HIV Nurse Navigation: Charting the Course to Improve Engagement in Care and HIV Virologic Suppression

Integrating HIV and Mental Health Services for Black Gay, Bisexual, and Other Men Who Have Sex with Men Living with HIV: Findings from the STYLE 2.0 Intervention

Black gay, bisexual, and other men who have sex with men (BMSM) in the US South are disproportionately impacted by HIV. We adapted Project Strength Through Youth Livin' Empowered (STYLE) to create STYLE 2.0 to assist young BMSM link and remain engaged in HIV care. The multi-component intervention included (1) health care navigators to facilitate linkage and engagement activities, (2) motivational interviewing by a behavioral health provider, and (3) a mobile app to reduce stigma and social isolation. We enrolled 66 BMSM from North and South Carolina in the 12-month intervention and analyzed longitudinal data to assess service utilization, dose, and delivery characteristics while also examining changes in HIV care continuum outcomes. We examined associations between intervention characteristics and HIV care continuum outcomes using logistic regression. We found that all HIV outcomes improved from baseline to 12-month follow-up, including receipt of HIV care (78.8-84.9%), retention in HIV care (75.9-87.7%), being prescribed antiretroviral therapy (ART) (96.8-98.5%), and achieving viral suppression (82.3-90.8%), although none were statistically significant. In multi-variable analyses, participants with more encounters categorized as food bank were more likely to report being prescribed ART [odds ratio (OR): 41.65; 95% confidence interval (CI): 2.72-637.74]. Clients with more referral to care encounters were less likely to have been prescribed ART (OR: 0.02; 95% CI: <0.001-0.42) and be virally suppressed (OR: 0.39; 95% CI: 0.18-0.84). Findings suggest that an integrated approach to HIV and behavioral health services may help BMSM living with HIV overcome structural and social barriers to HIV care.

Strategies to improve HIV care outcomes for people with HIV who are out of care

OBJECTIVE

The aim of this study was to evaluate the effectiveness of five intervention strategies: patient navigation, appointment help/alerts, psychosocial support, transportation/appointment accompaniment, and data-to-care on HIV care outcomes among persons with HIV (PWH) who are out of care (OOC).

DESIGN

A systematic review with meta-analysis.

METHODS

We searched CDC's Prevention Research Synthesis (PRS) Project's cumulative HIV database to identify intervention studies conducted in the U.S., published between 2000 and 2020 that included comparisons between groups or prepost, and reported at least one relevant outcome (i.e. re-engagement or retention in HIV care, and viral suppression). Effect sizes were meta-analyzed using random-effect models to assess intervention effectiveness.

RESULTS

Thirty-nine studies reporting on 42 unique interventions met the inclusion criteria. Overall, intervention strategies are effective in improving re-engagement in care [odds ratio (OR) = 1.79;95% confidence interval (95% CI): 1.36-2.36, k = 14], retention in care (OR = 2.01; 95% CI: 1.64-2.64, k = 22), and viral suppression (OR = 2.50;95% CI: 1.87-3.34, k = 27). Patient navigation, appointment help/alerts, psychosocial support, and transportation/appointment accompaniment improved all three HIV care outcomes. Data-to-care improved re-engagement and retention but had insufficient evidence for viral suppression.

CONCLUSION

Several strategies are effective for improving HIV care outcomes among PWH who are OOC. More work is still needed for consistent definitions of OOC and HIV care outcomes, better reporting of intervention and cost data, and identifying how best to implement and scale-up effective strategies to engage and retain OOC PWH in care and reach the ending the HIV epidemic goals.

Toward An Enhanced Understanding of HIV Patient Navigation as a Health Care Intervention: An Analysis of Navigation in Practice

Patient navigation is a promising strategy for improving health among persons with multiple barriers to HIV care, yet little is known about navigation's core components. From 24 systematically identified navigation studies, we abstracted navigators' activities, grouped activities into 20 thematic activity categories, and ordered them by frequency. Subsequently, Principal Components Analysis of activity categories was used identify independent clusters. Accompaniment characterized 71% of navigation programs; ≥ half included health education (58%), collaboration/coordination (58%), linkage-to-care (54%), transportation support (54%), service referrals (50%) and instrumental support (50%). Five unique components (comprising 13 activity categories) were identified: (1) services beyond office, (2) health education and relationship building, (3) accompaniment and instrumental support, (4) locating patients and tracking information, and (5) beyond HIV care. Navigators who located patients or tracked information were less likely to provide accompaniment or instrumental support (r = - 0.60, p = 0.002). Findings can enhance precision in developing, describing, evaluating and improving navigation programs.

Is Patient Navigation Used by People with HIV Who Need It? An Assessment from the Medical Monitoring Project, 2015 - 2017

We (1) estimated the prevalence of not getting patient navigation despite feeling a need for the service (unmet subjective need) or despite having unsuppressed viral load (unmet objective need) among people with HIV (PWH), (2) determined reasons why PWH did not use the service, and (3) determined factors associated with unmet need for patient navigation. We used combined data from the 2015 to 2017 cycles of the Medical Monitoring Project, an HIV surveillance system designed to produce nationally representative estimates of the characteristics of adults with diagnosed HIV infection in the United States. Six percent reported unmet subjective need and 28% had unmet objective need for patient navigation. When needs were combined, more than a third had unmet need for the service. Among PWH with unmet subjective need for patient navigation, 77% reported lack of knowledge about patient navigation as a reason for nonuse. Younger age, female gender, racial/ethnic minority status, limited health literacy, homelessness, incarceration history, lack of health insurance/coverage, noninjection drug use, depression, and recent HIV diagnosis were associated with unmet subjective or objective need for patient navigation. One in three PWH did not use patient navigation despite needing the service. Lack of knowledge about patient navigation was a barrier to use, calling for increased availability, and promotion of such services. PWH with social and economic vulnerabilities were less likely to get patient navigation when needed. It is important to address the question of how to make this service available to everyone who needs it.

Is HIV patient navigation associated with HIV care continuum outcomes?

OBJECTIVE

To provide the first systematic review on the associations between HIV patient navigation and HIV care continuum outcomes (i.e. linkage to care, retention in care, antiretroviral therapy (ART) uptake, medication adherence, and viral suppression) in the United States. We identified primary research studies that addressed these associations and qualitatively assessed whether provision of patient navigation was positively associated with these outcomes, including strength of the evidence.

METHODS

A systematic review, including both electronic [MEDLINE (OVID), EMBASE (OVID), PsycINFO (OVID), and CINAHL (EBSCOhost)] online databases and manual searches, was conducted to locate studies published from 1 January 1996 through 23 April 2018.

RESULTS

Twenty studies met our inclusion criteria. Of these, 17 found positive associations. Patient navigation was more likely to be positively associated with linkage to care (five of six studies that assessed this association), retention in care (10 of 11), and viral suppression (11 of 15) than with ART uptake (one of four) or ART adherence (two of four). However, almost two-thirds of the 17 studies were of weak study quality, and only three used a randomized controlled trial design.

CONCLUSION

Available evidence suggests that patient navigation is a potentially effective strategy to enhance engagement in care among persons with HIV. However encouraging, the evidence is still weak. Studies with more rigorous methodological designs, and research examining characteristics of navigators or navigational programs associated with better outcomes, are warranted given the current interest and use of this strategy.