Practice Guidelines for Peer Health Navigation for People Living with HIV: A new program development resource for community-based organizations (Part 1)

Prevention in Focus PiF 2017 Fall

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CATIE
PiF Peer Nav Guidelines

Practice Guidelines for Peer Health Navigation for People Living with HIV will soon be published. This new resource is for community-based organizations that want to strengthen existing HIV peer health navigation programs or establish new ones. The guidelines, which provide evidence-based and practice-based recommendations for program planners, were developed by a national expert working group of people living with HIV, frontline service providers, program planners, clinicians and researchers, in conjunction with CATIE.

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This article reviews the evidence that supports health navigation in HIV, explains the guidelines, and provides an overview of the recommendations on assessing whether a peer health navigation program is right for your agency and clients. An article in the next issue of Prevention in Focus will provide an overview of the recommendations from the guidelines related to managing a peer health navigation program.

Increasing access to a continuum of services for people living with HIV

For a person living with HIV to achieve optimal health outcomes, they need access to a continuum of services, including:

  • HIV testing and diagnosis
  • linkage to appropriate medical care and other health services
  • support while in care
  • access to HIV treatment (ART) when they are ready
  • support while on treatment

However, we know that there are significant barriers to care for some people living with HIV, which makes it difficult for them to be optimally engaged in care. System-level barriers, which are caused by the structure of the healthcare system, can include the appointment scheduling process,1 fragmented service delivery,2,3 and lack of specialized local healthcare services.4

Individual-level barriers to care are specific to each client. Examples of individual barriers are a lack of access to transportation5,6 and adequate food and lodging,6 insufficient finances,6,7 and lack of social support.4,6 Other significant individual-level barriers to care may also include substance use and mental illness.

What is health navigation?

Health navigation is a programming approach that helps clients to overcome both system-level and individual-level barriers to care.

Health navigation for people living with HIV was defined by the working group as a person-centred approach to guide, connect, refer, educate and accompany people living with HIV through systems of care. The goals of health navigation are to build the capacity of clients to self-manage their HIV care, navigate systems themselves and, ultimately, improve their health and wellness.

Health navigation has a positive impact on the health and well-being of people living with HIV

When HIV-positive clients are supported by navigation services, they are more likely to engage in care, which is an important step in accessing the benefits of treatment and other supports. A number of studies show that HIV health navigators (both peers and professionals) have a positive impact on rates of both engagement and retention in care.8,9,10,11,12,13,14,15,16,17 In addition to improving engagement in care, navigation services have a positive impact on treatment outcomes, such as an increase in CD4 count and a decrease in viral load.8,10,11,12,13,15

What are the Practice Guidelines for Health Navigation for People Living with HIV?

CATIE convened a 13-member national expert working group to inform and develop the guidelines on peer health navigation for people living with HIV. The working group was made up of people living with HIV, frontline service providers, program planners, public health practitioners, clinicians and researchers. A participatory process was established to develop and review the guidelines, which resulted in more than one hundred recommendations.

The working group was guided by six core values: the greater involvement and meaningful engagement of people living with HIV (GIPA/MEPA), harm reduction, anti-oppression, self-determination, resiliency and trauma-informed practice.

The aim of the guidelines is to:

  • improve the quality and consistency of peer health navigation programs
  • improve the effectiveness of peer health navigation programs to positively impact the health and wellness of people living with HIV
  • build on existing local/regional models and materials, many of which were developed and informed by people living with HIV

The practice guidelines are based on research and practice evidence, and include three components:

  1. Recommendations. Provide general research-based and practice-based recommendations on how to approach the development, implementation and strengthening of peer health navigation programs. The type of evidence (research or practice) used to inform each recommendation is provided.
  2. Evidence reviews. Synthesize and analyze the best possible evidence from the peer-reviewed and grey literature.
  3. Vignettes. Illustrate how the recommendations may be applied in practice, based on the experience of the expert working group.

Adapting agency structures to accommodate peer workers

Recommendations: Getting ready for peer health navigation programs

Assessing agency infrastructure (Chapter 1)

Agencies hosting peer health navigation programs need to assess their capacity to establish and sustain the program. There are three recommendations, which relate to:

  • Assessing the agency's capacity to support a peer health navigation program
  • Assessing the agency's capacity to work within a GIPA/MEPA framework
  • Assessing the agency’s readiness to ensure it has an inclusive culture

An example recommendation and accompanying vignette is:

Recommendation 2: Assess agency capacity to work within a GIPA/MEPA framework. (Type of evidence: research and practice).

Vignette: A local community-based agency currently provides case management for HIV-positive people. The agency is expanding to develop and deliver a peer health navigation program. In reviewing Practice Guidelines in Peer Health Navigation for People Living with HIV, a consultant working with the agency to develop the program recommends that they consider how GIPA/MEPA principles are currently incorporated into the agency’s work, and how they will be integrated into the peer health navigation program.

The agency’s leadership reflects reflects on how it has engaged people living with HIV in its work so far. The agency admits that it has not done as much as it could to work within a GIPA/MEPA framework. They understand that the GIPA/MEPA principles aim to realize the rights and responsibilities of people living with HIV, including the right to self-determination and participation in the decision-making process. Therefore, they engage people living with HIV who are currently using the services within their organization but they also reach out to other organizations to help actively link them to people living with HIV from other organizations. A large group of diverse people living with HIV from the community are brought together to help determine how they want their voices heard within the development of this program. Based on these consultations, multiple sessions are held to provide space for input into the development and delivery of the program and an ongoing committee is struck to ensure continued input into the delivery of the program. In the end, many of these people living with HIV become peer health navigators within the newly developed program.

Peer health navigator roles and responsibilities (Chapter 2)

Peer health navigator roles are the specific functions a peer navigator performs as a service provider. Navigators can play a variety of roles, which should reflect the local needs of the client population. The roles and responsibilities of navigators will vary based on the local context and the needs of clients. There are 20 recommendations, which relate to:

  • The development of the peer health navigator role
  • Core peer health navigator roles
  • Core peer health navigator responsibilities

An example recommendation and accompanying vignette is:

Recommendation 2: Define a clear peer health navigator scope of practice and draft job descriptions that reflect the roles and responsibilities within the scope of practice. Job descriptions should also clearly outline the goals of the program and qualifications and experience that are necessary and preferred. Determine and communicate the roles and responsibilities that are outside the peer health navigators’ scope of practice of peer health navigators. Ensure job descriptions are clear and straightforward. (Type of evidence: research and practice)

Vignette: Following their training, the peer health navigators felt quite confident that they understood their scope of practice. However, a few weeks after training, the program supervisor, Kai, notices that one peer health navigator named Zoe is crossing boundaries with clients and doing work outside her scope. This includes babysitting one of her client’s children. Kai likes that Zoe is using her great helping skills with her clients, but is worried that this is leading to inappropriate and unsustainable relationships with the organization’s clients. Over time, Kai works with Zoe to support her capacity to maintain required boundaries. Kai also starts to review the scope of practice regularly with all the navigators at team meetings to help them recognize when they are crossing boundaries. Within these meetings, the team also role-plays talking to clients about the need to maintain appropriate boundaries. This helps them understand and work within their scope of practice and maintain good boundaries with clients.

Ethical considerations (Chapter 3)

There are important ethical issues to consider when implementing a peer health navigation program. There are 16 recommendations, which relate to:

  • Ethical decision-making process
  • Boundaries
  • Confidentiality
  • Disclosure
  • Dual roles
  • Health and wellness
  • Cultural safety
  • Conflicts of interest
  • Power imbalances
  • Conflict resolution
  • Transition from the program

An example recommendation and accompanying vignette is:

Recommendation 10: Develop the capacity of peer health navigators to understand the impact of culture and identity on health and wellness. (Type of evidence: research and practice)

Vignette: A hospital clinic that sees mostly First Nations clients provides education to all new staff, including peer health navigators, about culture, power and privilege, and how these relate to health. The program includes First Nations and non-First Nations navigators so Alex, the program supervisor, must create an environment of learning that is open and safe. Navigators are supported to explore their own cultural heritage and beliefs and how these may affect interpersonal relationships. Alex ensures that education on First Nations history and health, and traditional ways of knowing, living and healing are regularly provided by a local Elder. Alex also provides navigators with culturally appropriate posters and materials that include the seven sacred teachings of love, respect, courage, honesty, wisdom, humility and truth. Materials are offered as a way to engage with clients in a way that promotes safety and inclusion.

What’s next?

An overview of the recommendations on how to manage a peer health navigation program will be covered in the next issue of Prevention in Focus, which will be published in January 2018.

Resources

Practice guidelines in peer health navigation for people living with HIV

 

References

  1. Percac-Lima S, Grant RW, Green AR, et al. A Culturally tailored navigator program for colorectal cancer screening in a community health center: A randomized, controlled trial. Journal of General Internal Medicine. 2009 Feb;24(2):211–7.
  2. Basu M, Linebarger J, Gabram SGA, et al. The effect of nurse navigation on timeliness of breast cancer care at an academic comprehensive cancer center: Nurse Navigation and Timeliness of Care. Cancer. 2013 Jul 15;119(14):2524–31.
  3. Cantril C, Haylock PJ. Patient navigation in the oncology care setting. Seminars in Oncology Nursing. 2013 May;29(2):76–90.
  4. a. b. Koh C, Nelson JM, Cook PF. Evaluation of a patient navigation program. Clinical Journal of Oncology Nursing. 2010;15(1):41–8.
  5. Whop LJ, Valery PC, Beesley VL, et al. Navigating the cancer journey: A review of patient navigator programs for Indigenous cancer patients. Asia-Pacific Journal of Clinical Oncology. 2012 Dec;8(4):e89–e96.
  6. a. b. c. d. Domingo JB, Davis EL, Allison AL, Braun KL. Cancer patient navigation case studies in Hawai‘i: The complimentary role of clinical and community navigators. Hawaii Medical Journal. 2011;70(12):257–61.
  7. Freeman HP. Patient Navigation: A community based strategy to reduce cancer disparities. Journal of Urban Health. 2006 Mar 3;83(2):139–41.
  8. a. b. 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):S49–S58.
  9. 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.
  10. a. b. 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.
  11. a. b. 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–S41.
  12. a. b. Irvine M, Chamberlin S, Robbins R, Kulkarni S, Robertson M, Nash D. Come as you are: Improving care engagement and viral load suppression among HIV care coordination clients with lower mental health functioning, unstable housing, and hard drug use. AIDS and Behavior. 2017 Jun;21(6):1572–9.
  13. a. b. Anderson E, Momplaisir F, Corson C, Brady K. Assessing the impact of perinatal HIV case management on outcomes along the HIV care continuum for pregnant and postpartum women living with HIV, Philadelphia 2005-2013. AIDS and Behavior. 2017 Feb 7. Epub ahead of print.
  14. 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.
  15. a. b. Brennan-Ing M, Seidel L, Rodgers L, et al. The impact of comprehensive case management on HIV client outcomes. PLoS One. 2016 Feb 5;11(2):e0148865. Available from: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0148865
  16. Broaddus M, Hanna CR, Schumann C, Meier A. “She makes me feel I’m not alone”: Linkage to Care Specialists provide social support to people living with HIV. AIDS Care. 2015;27(9):1104–7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596723/
  17. Sena A, Donovan J, Swygard H, et al. The North Carolina HIV Bridge Counselor Program: Outcomes form a statewide level intervention to link and re-engage HIV-infected persons in care in the south. Journal of Acquired Immune Deficiency Syndromes. 2017 Apr 6. Epub ahead of print.

 

About the author(s)

Logan Broeckaert holds a Master’s degree in History and was a researcher/writer at CATIE. Before joining CATIE, Logan worked on provincial and national research and knowledge exchange projects for the Canadian AIDS Society and the Ontario Public Health Association.