Implementation and Operational Research

Abstract

The Navigation Program is a health department-community agency collaboration to reengage lost HIV clinic patients in Los Angeles County using best practices from disease investigator services locator activities and the Antiretroviral Treatment Access Study (ARTAS), a CDC-recommended intervention. Clinic databases were reviewed to identify HIV patients who: (1) had no HIV care visits in 6-12 months and last viral load was greater than 200 copies per milliliter; (2) had no HIV care visits in >12 months; (3) were newly diagnosed and never in care; or (4) were recently released from jail/prison/other institution with no regular HIV medical provider. Patients were contacted by trained Navigators using locator information from clinic medical records, HIV/sexually transmitted disease surveillance, and people-finder databases and offered enrollment in a modified ARTAS intervention. Among the 1139 lost clinic patients identified, 36% were in care elsewhere, 29% could not be located, 8% returned to the clinic independently, 4% declined enrollment, and 7% (n = 78) were located and enrolled in the intervention. Participants received an average of 4.5 Navigator sessions over 11.6 hours. Among reengaged patients, 68% linked within 3 months, 85% linked within 6 months, and 94% linked within 12 months, and 82% of linked patients were retained in care 12 months after study enrollment. The percentage of linked patients virally suppressed was compared at time of linkage by the Navigators (52%) with a second viral load measure after linkage to care (63%) (χ(2) = 11.8; P = 0.01). The combined disease investigator services/ARTAS model of reengagement was effective for locating and reengaging lost HIV clinic patients. Access to HIV surveillance data is critical for the efficient identification of persons truly in need of reengagement.

Is HIV patient navigation associated with HIV care continuum outcomes?

“…Target populations were primarily PWH who had challenges being engaged in HIV care. Examples include PWH with a history of incarceration (n=8) [11, 14-17, 19-21], with recent/new HIV diagnosis (n=5) [10, 14, 18, 20-21], with comorbid conditions such as substance use and mental health problems (n=4) [10, 13, 19, 22], and those who were veterans (n=1) [23], women (n=1) [8], or racial minorities (n=1) [10].…”

“…Patient navigators engaged in a range of activities that can be summarized with the categorization used in Bradford et al, 2007 [5], i.e., accompanying HIV-positive clients to appointments, coordinating their clients’ appointments, providing non-clinical services (e.g., transportation, food, clothing), providing HIV information, referring clients to HIV care or other health services, and relationship building. Five studies [10-12, 15, 20] indicated that the navigators were “peers” (e.g., being PWH and/or having similar sociodemographic characteristics as the clients), 3 studies [8, 19, 23] indicated that the navigators had professional degrees such as nursing or clinical social work, and 3 studies [5, 14, 16] indicated that the navigators had Bachelors’ degrees. In some studies there was no clear boundary between the roles of patient navigators and case managers (e.g., case management was part of the navigator’s duty or the case manager performed patient navigation [11, 13-14, 16-18]), while others had a clear separation of roles between them or reflected the idea that patient navigation and case management are two separate strategies [5, 9-10, 12, 15, 20, 24-25] (Data not shown in the table).…”

“…Seventeen out of the 20 studies (85%) [5, 8-9, 11-12, 14-21, 23-26] reported any positive associations between patient navigation and any HIV care continuum outcome. Except for the three studies that did not provide statistical tests [14, 16, 20], all of the positive associations were statistically significant.…”

“…Eight studies reported more than one finding per specific outcome (average 2, minimum-maximum: 2-4 findings) as they used equally valid multiple measures [8-12] or multiple types of contrasts [5, 13-14]. For these cases, we designated the evidence as: 1) a “positive association” if >50% of the results showed statistically significant (p<0.05) positive associations between HIV patient navigation and the outcome; 2) a “mixed result” if 50% of the results showed statistically significant positive associations; and 3) a “null association” if <50% of the results showed statistically significant positive associations.…”

“Is a Bird in the Hand Worth 5 in the Bush?”: A Comparison of 3 Data-to-Care Referral Strategies on HIV Care Continuum Outcomes in San Francisco

“…To date, most HIV navigation program data have not been systematically analyzed, and there is marked heterogeneity in outcome reporting [ 22 ]. Prior evaluations of navigation efforts using public health surveillance data included NIC PWH with similar or higher pre-enrollment viral suppression than our cohort (17% in Seattle [ 28 ], 32% in New York City [ 29 ], 43% in Massachusetts [ 18 ], and 51% in Los Angeles County [ 30 ]). A unique aspect of our program is that some LINCS navigators were placed within public HIV clinics and built trust with clinical teams while also conducting field outreach and utilizing multiple data systems to locate patients.…”