Peer Support and the HIV Continuum of Care: Results from a Multi-Site Randomized Clinical Trial in Three Urban Clinics in the United States.

Racial/ethnic minorities living with HIV and behavioral health co-morbidities are more likely to be disengaged from HIV primary care. Peer programs have been effective in HIV outreach and prevention but effectiveness of such programs for retention in care and viral suppression is understudied. Subjects (n = 348) were randomized in equal allocation to a peer navigation and education intervention versus standard clinical care at three urban clinics in the United States. The intervention group received seven structured interventions plus weekly contact to address medical and social needs. Primary outcomes included time-to-first 4-month gap in HIV care and viral suppression up to 12 months of follow-up. Intention-to-treat analysis showed no difference between groups on 4-month gap in HIV primary care, but subgroup analysis showed a suggestive effect of the peer intervention in reducing gaps in care among stably housed subjects. Fully compliant subjects in the peer intervention experienced significantly fewer 4-month gaps in HIV primary care (p < 0.0001). Those in the peer group who had more clinical face-to-face encounters in the first 3 months were also significantly more likely to have better retention in care (p = 0.04). There were no significant differences between any study subgroups in viral suppression at 12 months. Peer interventions may improve retention in primary care among subgroups of people living with HIV from racial/ethnic minority communities, although such improved retention may not increase viral load suppression. Attending and completing structured educational sessions along with early, intensive contact with peers could improve retention in HIV primary care for patients. Future peer programs should consider training on housing referral systems to help increase retention for patients who are not stably housed. clinicaltrials.gov registration number: NCT01616940.

The Role of Patient Navigators in Building a Medical Home for Multiply Diagnosed HIV-Positive Homeless Populations.

CONTEXT: People living with human immunodeficiency virus (HIV) (PLWH) who are most at risk for falling out of HIV primary care and detectable viral loads include homeless and unstably housed individuals and those codiagnosed with behavioral health disorders. The patient-centered medical home (PCMH) is a model that promotes provision of comprehensive, patient-centered, accessible, coordinated, and quality care for patients. This initiative provided patient navigation to HIV-positive homeless and unstably housed individuals codiagnosed with a mental health or substance use disorder as a means to create an adapted PCMH to meet the specific needs of this population. OBJECTIVE: The purpose of this analysis was to characterize the roles and responsibilities of patient navigators as part of an effort to create a medical home for homeless and unstably housed PLWH with behavioral health comorbidities. DESIGN: Eighty-one in-depth interviews with clinic staff and 2 focus groups with patient navigators were conducted. Content analysis was performed to identify key roles and responsibilities of the patient navigators. RESULTS: Patient navigators played an important role in creating a PCMH by working with clients to schedule and complete appointments, develop comprehensive care plans, forging critical relationships with providers both within and outside of health care systems, providing holistic support to increase patient self-management, and assisting in achieving housing stability. CONCLUSIONS: It may be necessary to adapt the traditional PCMH model to effectively meet the social, behavior health, and medical needs of homeless and unstably housed PLWH with behavioral health comorbidities. A patient navigator who can invest time in supporting and connecting these patients to needed services may be a key component in creating an effective PCMH for this population. These findings highlight the roles and tasks of patient navigators that may contribute to developing a PCMH specific to homeless and unstably housed PLWH with mental health and substance use comorbidities. Implementation of such a model has the potential to improve health outcomes (such as retention in care and viral suppression) for particularly vulnerable PLWH and thereby reduce the burden of HIV infection.