United States
2017

The Mpowerment (MP) program is a community-level intervention designed to help prevent HIV among young men who have sex with men (MSM). The program works to address psychosocial factors (e.g., one’s sense of agency) that can affect sexual risk behaviours.^1,2 The MP program is one of the Effective Interventions – High Impact Prevention programs of the Centers for Disease Control and Prevention (CDC)³ and has been previously evaluated and found to have positive outcomes.²

A recent study that focused on outcomes of MP delivery in racial/ethnic minority communities found positive psychosocial changes, a reduction in sexual risk taking and an increase in HIV testing among participants when MP was delivered to a group of young MSM of colour.¹

Mpowerment (MP) program description

The MP program is tailored to the needs of the local community. A logic model provided by the CDC helps to guide program implementation.

MP targets a variety of factors (e.g., beliefs, social support, peer influence and community empowerment) that can reduce sexual risk behaviours and increase HIV testing in participants. The program includes six core elements that are intended to work together, although there is no requirement that participants attend activities; participants are free to attend as many elements of the MP program as they wish.¹ The core elements of MP are as follows: ^1,2

• A core group of 12 to 15 young men serve as the project's decision-making body; the group’s work can include designing project materials and outreach methods.
• Formal outreach includes young MSM going to places frequented by young MSM to deliver safer sex messages/education.
• M-groups (small peer-led group meetings) last 3 hours and focus on factors contributing to unsafe sex among young MSM (e.g., misperceptions about safer sex, having poor sexual communication skills).
• Informal outreach includes young MSM having casual conversations with their friends about the need for safer sex.
• Publicity is targeted at young MSM to provide messaging related to safer sex and to recruit participants.
• A project space is established where young MSM can meet and socialize.

The CDC recommends that volunteers and a project coordinator deliver and oversee MP and that a Community Advisory Board be convened³ to provide advice to the core group.²

Using a repeated measures design, participants of the study completed baseline and follow-up surveys at 3 and 6 months. An individual’s participation in M-group was considered to be the start of their involvement in MP because M-groups provided the most significant dose of the intervention.¹

Results¹

• Significant improvements in participants’ belief that they have the capacity to participate in safer sex were found at the 3 and 6 month follow ups (i.e., follow ups 1 and 2) compared with the baseline survey, and participants’ self-acceptance as an MSM improved by follow-up 2, as compared to baseline.
• More exposure to MP (measured by a score that considered participation in and weight of the core elements noted above) was associated with significant improvements in perceived social norms about safer sex and HIV testing among gay/bisexual/transgender friends, as well as increased discussions about safer sex among gay/bisexual/transgender friends.
• Participants reported significantly higher levels of HIV testing (in the past 6 months) at both follow-up points (54% at baseline to 65% at follow-up 1 to 70% at follow-up 2).
• Participants reported a significant reduction in condomless sex with any partner at follow-up 1, but this change was not sustained at follow-up 2 (40% at baseline to 34% at follow-up 1 to 41% at follow-up 2).
• No significant changes in participants’ reports of engaging in condomless sex with non-primary partners, while intoxicated or high (injection drugs), with a partner of unknown HIV status or in the context of transactional sex were found.

What does this mean for service providers?

The MP program has been adapted in Canada and may provide service providers with a way to promote new biomedical prevention strategies (e.g., pre-exposure prophylaxis) and empower individuals to take control of and manage their sexual health. The adaptable nature of MP allows for elements of the program such as outreach locations, the project space and program publicity to be tailored to individual target communities. The MP program has been shown to be successful in increasing testing within racially/ethnically diverse communities of young MSM¹ and could be further explored and used to promote testing among young MSM.

Related resources:

Sexual Health Information Project – Case Study

YouthCo Mpowerment Program (BC)

Mpowerment Effective Interventions (CDC)

Mpowerment Implementation Planning Tool and M&E Activities (CDC)

Mpowerment Project page – mpowerment.org

References:

1. a. b. c. d. e. f. g. Shelley G, Williams W, Uhl G et al. An evaluation of Mpowerment on individual-level HIV risk behavior, testing, and psychosocial factors among young MSM of color: The monitoring and evaluation of MP (MEM) Project. AIDS Education and Prevention. 2017;29(1):24–37.
2. a. b. c. d. Kegeles SM, Hays RB, Coates TJ. The MP Project: A community-level HIV prevention intervention for young gay men. American Journal of Public Health. 1996;86:1129–36. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380625/pdf/amjph00519-0075.pdf
3. a. b. Centers for Disease Control and Prevention. Effective interventions: HIV prevention that works. High impact prevention: Mpowerment. 2017. Available from: https://effectiveinterventions.cdc.gov/en/HighImpactPrevention/Interventions/Mpowerment.aspx

USA
2017

A recent study evaluated the effectiveness of a nurse navigator program in supporting engagement in care and improving clinical outcomes among veterans with HIV. For those who used the nurse navigator program, the number of clinic visits doubled, medication renewal increased from 41% to 81%, and attainment of an undetectable viral load (<200 copies/mL) increased from 48% to 69% after approximately one year.

Nurse-led navigation program

The program employed a nurse who provided HIV education, appointment reminders to support clinic attendance, and adherence support interventions to veterans. Patients were referred for navigation if they were identified as being poorly engaged (e.g., multiple no shows for appointments, inconsistent medication renewals, and elevated viral loads) by a member of the clinical team. An intensive follow-up process for missed appointments was used, which included the nurse navigator calling both the veteran and emergency contacts.

A variety of strategies to increase adherence to medication and clinic engagement were used, including:

• reminder calls (appointments and medication renewal)
• text reminders
• same-day walk-in appointments
• collaboration with family members and medical staff
• pillbox renewals

This study took place within the Veterans Affairs (VA) Infectious Disease (ID) primary care clinic in Washington DC, which strives to create an inclusive and accepting “medical home” for veterans.

Results

Patients referred to the nurse-led navigation program were compared with the overall cohort of veterans with HIV who were receiving care from the ID primary care clinic. At the start of the program, those who enrolled in the nurse navigator program were less likely to have a viral load <200 copies/mL, less likely to live in permanent housing, more likely to have substance use, and more likely to have comorbid depression or a disability than the overall ID primary care clinic study cohort.

When participants in the nurse navigation program were followed up approximately one year after they enrolled in the program, the percentage of participants with a viral load of <200 cells/mL increased from 48% to 69%. Additionally, the study found a significant increase in the average number of clinic visits (from one to two clinic visits) and in the rate of medication renewal (from 41% to 81%).

What does this mean for Canadian service providers?

This study demonstrates the importance of individualized care in a vulnerable population with a variety of comorbid conditions, as well as the potential benefits to having a nurse navigator as part of a primary care team treating people with HIV.

This program worked with a group of poorly engaged veterans; however, there is potential that this approach could also be used in other populations that show signs of poor engagement.

Examples of patient navigation services exist in the Canadian context, for example, Peer Navigation Services and Chronic Health Navigation Program. This study provides an additional example of the roles that a patient navigator could play, as well as the potential benefits to having a nurse provide a navigation role as a member of the treatment team.

Related resources

Health Navigation – Evidence Review

Patient Navigation – Evidence Brief

ARTAS – Evidence Brief

Effective Interventions: Patient Navigation Resources and Tools – Center for Disease Control and Prevention

References

Hemmy Asamsama O, Squires L, Tessema A, et al. HIV Nurse Navigation: Charting the course to improve engagement in care and HIV virologic suppression. Journal of the International Association of Providers of AIDS Care. 2017; 1-5.

United States
2017

A hepatitis testing and linkage-to-care initiative reaches those at greatest risk of HCV and HBV infection

The U.S. Centers for Disease Control and Prevention (CDC) developed the Hepatitis Testing and Linkage to Care initiative (HepTLC), which awarded grants to 34 organizations committed to increasing hepatitis B and C testing and linkage-to-care efforts. The initiative targeted people at risk for hepatitis B and hepatitis C infection and tested over 87,000 people. Of the 4,766 people found to have hepatitis B or C, 44% were linked to care. The HepTLC Initiative identified lessons learned on how to effectively test and link high-risk populations to care.

What is the HepTLC initiative?

The HepTLC initiative had two main goals:

1. Early identification and linkage to care of foreign-born people with hepatitis B.
2. Early identification and linkage to care of people with hepatitis C.

The HepTLC initiative provided grants to 34 organizations across the United States that demonstrated capacity, skill and experience working with the initiative’s target populations. The organizations designed and implemented their testing and linkage-to-care programs independently. The CDC provided access to educational materials, fact sheets, training tools and support for data collection and data entry.

Each organization was expected to conduct 1,000 to 4,000 hepatitis B or C tests per year over a two-year period from September 2012 to September 2014. Organizations included HIV prevention and education centres, state and local health departments, community health centres or coalitions, drug treatment centres and universities. Testing sites for hepatitis B included community outreach events, health centres and community-based organizations that serve foreign-born people. Testing sites for hepatitis C included homeless shelters, harm reduction programs, methadone clinics, alcohol and drug treatment centres and correctional facilities.    

Results

A total of 87,860 people were tested for hepatitis B or C (71% of the CDC’s 123,139 testing goal).

Hepatitis B testing and linkage to care

A total of 23,144 hepatitis B tests were conducted. Most of the people tested (86%) originated from countries where hepatitis B is endemic. Among all the people tested, 6% (1,317 people) were hepatitis B positive. Of the people who tested positive, 90% received their test result, 83% were referred to care and 46% were successfully linked with follow-up care (had a verified visit to a healthcare provider).

Hepatitis C testing and linkage to care

A total of 64,716 people were tested for hepatitis C (with an antibody test and/or hepatitis C RNA test).  Of those tested, 13% were positive for hepatitis C antibodies and 63% received a follow-up hepatitis C RNA test. Of the 4,765 people who received a hepatitis C RNA test, 72% tested positive, meaning they had a chronic hepatitis C infection. Of the 3,449 people with a chronic hepatitis C infection, 81% received their results, 76% were referred to care and 44% were successfully linked with care.

What does this mean for Canadian service providers?

The HepTLC initiative demonstrates that it is possible to reach, test and find people who are positive, and provide linkage to care for high-risk populations using targeted testing and linkage-to-care interventions across a range of organizations and venues. Venues which already served high-risk populations were well suited to design and implement hepatitis testing and linkage-to-care interventions in their communities. 

The initiative shows that offering hepatitis testing and linkage-to-care services can be effective in a range of clinical and non-clinical sites (including homeless shelters, methadone clinics, drug and alcohol treatment centres, and correctional facilities).

While rapid hepatitis C antibody testing enables testing in a range of settings, non-clinical settings can have greater challenges in ensuring follow-up hepatitis C RNA testing is completed and people successfully linked to care. This is because people need to return for testing or accept a referral for RNA testing at another location. In addition, sites that don’t have clinical care services integrated within them also have to refer people to other locations for clinical services. This presents barriers to RNA testing and linkage to care.

One of the successful ways that some projects in the HepTLC initiative overcame these barriers was to use patient navigators to support people to attend follow-up testing and linkage-to-care services, especially when initial testing was done in a non-clinical setting. Hepatitis B testing was more successful when done by staff members who were culturally and linguistically similar to the clients being tested.

Organizations that offered a one-stop shop model of care with a range of services in one location were more effective at getting people into care. Each additional offsite referral or medical appointment provided another barrier to follow-up testing and linkage to care. Integrated services were particularly beneficial at linking to care clients who used injection drugs, were homeless or did not have a permanent address.

Reference

Ramirez G. Cabral R, Patterson M, et al. Early Identification and Linkage to Care for People with Chronic HBV and HCV Infection:  The HepTLC Initiative. Public Health Reports. 2016;131 (Supplt 2):5–11.

South Carolina, United States
2017

A study from the United States found that the addition of a part-time outreach coordinator in a clinic environment resulted in re-engagement in care for 44% of people who were previously lost to care. Of those who re-engaged, 50% were retained in care.

Outreach program in a clinical environment

In 2014, a part-time outreach coordinator was added to a clinical team in South Carolina. The person had a Masters in Clinical Counselling and experience working with people with HIV.

The coordinator worked to identify patients who were out of care (patients who had attended the clinic at least once from 2009 to 2014 but were not engaged in care in 2014). The coordinator then determined whether these patients were lost to care or if they had died, been incarcerated or had transferred care. Multiple sources were used to make this determination including electronic medical records, obituaries and personal communications.

Once a client was identified as lost to care, the outreach coordinator used the last known phone number to try to contact the client. If contact was made, the coordinator worked to re-engage the client in care. If there was no answer then a message was left. No confidential information was left by the coordinator and a phone number was provided, which connected to the coordinator’s secure direct cell phone that was not linked to the clinic. These precautions were taken to protect the privacy of the client.

If contact was not made by phone, the next step was a personalized letter mailed to the last known address. The letter only broadly offered help with re-engagement and included the contact information for the outreach coordinator. If contact was made by letter, the coordinator worked to re-engage the client in care.

If contact was not made through the letter, a home visit was attempted. If contact was made, the coordinator worked to re-engage the client in care. If contact was not made, a card was left with contact information for the outreach coordinator. If after this there was still no contact made, then return visits to the home were an option.  

The study

There were 1,242 adult patients enrolled in the clinic in 2014, and 233 of them were identified as out of care. Only 51% (119) of these were determined to be lost to care by the outreach coordinator. Almost all (99%) of those lost to care received a phone call. Of those who did not respond, 97 received a letter and 14 received a home visit.

The intervention re-engaged in care 44% of patients that were lost to care. In 2015, 50% of those who re-engaged were still retained in care (with at least one clinic visit that year).

What does this mean for service providers?

A low-touch outreach intervention has the ability to re-engage people into care and retain them in care. In most cases, the phone calls alone were successful at re-engaging patients – creating a low cost and time limiting approach.

Reference

Bean MC, Scott L, Kilby MJ et al. Use of an outreach coordinator to reengage and retain patients with HIV in care. AIDS Patient Care and STDs. 2017 May;31(5):222-226.

North Carolina, United States
2017

The North Carolina State Bridge Counselor (SBC) Program, increases participant motivation to overcome barriers to care.¹ The SBC program successfully links people newly diagnosed with HIV to care, and re-engages people living with HIV who had been lost to care. Within one year, care was initiated for 83% of newly diagnosed clients, 68% were retained in care and 69% achieved viral load suppression. Within one year, care was re-initiated for 46% of clients who were lost to care, 50% were retained in care and 51% achieved viral load suppression.²

State Bridge Counsellors²

The SBC program is a statewide intervention developed to link people newly diagnosed with HIV to care; and re-engage into care people with HIV who had fallen out of care. Standard protocols were developed for service delivery and coordination for SBCs to provide services across multiple counties.

The SBCs received training in:

• ARTAS (an evidence-based program that uses strengths-based counselling and case management to increase linkage to care)
• substance use and mental health
• addressing barriers to care.

The SBCs provided services to people newly diagnosed with HIV; people from out of state new to care in North Carolina; people out of care; and high-risk clients in need of urgent care (such as pregnant women).

The SBCs provided brief assistance (one to two contacts) to ensure linkage and re-engagement. This included assistance addressing barriers to care by providing services or supports such as:

• medical appointments
• financial or insurance coverage
• housing
• transportation
• referrals to other services (for example, mental health)
• language issues
• childcare
• partner violence counselling.

People newly diagnosed with HIV were referred to SBCs by public health after they made an initial HIV care appointment. SBCs then confirmed attendance at the appointment by contacting the patient or clinic, or by documentation of a viral load test. If the patient did not attend the appointment, the SBC located the client and helped to address their barriers to care.

Clients who had not kept medical appointments for more than six to nine months were determined to be lost to care and referred to SBCs by public health for follow-up. For these clients, SBCs attempted to locate the client with up to three phone calls and three visits. If the client was contacted, SBCs provided strengths-based counselling to address the reasons for disengaging from care. For clients willing to re-engage in care, appointments were booked and the SBCs confirmed they attended these appointments. A case was closed when a client was linked to care, refused services, died or could not be located after trying for 90 days.

Results^1,2

All activities by the SBCs were recorded in a database and service data was analyzed between January 2013 and June 2015 to determine the characteristics of the clients who were referred to the SBCs, and the proportions who were linked to or re-engaged with care and/or achieved viral suppression.

People who received linkage services

There were 1,173 people who were newly diagnosed with HIV and referred to SBCs for linkage to care between January 2013 and June 2015. Of these, 299 (25.5%) people received services. Among the 874 people who were not linked to services, 79% were found to be already in care, 11% could not be found and 10% were not eligible for the intervention because they had been imprisoned, died or moved out of state.

The number of SBC linkage referrals increased from 34 clients in the first quarter of 2013 to 208 in the second quarter of 2015. Overall, SBCs provided 1,327 services for linkage of newly diagnosed clients. Services provided included:

• appointment scheduling and attendance (43%)
• financial or insurance assistance (19%)
• transportation (14%)
• housing (6%)
• mental health, substance use or intimate partner violence counselling (7%)
• language assistance (1%)
• childcare (1%)
• other (10%).

There was a median one contact and two services per client. The total median time spent on each client was 30 minutes.

Care was initiated within 90 days of referral for 63% of clients and within one year for 83% of clients. Within one year of referral, 68% were retained in care and 69% achieved viral load suppression.

People who received re-engagement services

There were 2,099 referrals to SBCs for re-engagement services between January 2013 and June 2015. Services were provided to 606 (28.9%) people. Among the 1,493 people who did not receive services, 56% were found to be already in care, 31% could not be found and 13% were not eligible for the intervention because they had been imprisoned, died or moved out of state.

The number of SBC re-engagement referrals increased from 18 in the first quarter of 2013 to 302 in the second quarter of 2015. Overall, SBCs provided 2,640 services for re-engagement. Services provided included:

• appointment scheduling and attendance (35%)
• financial or insurance assistance (17%)
• transportation (12%)
• housing (5%)
• mental health, substance use or intimate partner violence counselling (5%)
• language assistance (1%)
• childcare (1%)
• other (8%).

There was a median one contact and three services per client. The total median time spent on each client was 39 minutes.

There was re-initiation of care within 90 days of referral for 46% of clients and within one year for 78%. Within one year of referral, 50% were retained in care and 51% achieved viral load suppression.²

In a qualitative study participants shared that the SBCs increased their motivation to return to HIV care and to overcome barriers associated with re-engaging in care. SBCs described that the strength based approach focused on engagement (e.g., meeting clients where they were in life, attempting to identify skills, talents and abilities, and informing client of rights at every opportunity) helped to facilitate HIV care re-engagement.¹

What does this mean for Canadian service delivery?

People with HIV in Canada are not optimally engaged in care.^3,4 The SBC Program was successful at linking people newly diagnosed with HIV to care and re-engaging people in care who had fallen out of care by helping address the barriers to care people may face. This was achieved with limited time interaction with each client, and building on the existing public health infrastructure. This was a statewide intervention that included rural areas, and is an example of an intervention that can successfully engage people in care in rural areas.² A strengths based approach that focuses on engagement may inform the development of effective HIV navigation programs to re-engage people with HIV who have fallen out of care and require re-engagement mechanisms that fall out of the norm (e.g., emails, phone calls).¹

References

1. a. b. c. d. Parnell HE, Berger MB, Gichane MW, et al. Lost to Care and Back Again: Patient and Navigator Perspectives on HIV Care Re-Engagement. AIDS Behaviour. 2017 Oct 3 [Epub ahead of print].
2. a. b. c. d. e. Seña AC, Donovan J, Swygard H, et al. The North Carolina HIV Bridge Counselor Program: Outcomes From a Statewide Level Intervention to Link and Reengage HIV-Infected Persons in Care in the South. Journal of Acquired Immune Deficiency Syndromes. 2017 Sep 1;76(1):e7–e14.
3. Nosyk B, Montaner JSG, Colley G, et al. The cascade of HIV care in British Columbia, Canada, 1996–2011: a population-based retrospective cohort study. The Lancet Infectious Diseases. 2014 Jan;14(1):40–49.
4. Gilbert M, Gardner S, Murray J, et al. Quantifying the HIV care cascade in Ontario: Challenges and future directions. Poster presented at: 24th Annual Canadian Conference on HIV/AIDS Research; 2015 May 30; Toronto, Ontario. Available from: http://www.cahr-acrv.ca/wp-content/uploads/2012/10/InfDis_26_SB_MarApr2015_Final.pdf