2017

A recent scoping review¹ has described the factors that impact the success of health navigation programs that link primary care (community health centres, family health teams, etc.) with community-based health and social services. The review identified 11 factors that can impact the success of health navigation programs:

1. client characteristics
2. navigator recruitment and training
3. navigator role clarity
4. clear operational processes
5. time and resources
6. partnerships
7. community services
8. communication
9. client uptake
10. valuing navigators
11. evaluation

What is navigation?

In navigation programs, clients are paired with a service provider—sometimes a nurse, case manager, or peer—whose job is to support and guide clients through the healthcare system until they can manage it themselves. The review’s authors describe the roles of navigators as:

1. facilitating access to health-related programs and services
2. promoting and facilitating continuity of care
3. identifying and removing barriers to care
4. ensuring effective and efficient use of the healthcare system by clients, families, and providers

Methods

Study authors reviewed the research-based evidence related to health navigation published between January 1990 and June 2013. Articles were eligible for inclusion if they contained information about navigators or navigation programs in primary care settings that linked clients to community-based health and social services.

There were 34 articles included in the review:

• 29 from the United States
• two from Canada
• two from the United Kingdom
• one from Australia

What factors impact the success of health navigation programs in primary care?

The scoping review identified 11 factors that impact the success of health navigation programs in primary care settings:

1. Client characteristics: Agencies should consider the complexity of client needs, language and geographic barriers, and the ability of the agency to provide culturally appropriate services when designing a navigation program.
2. Navigator recruitment and training: Agencies should consider encouraging the growth and development of navigators, training on problem solving for complex cases, fostering collaboration among navigators, and orienting navigators to the specific needs of their clients.
3. Role clarity: Agencies should set clear boundaries for navigators to ensure they understand their role.
4. Clear operational processes: Agencies should develop processes, policies, and procedures that support navigation; use consensus decision-making processes; provide clinical supervision; communicate regularly with partners; and identify mechanisms to address scheduling and referral challenges.
5. Time and resources: Agencies should provide for adequate human resources; financial resources; physical resources such as space for navigators to work; and technological resources such as electronic health record systems.
6. Partnerships: Agencies should encourage commitment from all staff involved, and develop strong relationships with external partners using a community charter, a steering committee, and a communication strategy that includes a way to address power imbalances and other conflicts.
7. Community services: Agencies should consider whether there are sufficient resources in the community where clients can be referred.
8. Communication: Agencies should encourage attendance at staff meetings, share client updates through the electronic health record, and involve physicians in regular meetings.
9. Client uptake: Agencies should get buy-in for the navigation program from clients, use diverse strategies to recruit to the program, and address any potential stigmas that may exist.
10. Valuing navigators: Agencies should demonstrate to navigators they are valued by facilitating opportunities for them to be recognized and heard.
11. Evaluation: Agencies should develop an evaluation plan, consider participatory research processes, focus on program processes, use pre-identified indicators, and address potential problems with lack of access to data, monitoring health changes over time, and attribution of outcomes to the navigation program.

Navigation already being used to support people living with HIV

Research evidence also exists to support the use of navigation programs specifically for people living with HIV. Linkage to care rates among clients of navigation programs significantly increased after program implementation.^2,3 There is also evidence to show that navigators significantly improve retention rates of HIV-positive clients in care.^2–5 Critically, research shows that working with a navigator can significantly improve treatment outcomes among people living with HIV, including increased CD4 counts and decreased viral loads.^2,3

Navigation programs are already used in Canada to support people living with HIV to achieve optimal health and wellness outcomes, including programs in Vancouver, Kamloops, and Regina. Canadian guidelines that will support the strengthening of existing programs and the development of new peer health navigation programs for people living with HIV will be published in 2017.

References

1. Valaitis RK, Carter N, Lam A, et al. Implementation and maintenance of patient navigation programs linking primary care with community-based health and social services: a scoping literature review. BMC Health Services Research. 2017 Dec;17(1):116. Available from: http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2046-1
2. Bradford JB, Coleman S, Cunningham W. HIV System Navigation: An emerging model to improve HIV care access. AIDS Patient Care and STDs. 2007 Jun;21(s1):S-49–58.
3. Farrisi D, Dietz N. Patient navigation is a client-centered approach that helps to engage people in HIV care. HIV Clinician. 2013;25(1):1–3.
4. Zaller ND, Holmes L, Dyl AC, et al. Linkage to treatment and supportive services among HIV-positive ex-offenders in Project Bridge. Journal of Health Care for the Poor and Underserved. 2008 May;19(2):522–31.
5. Willis S, Castel AD, Ahmed T, et al. Linkage, engagement, and viral suppression rates among HIV-infected persons receiving care at medical case management programs in Washington D.C. Journal of Acquired Immune Deficiency Syndromes. 2013 Nov;64(Supplement 1):S33–41.

Los Angeles County, United States
2017

A study¹ has shown that, among people living with HIV who are disengaged from care, a social network approach can successfully find and link them into HIV care. Using this social network approach, Project Engage linked 69% of participants to care within three months, and retained 79% in care. Within 12 months, 40% of participants achieved an undetectable viral load, which was a significant increase from when they were first linked to care (26%).

Project Engage

Project Engage is a linkage-to-care program in Los Angeles County that targets people living with HIV who are out of care. Opinion leaders and others who were not necessarily HIV positive but who had large social networks (known as seeds) were recruited to, in turn, recruit HIV-positive people disengaged from care (known as alters) into HIV care. As part of the study, program staff also recruited people living with HIV who were out of care through passive outreach (flyers and pocket cards) and active outreach (going to places where HIV-positive people are likely to hang out).

Staff from agencies such as homeless shelters and substance use programs were asked to recruit seeds using a screening form that identified people with large social networks. Potential seeds were asked:

• if they knew anyone in their social network who was living with HIV and out of care
• the number of people they knew out of care
• whether they felt comfortable talking to their friends about their HIV status and HIV care

Seeds received 10 vouchers that included an identification number that linked alters back to the seed who referred them. An alter was defined as an HIV-positive person who had at least one of the following characteristics:

• had no HIV lab tests reported in the Los Angeles County HIV surveillance system for more than 12 months
• had no HIV lab tests reported in the Los Angeles County HIV surveillance system for the last six to 12 months AND had a detectable viral load at their last viral load test
• was recently released from jail, a residential treatment facility, or other institution and had no regular HIV care provider
• had fewer than two medical visits in a 12-month period with the same HIV care provider
• was recently diagnosed with HIV and had no medical visits within three months of diagnosis

Seeds and alters both received US$40 when they completed a Project Engage questionnaire. Both also received US$40 when an alter completed their first medical visit. Alters who completed their first medical visit were then eligible to become seeds.

At the same time as seeds were recruiting alters from their social networks, Project Engage staff were recruiting seeds and alters directly in public areas, and distributing program flyers and pocket cards to agencies and clinics, and posting them in public areas.

Once an eligible alter was identified by project staff or by seeds, they met with a trained staff member to assess their needs. Alters who were not interested in engaging in care received education on the importance of HIV care, and were asked if staff could continue to follow up with them.

Alters identified by project staff and by seeds, and who were interested in accessing care, were linked by project staff to an HIV clinic with a medical coordination team. Clinics with medical coordination teams have a nurse, case manager, and social worker, and the resources to support and retain clients with complex health and social needs. The team coordinates with medical providers, and makes referrals to substance use treatment, mental health services, housing, transportation, and other non-medical services.

Project staff helped alters choose a clinic, made the first appointment, sent reminders, provided transportation, and accompanied them to their first visit.

Who did Project Engage reach?

Project Engage recruited 62 eligible seeds and 112 eligible alters. Seeds recruited 67% of alters and project staff recruited 33%. The majority of seeds recruited between one and four eligible people from their social network; one seed recruited 59 eligible people from their social network.

Most alters (61%) were between the ages of 30 and 49, 80% were male, 14% were trans women, 60% were gay men, 23% were bisexual, 38% were African-American, and 22% were Latino. Most (89%) had annual incomes of less than US$12,000 a year, 63% were disabled or received social assistance, and 60% were publicly insured. Alters reported being homeless (78%), ever using illicit drugs (74%), being incarcerated in the past 12 months (50%), engaging in sex work in the past six months (32%), and injecting drugs in the past three months (24%).

The medical histories of alters showed that:

• 68% had been on HIV treatment (ART) at some point in the past
• 47% had been recently released from jail where there was no regular HIV medical provider
• 38% had no HIV medical visits in more than 12 months before enrollment
• 24% had only received HIV care in jail or prison in the last five years
• 14% were newly diagnosed with no medical visit within three months of their diagnosis
• 11% had no HIV medical visits for seven to 12 months and their viral load was detectable on their most recent viral load test

When alters were asked about the services they needed the most, 96% reported needing medical care, 91% needed case management, 89% needed general healthcare services, and 81% needed mental health counselling. The most commonly reported barriers to care were difficulty navigating the system (26%), substance use (14%), and incarceration (10%).

Most people living with HIV out of care were linked and retained in care

Out of 112 alters recruited by Project Engage, 69% were linked to care within three months, 5% within four to six months, 8% within seven to 12 months, and 4% in more than 12 months. Fifteen percent (17 participants) were lost to follow-up.

Seventy-nine percent of alters were retained in care, defined as a second viral load test between six and 12 months following linkage to care.

A significant increase in undetectable viral load among participants

Twenty-six percent of alters had an undetectable viral load when they were first linked to care. This increased significantly to 40% at the time of their second viral load test.

Project Engage acceptable to participants linked to care

Among 75 alters who completed a survey about Project Engage, 100% would recommend the program to others, 100% were satisfied with the program, and 81% reported they would not have entered HIV care without it.

What does this mean for Canadian service providers?

Effective and lasting linkage to care is crucial to improving the health of people living with HIV. Effective linkage can lead to HIV treatment for people who are ready to start. Effective treatment (resulting in an undetectable viral load) allows an HIV-positive person to live a long and healthy life.²  Engagement in treatment and care can also have a significant impact on HIV prevention. People who are engaged in care, taking ART, and have an ongoing undetectable viral load are substantially less likely to transmit HIV to others. In fact, studies show that people who maintain an undetectable viral load do not pass HIV to their sexual partners.

This study demonstrates that social networks can be one way to recruit people into care. However, the study has a significant limitation. The effectiveness of the program relied, in part, on what the study authors described as a “super seed,” one participant who recruited most of the alters. When developing a social network intervention like Project Engage, Canadian service providers should consider strategies to identify more super seeds.

Social network approaches to HIV work have been used in Canada to link people to HIV testing. The Saskatoon Health Region uses a social network approach to encourage HIV testing and counselling during HIV outbreaks; AIDS Community Care Montreal has  used a social network strategy in the past to recruit gay, bisexual, and other men who have sex with men to test for HIV. 

References

1. Wohl AR, Ludwig-Barron N, Dierst-Davies R, et al. Project Engage: Snowball sampling and direct recruitment to identify and link hard-to-reach HIV-infected persons who are out of care. Journal of Acquired Immune Deficiency Syndromes. 2017 Feb 6;1. (in press)
2. CANOC collaboration, Patterson S, Cescon A, Samji H, et al. Life expectancy of HIV-positive individuals on combination antiretroviral therapy in Canada. BMC Infectious Diseases. 2015 Dec;15(1):274. Available from: http://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-015-0969-x

San Francisco, United States
2017

A study¹ has shown that 95% of participants in a rapid HIV treatment initiation program start antiretroviral treatment (ART) within 24 hours of being diagnosed with HIV. The Rapid ART Program for Individuals with an HIV Diagnosis, known as RAPID, was established at the San Francisco General Hospital in 2013.

There are seven components to RAPID:

1. Same-day access to an HIV provider. When diagnosed with HIV, people are offered a same-day appointment with an HIV specialist. Taxi vouchers are provided to get from the testing site to the hospital.
2. Same-day medical visit. People diagnosed with HIV spend time with an HIV healthcare provider who educates them on HIV infection, risk reduction, sexual health, and the benefits of treatment. People are offered same-day treatment and patients can decline if they are not ready. Baseline tests are ordered, including CD4 cell count, HIV viral load, kidney and liver function tests, drug hypersensitivity and resistance testing, and hepatitis testing.
3. Accelerated health insurance approval process. Pre-existing, available protocols for emergency drug assistance are used for clients without health insurance.  
4. Pre-approved treatment regimens. Drug regimens that can be used without the results of genotyping or laboratory testing have been pre-approved by a local HIV expert committee and are based on known local drug-resistant strains of HIV.
5. Five-day starter pack. Starter packs are available for patients who are waiting for insurance coverage.
6. Observed first dose of treatment. Patients who want to start treatment are offered the opportunity to take their first dose during the medical visit.
7. Telephone follow-up. Nurses contact patients within seven days to review laboratory results, ask about adherence, pharmacy/prescription issues, and any side effects.

The study

The study compared patients who were managed through the RAPID protocol to those who were managed according to the standard of care between July 2013 and December 2014. The study also compared the RAPID patients to a historical cohort of HIV-positive patients referred to the hospital between 2006 and 2013, before RAPID was developed. People were targeted for the RAPID protocol if they had an acute or recent infection, or had a CD4 count below 200 copies/ml, an active opportunistic infection, or an HIV-negative partner at the time of diagnosis.

Among 86 patients referred for HIV treatment initiation between July 2013 and December 2014, 39 were managed through RAPID and 47 were managed according to the standard of care. The characteristics of the 86 patients in the study were as follows:

• 97% male
• 66% were people of colour
• 42% reported major mental health disorders
• 42% reported illicit substance use
• 28% reported homelessness

Referrals to the RAPID program took a median of six days after the HIV test was performed and typically happened the day the patient was diagnosed with HIV. Following their referral, intake into the RAPID program and prescribing of treatment happened a median of one day later.

Among patients who received the standard of care, the intake time into the clinic and time to prescription of treatment were significantly longer, 10 days and 22 days respectively. There was no significant difference in loss to follow-up between RAPID and standard of care patients (10% vs. 15%).

Using the RAPID protocol for HIV treatment initiation:

• 90% of patients started HIV treatment at the clinic
• 95% of patients started HIV treatment within 24 hours of clinic visit

The median time to an undetectable viral load (below 200 copies/ml) was significantly faster for RAPID patients than for standard of care patients (56 days vs. 79 days).

When time to undetectable viral load was also compared to the historical group of patients, the study found that median time to undetectable viral load was significantly shorter among RAPID patients. In RAPID patients, the median time was 1.8 months, compared to 4.3 months during the period 2010–2013 in San Francisco when treatment was offered to everyone that was diagnosed with HIV, and 7.2 months during the period 2006–2009 in San Francisco when treatment was offered to patients who had a CD4 count less than 500 cells/mm³.

What does this mean for Canadian service providers?

People with HIV who start treatment as soon as possible after diagnosis achieve better health outcomes than those who wait to start treatment.² Once a person is on treatment and has achieved an undetectable viral load, the risk of transmitting HIV to others is negligible.^3–10

This study demonstrates that a RAPID protocol, which helps people living with HIV access the benefits of treatment as soon as possible, is feasible in a hospital setting and is acceptable to people just diagnosed with HIV. In Canada, a similar approach is being used to treat people with acute HIV infection in two clinics in British Columbia.

Resources

CATIE statement on the use of antiretroviral treatment (ART) to maintain an undetectable viral load to prevent the sexual transmission of HIV

Prevention Access Campaign

References

1. Pilcher C, Ospina-Norvell C, Dasgupta A, et al. The effect of same-day observed initiation of antiretroviral therapy on HIV viral load and treatment outcomes in a US public health setting. Journal of Acquired Immune Deficiency Syndromes. 2016;74(1):44–51.
2. The INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. New England Journal of Medicine. 2015 Aug 27; 373:795–807.
3. Cohen M, Chen YQ, Macauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine. 365(6):493–505.
4. Reynolds SJ, Makumbi F, Nakigozi G, et al. HIV-1 transmission among HIV-1 discordant couples before and after the introduction of antiretroviral therapy. AIDS. 2011 Feb 20;25(4):473–7.
5. Melo MG, Santos BR, De Cassia Lira R, et al. Sexual transmission of HIV-1 among serodiscordant couples in Porto Alegre, southern Brazil. Sexually Transmitted Diseases. 2008 Nov;35(11):912–5.
6. Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet. 2010 Jun 12;375(9731):2092–8.
7. Rodger A. HIV Transmission risk through condomless sex if HIV+ partner on suppressive ART: Partner STUDY. Oral presentation at: Conference on Retroviruses and Opportunistic Infections; 2014 Mar 3; Boston, MA. Available from: http://www.croiwebcasts.org/console/player/22072
8. Eshleman SH, Hudelson SE, Redd AD, et al. Treatment as Prevention: Characterization of partner infections in the HIV Prevention Trials Network 052 trial. Journal of Acquired Immune Deficiency Syndromes. 2017 Jan 1;74(1):112–6.
9. Rodger A, Cambiano V, Braun T. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. Journal of the American Medical Association. 2016;316(2):171–81.
10. Grulich AE, Bavinton B, Jin F. HIV Transmission in male serodiscordant couples in Australia, Thailand and Brazil. Late breaker poster 1019 LB presented at: 22nd Conference on Retroviruses and Opportunistic Infections; 2015 Feb 23; Seattle, WA.

United States
2017

An American demonstration project¹ has shown that young gay, bisexual and other men who have sex with men (MSM) who have sex that may expose them to HIV in an ongoing way find the care and support related to taking pre-exposure prophylaxis (PrEP) acceptable. The study also showed that young MSM may experience significant challenges to adherence over time, suggesting young MSM may need intensive care and support while on PrEP.

Project PrEPare 2

Project PrEPare 2 was a PrEP demonstration project that recruited young MSM at 12 urban sites in the United States between January and September 2013.The objectives of the study were to:

• add to the safety evidence of Truvada as PrEP among HIV-negative young MSM
• examine acceptability of, patterns of use of, rates of adherence to PrEP, and drug blood levels
• examine patterns of risk behaviour when young MSM are provided with an evidence-based behaviour intervention before PrEP initiation (Many Men, Many Voices (3MV) or Personalized Cognitive Counselling (PCC))

Young men were eligible for the study if they were:

• born male
• between the ages of 18 and 22
• HIV negative at the time of screening
• reported HIV transmission risk behaviour

Participants participated in either 3MV or PCC depending on the study site. Once the behavioural intervention was completed, participants were scheduled for their first visit. At this visit they received additional PrEP education and were given a 30-day supply of Truvada.

Participants returned for clinic visits every four weeks for the first three months of the study and then every three months for the rest of the 12-month study period. At each visit, a medical history was taken for signs and symptoms of any illness, and a symptom-directed physical exam was conducted. Behavioural data was also collected.

At every visit, participants were tested for HIV, hepatitis B, gonorrhea, and chlamydia; kidney, liver, and pancreas function; and for adherence to PrEP through dried blood spots. Rectal swabs for chlamydia and gonorrhea were collected at baseline, six months and 12 months or when clinically indicated. Syphilis tests were conducted at baseline and then at the end of the study, unless symptoms were observed. Participants also received a comprehensive HIV prevention package that included risk reduction counselling, condoms, sexually transmitted infection (STI) screening and treatment, and met with a counsellor.

Who participated in Project PrEPare 2?

Two hundred young MSM were enrolled in the study. The median age was 20. Sixty-six percent of participants identified as Black, 29% identified as White, and 26% identified as Latino. Most participants identified as gay (78%) or bisexual (14%). Thirty percent were unemployed, 29% had ever exchanged sex for money, and 15% had ever been homeless. Study retention was 71%.

PrEP safe in young MSM

The study showed that side effects such as nausea, weight loss and headache associated with Truvada resolved when the drug was discontinued. A small but significant decrease in bone mineral density was observed among participants. There was no harm to participants’ kidneys.

PrEP care acceptable to young MSM

Over 90% of participants said they liked PrEP care (or liked it a lot) during the study, including regular STI testing, physical exams, and counselling. Sixty percent found taking the Truvada pill every day acceptable.

Adherence to PrEP decreased as time between clinic visits increased

Truvada was detectable in the blood of 90% of participants through the first three months of the study. This decreased to 81% six months into the study, and decreased again to 69% at the end of the study.

Although 69% of participants had detectable levels of Truvada in their blood at the end of the study, only 34% had a protective level of Truvada in their blood. Median levels of Truvada in the blood of Black participants were below the protective level at each time point in the study.  

The most common reasons for low adherence among all participants were forgetting (29%), travelling (27%), and being busy (27%).

STI rates remained high

Twenty-two percent of participants were diagnosed with an STI at the start of the study. Overall, STI diagnoses remained high over the course of the study with an incidence rate of 66 per 100 person years.

HIV seroconversions

Four men seroconverted during the study; none had detectable levels of Truvada in the blood sample drawn closest to their seroconversion.

What does this mean for Canadian service providers?

The Project PrEPare 2 study showed that young MSM who have sex that may expose them to HIV in an ongoing way find PrEP care acceptable. However, the study found that young MSM find adherence challenging, especially when the time between visits was increased from one month to three. More frequent clinical visits may be optimal care for young MSM on PrEP.

Service providers offering PrEP care and support may want to tailor support programs to clients—including culturally competent and age-tailored programs—as ways to improve rates of adherence among younger MSM.

Reference

Hosek S, Landovitz R, Kapogiannis B, et al. An HIV pre-exposure prophylaxis (PrEP) demonstration project and safety study for young MSM. Journal of Acquired Immune Deficiency Syndromes. 2017 Jan 1;74(1):21-29.

United States
2017

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:

1. Six months of health navigation with financial incentives
2. Six months of health navigation without financial incentives
3. 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.

The results

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.

Resources

Health navigation: A review of the evidence – Prevention in Focus

References

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.