Outcomes and costs of publicly funded patient navigation interventions to enhance HIV care continuum outcomes in the United States: A before-and-after study

Abstract

Background In the United States, patients with HIV face significant barriers to linkage to and retention in care which impede the necessary steps toward achieving the desired clinical outcome of viral suppression. Individual-level interventions, such as patient navigation, are evidence based, effective strategies for improving care engagement. In addition, use of surveillance and clinical data to identify patients who are not fully engaged in care may improve the effectiveness and cost-effectiveness of these programs. Methods and findings We employed a pre-post design to estimate the outcomes and costs, from the program perspective, of 5 state-level demonstration programs funded under the Health Resources and Services Administration’s Special Projects of National Significance Program (HRSA/SPNS) Systems Linkages Initiative that employed existing surveillance and/or clinical data to identify individuals who had never entered HIV care, had fallen out of care, or were at risk of falling out of care and navigation strategies to engage patients in HIV care. Outcomes and costs were measured relative to standard of care during the first year of implementation of the interventions (2013 to 2014). We followed patients to estimate the number and proportion of additional patients linked, reengaged, retained, and virally suppressed by 12 months after enrollment in the interventions. We employed inverse probability weighting to adjust for differences in patient characteristics across programs, missing data, and loss to follow-up. We estimated the additional costs expended during the first year of each intervention and the cost per outcome of each intervention as the additional cost per HIV additional care continuum target achieved (cost per patient linked, reengaged, retained, and virally suppressed) 12 months after enrollment in each intervention. In this study, 3,443 patients were enrolled in Louisiana (LA), Massachusetts (MA), North Carolina (NC), Virginia (VA), and Wisconsin (WI) (147, 151, 2,491, 321, and 333, respectively). Patients were a mean of 40 years old, 75% male, and African American (69%) or Caucasian (22%). At baseline, 24% were newly diagnosed, 2% had never been in HIV care, 45% had fallen out of care, and 29% were at risk of falling out of care. All 5 interventions were associated with increases in the number and proportion of patients with viral suppression [percent increase: LA = 90.9%, 95% confidence interval (CI) = 88.4 to 93.4; MA = 78.1%, 95% CI = 72.4 to 83.8; NC = 47.5%, 95% CI = 45.2 to 49.8; VA = 54.6, 95% CI = 49.4 to 59.9; WI = 58.4, 95% CI = 53.4 to 63.4]. Overall, interventions cost an additional $4,415 (range = $3,746 to $5,619), $2,009 (range = $1,516 to $2,274), $920 (range = $627 to $941), $2,212 (range = $1,789 to $2,683), and $3,700 ($2,734 to $4,101), respectively per additional patient virally suppressed. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess patients against themselves at baseline and not against standard of care during the same time period. Conclusions Patient navigation programs were associated with improvements in engagement of patients in HIV care and viral suppression. Cost per outcome was minimized in states that utilized surveillance data to identify individuals who were out of care and/or those that were able to identify a larger number of patients in need of improvement at baseline. These results have the potential to inform the targeting and design of future navigation-type interventions.

“Entre Nosotras:” A qualitative evaluation of a peer-led PrEP project for transgender Latinas

“…PHEs leveraged their social capital, empathy, and personal experience to recruit participants for the program and support their retention in care. While an ample body of evidence shows the value of peer navigation in HIV services (20)(21)(22)(23), our research adds nuance to the existing literature by pro ling the multifaced roles that PHEs served for primarily Latina, transgender, immigrant participants; addressing their needs for gender a rming care, information around immigration, and bilingual services from primarily Latinx staff. Navigation in Triunfo encompassed case management, peer counseling and education, and both in-clinic and external service navigation.…”

A Pilot Study of a Patient Navigation Intervention to Improve HIV Pre-exposure Prophylaxis Persistence Among Black/African American Men Who Have Sex With Men

“…To date, several interventions have been developed to improve PrEP uptake and adherence among Black/African American MSM, [17][18][19][20] but far fewer interventions have been developed to improve PrEP persistence. Although patient navigation is a commonly used approach for improving care engagement among people living with HIV infection, [32][33][34] it is less often implemented in the context for improving care engagement among people accessing PrEP. Several recent studies have demonstrated the benefits of patient navigation programs in improving PrEP initiation.…”

“…In several jurisdictions, HIV surveillance information is used by local health departments as a means of systematically identifying patients who were never in care after their diagnosis with HIV infection, who recently disengaged in care, or who are at high risk for disengaging from care for patient navigators to locate and attempt to link or relink them or keep them engaged. 32,[41][42][43] Use of these data allow for efficient allocation of limited patient navigation resources to those most in need of their services. In this study, the PrEP navigator benefited from the use of near real-time data on pharmacy purchases to quickly identify patients at high risk of experiencing gaps in care or disengaging from care entirely because of problems acquiring medication.…”

Cultivating resilience and hope: A qualitative study of a pilot program using patient navigators to assist men who have sex with men with retention in the HIV care continuum in Uganda

“…Because this individualized approach to support was key to this pilot's success, further research is recommended to understand the financial feasibility of this individualized approach for long term and larger scale programs. This recommendation was similarly made by Shade et al [36], who in their review of 16 PN interventions across the United States found that among these interventions (all of them taking place over 11-12 months) most of their intervention costs went towards providing tailored support to patients at the individual level [36].…”