ARTAS

Los Angeles County, United States
2016

Short-term health navigation program increases percentage of people living with HIV engaged in care

A navigation program that actively seeks and supports clients who are not engaged in HIV care can successfully link clients to care. A study1 showed that the program, based in Los Angeles County, California, can also significantly increase the percentage of clients with an undetectable viral load.

The Navigation Program

The Navigation Program is a partnership between Los Angeles County Department of Public Health, AIDS Project of Los Angeles, AIDS United, and Johns Hopkins University. The goal of the program is to link to care people living with HIV who are not already well-engaged in care. The program is staffed by six paraprofessional health navigators who have experience working with people living with HIV. The intervention has four components:

  1. Building relationships with clients
  2. Assessing client needs
  3. Linking clients to resources and enhancing client strengths
  4. Transitioning clients to more long-term care at the end of the program

Navigators use clinic records to identify potential participants. Using clinic records and public health databases, the navigators then to try to locate and contact potential participants using phone, text, email, letter or home visit. If this approach is unsuccessful, navigators also look through jail and prison databases, people-finder websites and, if a person has a history of homelessness, by connecting with shelters. Once enrolled in the program, navigators schedule and remind clients about appointments, follow-up on client referrals. After three months in the program, clients are transitioned back to either their home clinic or a new clinic of their choice.

The results

Participants in the study were recruited from seven clinics between January 2012 and August 2014. Eligible participants had to be out of care, which was defined as:

  • no HIV care visits in the previous six to 12 months and a viral load greater than 200 copies/mL;
  • no HIV care visits in more than 12 months;
  • new diagnosis and never in care; or
  • recently released from jail, prison or other institution and with no current regular HIV care provider.

A total of 1,139 clients were identified as being out of care, and 7% (78) were located and enrolled in the program. Of the clients who were contacted, 5% were re-engaged in care through the initial call with a navigator but did not enroll in the program. Clients who did not enroll in the program were in care elsewhere, had left Los Angeles County, had passed away, were in jail, prison or a mental health facility, could not be located, or declined enrollment.

Most program participants were men (78%), Latino (71%), gay (50%), and had an annual income of less than $10,000 (64%). A significant minority identified as Black (18%).

Out of the 78 individuals enrolled in the program:

  • 47% (37) had no history of care in the previous 12 months
  • 32% (25) were deemed to have unstable care (recently released from an institution with no regular HIV care provider)
  • 18% (14) had no HIV care in the last six to 12 months and had a viral load greater than 200 copies/mL
  • 3% (2) were newly diagnosed and had never been in care

Most clients had a number of service needs at the time of enrollment. On average, navigators met with clients five times and clients needed five referrals (mental health, housing/transportation, and financial/employment) while participating in the program. Almost half of the participants (46%) needed fewer than three visits to re-engage in care. Common services required by clients at time of enrollment included:

  • dental care (60%)
  • benefits assistance (43%)
  • medication assistance (42%)
  • food or other basic needs (35%)
  • HIV healthcare (34%)

Almost all clients (94%) were linked to care within 12 months of enrolling in the program. Of the clients who were linked to care, 82% were retained, which is defined as attending a second medical appointment three to 12 months after they were linked. There was a significant increase in the percentage of participants with an undetectable viral load after they were retained in care (63%) compared to 52% at the time of enrollment.

What does this mean for Canadian service providers?

This study has shown that short-term intensive navigation by paraprofessionals can successfully re-engage clients who have not been successfully retained in care. Most clients needed only a phone call or fewer than three visits to be linked to care, and once linked most were retained in care.

There are currently a number health navigation programs in Canada that support clients to engage in care, including Peer Navigation Services in Vancouver, the Chronic Health Navigation Program in Kelowna, the Peer-to-Peer Program in Regina, and the Making The Links program in Toronto.

Canadian practice guidelines on how to provide peer health navigation services to people living with HIV will be published in 2017.

Resource

Health navigation: A review of the evidence —CATIE

References

Wohl AR, Dierst-Davies R, Victoroff A, et al. Implementation and operational research: The Navigation Program: An intervention to reengage lost patients at 7 HIV clinics in Los Angeles County, 2012–2014. Journal of Acquired Immune Deficiency Syndromes. 2016;71(2):e44–e50.