treatment (26% vs. 18%)
There was no differences found among any of the arms at six or 12 months for urine drug screens, self-reported days of substance use, or self-reported substance use severity.
What does this mean for Canadian service providers?
Although this study did not report any long-term difference in health outcomes between navigated and non-navigated participants, it did show that when participants were receiving navigation services (with and without incentives), they did significantly better than those who received treatment as usual. This may suggest that people living with HIV who use substances may face many personal and structural barriers to care (racism, inadequate housing, poverty) and thus need ongoing support to address and achieve better health and well-being. Navigation programs in Canada, including Peer Navigation Services, Chronic Health Navigation Program and Peer-to-Peer Program, take this approach and do not set limits on the length of engagement.
Health navigation: A review of the evidence – Prevention in Focus
Metsch L, Feaster DJ, Gooden L, et al. Effect of patient navigation with or without financial incentives on viral suppression among hospitalized patients with HIV infection and substance use: a randomized clinical trial. Journal of the American Medical Association. 2016 Jul 12;316(2):156–70.