Peer health navigation and incentive-facilitated advancement along the HIV continuum of care

Los Angeles, USA

The Alexis Project combined peer health navigation and contingency management (i.e., incentives) to support linkage and engagement of trans women of colour in HIV care. The project increased progression along the HIV continuum of care, with 85% of people attending a first HIV care visit, 71% receiving HIV treatment, 69% receiving viral load and CD4 tests, 57% returning for a second HIV care visit and 14% attaining an undetectable viral load.

Program description

The Alexis Project used peer health navigation and contingency management to link trans women into HIV care and help them progress along the HIV continuum of care (e.g., viral load suppression). To participate, a trans woman had to:

  • be between the ages of 18 and 65 years
  • report their racial/ethnic identity as other than Caucasian/White
  • be HIV positive
  • either (a) not currently be in HIV care or (b) not have seen a HIV medical provider in the previous six months or (c) not be prescribed HIV treatment or (d) be prescribed HIV treatment but not always adherent.

Participants were recruited via:

  • a community-wide social network recruitment and engagement strategy
  • venue- and street-based outreach at food lines or food banks, at bars, on street corners and at other locations where trans women congregate
  • project flyers
  • in-reach at other programs and local agencies that provide services to trans women
  • collaborating HIV medical care clinics

Peer health navigation

Peer health navigators (i.e., navigators) were trans women of colour with HIV. Navigators provided case management and worked with participants to develop individualized care plans with the goal to increase linkage and engagement in HIV care alongside medication adherence and attainment and maintenance of an undetectable viral load. The goal of the care plans was to address individual-level barriers to care (e.g., transportation, legal services, housing) to increase engagement. Navigators also provided referrals to trans-competent providers and services, reminded people of appointments and provided transportation and accompaniment to HIV medical care or other appointments (e.g., applying for government-issued identification) if needed.

Participants were encouraged to have ongoing contact with navigators for information, guidance, support and/or referral to other services. The goal over time was for navigators to increase participants’ self-efficacy in managing their own treatment plan.

Navigators were trained in setting boundaries, maintaining confidentiality, developing active listening communication skills and self-care (among other areas). Clinical supervision was provided semi-monthly by a PhD-level clinical advisor. A medical advisor provided training on HIV care, the interpretation of medical records and other clinical topics (e.g., information on treatment choices, guidance on how to coach people to maintain viral load suppression).

Contingency management

The contingency management component of the project was used to increase the number of HIV care visits that participants attended and their adherence to medication with the intent of helping them to achieve viral load suppression. The contingency management (CM) component used CM points (equivalent to money). Participants received CM points for behavioural milestones, which included attending a first HIV care visit ($20), attending subsequent HIV care visits ($30-$50 per visit), picking up medications ($20) and bringing laboratory records to navigators ($20). They also received CM points for biomedical milestones, which included reducing viral loads (e.g., $30 for a 1-log viral load reduction at 3 months) and achieving and maintaining viral load suppression ($50 at 9, 12 and 18 months). CM points were exchanged for goods or services (e.g., gift cards to grocery stores, clothing, wigs and makeup, electrolysis and other skin care services or other gender-promoting services).


Between February 2014 and August 2016, 139 participants enrolled in The Alexis Project. The majority of participants were African American/Black (39%) or Hispanic/Latina (38%). Additionally:

  • 47% were heterosexual/straight
  • 23% were gay
  • 38% reported having less than a high school diploma or equivalent
  • 32% were currently experiencing homelessness or living in a homeless shelter
  • 29% indicated that sex work was a main source of their income

There were 35 participants (25%) who reported trouble adhering to HIV treatment and/or maintaining their HIV primary care regimen but tested undetectable upon enrolling. There were 11 participants (8%) who were unaware of their HIV status and found to be HIV positive through onsite testing that was used to verify HIV-positive status for participation in the study.

The majority (85%) of the participants attended the first HIV care visit, 71% received HIV treatment, 69% received viral load and CD4 tests, 57% returned for a second HIV care visit and 14% attained an undetectable viral load. Overall, 88% of people attended at least two peer health navigation sessions. The average number of sessions attended was 6.6 (attendance at the peer health navigation sessions was unincentivized). Participants earned a total of $19,960 CM points, with the average being $143.60.

Greater attendance at peer health navigation sessions was significantly associated with achievement of both behavioural and biomedical HIV milestones, including achieving and maintaining viral load suppression.

What does this mean for service providers?

This study showed that combining peer health navigation with contingency management was effective at advancing trans women of colour with HIV through the HIV continuum of care. The program had a notably positive impact on outcomes (e.g., linkage to care, picking up HIV medications and receiving laboratory results).

Peer health navigation for people with HIV has been shown to be an effective approach to support people through HIV treatment and care. The use of trans women of colour as peer health navigators in this project probably created trust and rapport that led to better discussions around service accessibility barriers and ways to address them. Peer health navigators who have successfully navigated the HIV healthcare system themselves may be in a unique position to help their community navigate the healthcare system. The success of this program may also be due to the very hands-on approach, which included warm hand-offs to other service providers, encouragement to contact navigators at any time and accompaniment to a variety of appointments (e.g., applying for government-issued identification) when requested.

Related resources

A low-threshold and multicomponent program for homeless or unstably housed people with HIV

Practice Guidelines in Peer Health Navigation for People Living with HIV

Health Navigation in HIV Services: A review of the evidence


Reback C, Kisler KA, Fletcher JB. A novel adaptation of peer health navigation and contingency management for advancement along the HIV care continuum among transgender women of colour. AIDS and Behaviour. 2021 July; 25(Suppl 1): 40-51. doi:10.1007/s10461-019-02554-0.