HIV-positive inmates who receive healthcare navigation services from peer mentors stand a better chance at maintaining long-term viral suppression after their release from incarceration.
Researchers from the University of California – Los Angeles, studied 356 soon-to-be-released HIV-positive inmates at the Los Angeles County Jail. Half of the enrolees participated in a programme called LINK LA. Those enrolees met every other week for 24 weeks with trained peer navigators who helped them set goals and solve problems associated with their post-incarceration healthcare. Counselling continued after release, and the peer navigators accompanied each patient on two physician visits. The other half – the control group – received a list of housing referrals and doctor’s appointments, but no other services.
Among the peer navigation group, 49% had achieved viral suppression at release, and the same percentage still had the virus under control 12 months after release. Meanwhile, among patients in the control group, 52% had viral suppression at release, but only 30% still had the virus under control after 12 months – 42% of the study enrolees were black, 31% were Latino, 85% were male, and 15% were transgender women.
Dr William Cunningham, the study’s principal investigator and a professor of medicine at UCLA’s David Geffen School of Medicine, said the human element of the peer navigation program is critical.
“Evidence strongly suggests having a human navigator who is trained to carry out a behavioural intervention makes a world of difference,” Cunningham is quoted in the report as saying. “A number of other studies have attempted a variety of smartphone-based interventions and none have shown a sustained effect on viral suppression over 12 months, as we did.”
Cunningham said the study wasn’t designed to identify which specific elements of the programme were most effective, but he noted that the peer navigators can offer services a smartphone app cannot, such as helping to facilitate better communication between the patient and his physician. However, Cunningham also noted that smartphone apps could potentially play a role in helping the peer navigator do her or his job.
Though this was only a small programme carried out at a single facility, Cunningham said he believes this type of approach could be rolled out at other municipal jails, and at larger facilities elsewhere. He and his fellow researchers are already looking at ways the program could be tailored to fit other jails and prisons.
“It most likely needs to be adapted for these purposes, but when it is, it needs to be tested scientifically before being adopted nationwide,” he said. “Other investigators around the US are trying this and other approaches at present.”
One critical element of making such a program work will be getting buy-in from jails and prisons, since this approach is predicated upon counselling beginning prior to release. For the study, Cunningham and his team worked closely with the Los Angeles Sheriff’s Department, which operates the county jail, as well as LA’s Department of Public Health and Department of Health Services.
“As with any collaboration among large complex institutions, of course it required a lot of work to align our interests, comply with all regulator requirements, and perform the study,” he said. “But, the knowledge gained and the outcomes achieved made it all worth it.”
The programme also requires funding. Cunningham said he is currently working on a cost-benefit analysis that will make the case for why these programmes are cost-effective. However, he said a simple analysis shows the high potential benefits. Just in this one small study, the programme helped control the virus for a long period of time in more than 100 high-risk patients. He said newly released inmates often engage in drug use and unprotected sex in the period immediately following release, creating a high risk of transmission if those patients don’t have their HIV under control.
“You can see how there is potential for enormous public health benefit from this, despite the costs,” he said. “We already spend millions testing low-risk populations and conducting campaigns to promote condom use, often in low-risk populations that may not have anywhere near the yield of a programme like this.”
Importance: Diagnosis of human immunodeficiency virus (HIV) infection, linkage and retention in care, and adherence to antiretroviral therapy are steps in the care continuum enabling consistent viral suppression for people living with HIV, extending longevity and preventing further transmission. While incarcerated, people living with HIV receive antiretroviral therapy and achieve viral suppression more consistently than after they are released. No interventions have shown sustained viral suppression after jail release.
Objective: To test the effect on viral suppression in released inmates of the manualized LINK LA (Linking Inmates to Care in Los Angeles) peer navigation intervention compared with standard transitional case management controls.
Design, Setting, and Participants: Randomized clinical trial conducted from December 2012 through October 2016 with people living with HIV being released from Los Angeles (LA) County Jail. All participants were (1) 18 years or older; (2) either men or transgender women diagnosed with HIV; (3) English speaking; (4) selected for the transitional case management program prior to enrollment; (5) residing in LA County; and (6) eligible for antiretroviral therapy.
Main Outcomes and Measures: Change in HIV viral suppression (<75 copies/mL) over a 12-month period.
Interventions: During the 12-session, 24-week LINK LA Peer Navigation intervention, trained peer navigators counseled participants on goal setting and problem solving around barriers to HIV care and adherence, starting while the participants were still in jail. After their release, they continued counseling while they accompanied participants to 2 HIV care visits, then facilitated communication with clinicians during visits.
Results: Of 356 participants randomized, 151 (42%) were black; 110 (31%) were Latino; 303 (85%) were men; 53 (15%) were transgender women; and the mean (SD) age was 39.5 (10.4) years. At 12 months, viral suppression was achieved by 62 (49.6%) of 125 participants in the peer navigation (intervention) arm compared with 45 (36.0%) of 125 in the transitional case management (control) arm, for an unadjusted treatment difference of 13.6% (95% CI, 1.34%-25.9%; P = .03). In the repeated measures, random effects, logistic model the adjusted probability of viral suppression declined from 52% at baseline to 30% among controls, while those in the peer navigation arm maintained viral suppression at 49% from baseline to 12 months, for a difference-in-difference of 22% (95% CI, 0.03-0.41; P = .02).
Conclusions and Relevance: The LINK LA peer navigation intervention was successful at preventing declines in viral suppression, typically seen after release from incarceration, compared with standard transitional case management. Future research should examine ways to strengthen the intervention to increase viral suppression above baseline levels.
William E Cunningham; Robert E Weiss; Terry Nakazono; Mark A Malek; Steve J Shoptaw; Susan L Ettner; Nina T Harawa