The Enhanced Patient Navigation for Women of Color with HIV intervention uses patient navigators, who are non-medical staff in clinical settings, to reduce barriers to health care and optimize care. The intervention combines client support and education activities to improve client autonomy as a means to link women of color to HIV primary care, increase retention in care and adherence to medication, and ultimately reach viral suppression. Three sites implemented this intervention as part of the Dissemination of Evidence-Informed Interventions project funded by the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) program from 2016–2019. The intervention was effective in improving linkage to and retention in care, as well as viral suppression.
Los Angeles, CA
Women of color are disproportionately affected by HIV as compared to their white peers.1 Black and Hispanic women have lower rates of antiretroviral use and viral suppression and higher HIV-related morbidity than white women.2,3 Barriers to care include lack of family support, inadequate HIV services, and stigma. Women of color may also face greater unmet needs for services including housing and employment. By providing enhanced navigation services to women of color who are not fully engaged in care, clinics provide additional support to clients and build clinic-client trust, address client care and service priorities first, increase client health literacy, and support clients in developing self-efficacy to manage their care.
“The Enhanced Patient Navigation intervention is designed to utilize patient navigators (non-medical staff in clinical settings) to increase linkage and retention in HIV primary care among cis- and transgender women of color.”
Patient navigators are integrated into the multidisciplinary healthcare team and are responsible for: conducting outreach to, finding, and re-engaging women of color lost to care or with a new diagnosis of HIV, and contacting eligible clients; developing rapport, and providing support to clients; assisting clients in obtaining referrals for needed services (such as transportation, housing, etc.); scheduling and accompanying clients to medical appointments; working in tandem with standard case management throughout the intervention; and transitioning the client to the standard of care (standard case management) using a standard transition protocol.
Patient navigators work with clients for a minimum of six months and a suggested maximum of 12 months. After six months, clients are reassessed every three months using an acuity-based system to determine if they still need the support of the patient navigator.
Using motivational interviewing and trauma-informed care principles, patient navigators assess client barriers, needs, and acuity, and work with the client to develop, implement, and monitor the patient care plan.
Patient navigators conduct a series of one-on-one educational sessions with clients on six health education topics:
- HIV, the viral life cycle, and understanding antiretroviral therapy (ART)
- Communicating with health care providers about adherence and managing side effects
- Basic lab work and adherence
- Stigma and disclosure
- HIV and substance use
- HIV and mental health
The educational sessions are 30- to 60-minute face-to-face meetings that are scheduled on a weekly or every other week basis.
The goals of the sessions are to:
- Document enhanced client knowledge of health maintenance activities for the management of HIV
- Improve the client’s involvement in their HIV care
- Assist the client in making healthy life choices
- Improve client attitudes toward ART
- Reduce client fears regarding ART
- Reduce client isolation
- Decrease stigma
Across the three sites (Grady Health System; Keck School of Medicine at the University of Southern California; and Newark Beth Israel Medical Center), 332 cis- and transgender women participated in Enhanced Patient Navigation from 2016–2019. Three-quarters of participants were linked to HIV medical care within 90 days and retained in care; viral suppression improved from 36% at baseline to 64% after 12 months.
Source: Dissemination of Evidence-Informed Interventions. Enhanced Patient Navigation for Women of Color with HIV (2020).
- Patient navigator hiring and supervision. The intervention sites hired patient navigators with strong interpersonal skills, and ideally, people with lived experience who had worked in a medical setting. They established a supervision system for navigators within the HIV care team and trained them on the intervention, educational materials, content related to HIV, how to engage hard-to-reach clients, trauma-informed care, and other relevant topics. Patient navigators were given access to the electronic medical record to document client activities and integrated as part of the clinical team.
- Out-of-care criteria. For this project, sites used the following criteria to identify potential participants to approach about the intervention: cis- or transgender women of color with HIV who are 18 years of age or older, have fallen out of care for six months or more; OR are loosely engaged in care (have canceled or missed two or more appointments in the past 12 months); OR are not virally suppressed (>200 copies/ml); OR have more than one health condition that threaten their ability to be retained in care (at the discretion of the clinician and the clinical team).
- Support for patient navigators. An administrative supervisor worked with patient navigators to help identify women who had a recent diagnosis of HIV, or were out of care. The clinical supervisor provided regular support to patient navigators for managing client cases and addressing self-care. The program also provided ongoing professional development and mentorship to patient navigators.
- Community partnerships. Intervention team members established formal and/or informal relationships with community-based agencies and clarified the mechanisms to generate referrals.
- The average cost per participant per year across the three sites was $2,894 (2019 dollars), with the number of clients served ranging from 157–299 per year. The costs included salary and fringe benefits for intervention staff and supervisors, materials for non-research related activities, transportation costs for staff and clients, other direct costs to provide client services such as incentives to attend medical appointments and agency overhead rates.
- To incorporate patient navigation into the standard of care at the clinic, it is important to train clinic staff who interact with clients (e.g., front desk staff, appointment scheduling staff) to identify clients who may benefit from enhanced patient navigation, and explain how staff members can connect these clients to patient navigation services.
- Clinics can explore other potential funding sources including funding through Medicaid programs and Accountable Care Organizations, as well as other program income streams.
- Identify a champion (health care provider, program manager supervisor) to maintain support and integration of the patient navigators as part of the care team.
- Provide private, confidential space for patient navigators to meet with clients.
- Set up an orientation and training program for up to 30 hours of skills development for patient navigators and for other clinic staff to ensure smooth implementation.
- Use a variety of recruitment strategies to identify and reach out to women of color, including generating out-of-care lists and working with Early Intervention Specialists and outreach teams to find women, use of support groups, and social media and marketing in high-risk communities.
- Involve case managers early in the process to work with the patient navigator and clients to ensure a smooth transition from the intensive services provided by patient navigators to standard case management services.
- Create opportunities for self-care and professional development for patient navigators.
- Dissemination of Evidence-Informed Interventions (DEII): Enhanced Patient Navigation for Women of Color with HIV
- Enhanced Patient Navigation for Women of Color with HIV Intervention Manual
- Enhanced Patient Navigation for Women of Color with HIV Patient Navigation Curriculum
- Orientación Del Paciente Mejorada Para Mujeres De Color Que Viven Con el VIH Programa De Capacitación Prientación Del Paciente
- Educational Videos for Women of Color with HIV
- Videos educativos para mujeres de color con el VIH
- Centers for Disease Control and Prevention. Estimated HIV incidence and prevalence in the United States, 2015–2019. HIV Surveillance Supplemental Report 2021;26(No. 1).
- Centers for Disease Control and Prevention. HIV Surveillance Report, 2020; vol. 33.
- Beer L, Mattson CL, Bradley H, Skarbinski J; Medical Monitoring Project. Understanding cross-sectional racial, ethnic, and gender disparities in antiretroviral use and viral suppression among HIV patients in the United States. Medicine (Baltimore). 2016;95(13):e3171. doi: 10.1097/MD.0000000000003171.