Enlaces Por La Salud

Enlaces Por La Salud is an HIV linkage, navigation, and education program for Mexican men and transgender women. The intervention is grounded in a transnational framework for providing cultural context to support the delivery of one-on-one educational sessions to Latina(o/x) people with a new HIV diagnosis, as well as people with HIV who are not yet retained in care. The Enlaces Por La Salud intervention, launched by the University of North Carolina at Chapel Hill (UNC), was funded through the Ryan White HIV/ AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) Culturally Appropriate Interventions of Outreach, Access and Retention Among Latino(a) Populations initiative. After 12 months, the majority of people participating in Enlaces Por La Salud were retained in care and reached viral suppression.

Wake County, NC

Mecklenburg County, NC

Implementation Guide
True
Emerging Intervention
Icon for Intervention Type
Support service delivery model; Outreach and reengagement activities
Icon for HIV Care Continuum
Retention in HIV medical care; Viral suppression
Icon for Ending the HIV Epidemic in the U.S. Strategy
Treat
Icon for Focus Population
Hispanic/Latina(o/x) people; Gay, bisexual, and other men who have sex with men (MSM); Transgender women; People with a new diagnosis of HIV; People with HIV who are not in care
Icon for Priority Funding
RWHAP Part F SPNS
Icon for Setting
RWHAP-funded clinic or organization; Community-based organization/non-clinical setting
Need Addressed

North Carolina has one of the fastest-growing Latina(o/x) populations in the United States. The state’s Latina(o/x) population grew by 40% from 2010 to 2020, growing nearly two times faster than the average growth of the Latina(o/x) population nationwide.1 Nationally, the Latina(o/x) community is disproportionately affected by the HIV epidemic.2 Social and structural issues, some unique to the transnational experience, make it more difficult for Latina(o/x) people to find, engage with, and be retained in high-quality HIV care. UNC developed the Enlaces Por La Salud intervention to help Latina(o/x) men who have sex with men and transgender women, particularly those of Mexican origin, link to and stay engaged in care and treatment to achieve better health outcomes. The intervention is grounded in the transnational framework which recognizes that people simultaneously draw upon cultural resources, influences, and social networks from their country of origin as well as their migration destination.

Core Elements
Intensive support services provided by a personal health navigator

Personal health navigators trained in strengths-based counseling work one-on-one with Mexican men and transgender women clients to connect or reconnect them to care and link them to support services. A key component of the intervention is the delivery of six one-on-one educational sessions (see below) by the personal health navigator, focused on the client’s migration story. Personal health navigators’ services are intended to be an enhancement to routine medical case management.

These enhanced services include:

  • Enroll clients and develop a service and care plan. During enrollment, personal health navigators explain the intervention and expectations for the client. They also assess the client’s strengths, needs, and barriers to accessing HIV medical care. After the client is enrolled in the intervention, the personal health navigator in collaboration with the client, develops a service and care plan that outlines goals, action steps, and a timeline. The personal health navigator monitors and updates the plan as necessary. 
  • Provide intensive and ongoing client support. The personal health navigator delivers six one-on-one educational sessions, helps with medical appointments, and establishes a relationship with each client by building rapport and providing emotional support. The personal health navigator provides an enhanced level of medical case management and provides one-on-one adherence support. 
  • Transition the client to traditional long-term case management with an established partner. The personal health navigator prepares the client for the transition at the beginning of the intervention by delivering services that are intended to be an enhancement to routine medical case management. Throughout the intervention, the personal health navigator should provide and coordinate as many medical case management service components as possible including linkage to healthcare, psychosocial, and other services. At the end of 12 months, the personal health navigator transitions the client to case management services provided by an established partner.
Six one-on-one educational sessions

Enlaces Por La Salud includes six one-on-one educational sessions over six months with a personal health navigator that focus on the client’s migration history and address a goal. Each session is designed to last between one and two hours, depending upon the client’s availability and comfort discussing the topic.

The six sessions focus on the following topics:

  • Life and migration history to understand how migration history and relevant life events or experiences may shape the HIV care and treatment experience.
  • Medical visits to understand healthcare history prior to, during, and following migration to provide context for initiation of or reengagement with care.
  • Social networks to identify a social network and support inventory (both local and transnational) to understand the social context in which the client currently lives, and to identify messages clients are receiving from their community about HIV status and how this affects them.
  • Stigma and discrimination to identify people in the client’s social support networks to whom they would like to disclose their status, and practice how they want to talk about their HIV diagnosis.
  • Healthy living to discuss the client’s responsibilities as a migrant to improve the understanding of external pressures that may impact healthy living, HIV care, and treatment behaviors and outcomes.
  • Transition plan to discuss future plans with regard to migration and relations with their country of origin and current community of residence.

“Using the transnational framework provides cultural context and helps to tailor the sessions to each individual client.”

Outcomes

Enlaces Por La Salud served a total of 91 participants between October 2014 and August 2017: 50 were new to care and 41 were reengaging in care. After 12 months in the intervention, the majority of participants were retained in care and reached viral suppression. In addition, 81% completed all six educational sessions.

CategoryInformation
Evaluation data
  • Medical record data
Measures
  • Retention in care
  • Viral suppression (HIV viral load <200 copies/mL) 
  • Undetectable viral load (so few copies of HIV in the blood that it cannot be detected on an HIV test)
Results
  • At 12 months:
    • 73.6% were retained in care
    • 90.5% were virally suppressed 
    • 85.7% had undetectable viral loads

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau. Enlaces Por La Salud Intervention Implementation Guide. Rockville, Maryland. 2023.

“Participants expressed how the navigators help lift their spirits, understand their condition, discuss it with others, and be accountable to themselves.”

Planning & Implementation

Hire and train staff. Hire staff with the ability to connect with Mexican men who have sex with men and transgender women, and treat them with dignity and respect. The staff should be able to address issues of relevance to this population through a transnational framework.

Staffing. The following staff and roles are necessary to successfully replicate this intervention.

  • Project Coordinator (50% FTE): Oversees day-to-day intervention activities, meets with personal health navigators weekly, visits community partner sites biweekly, and holds case conferences to facilitate the discussion of specific cases, insights, and difficulties, and ways to address client recruitment and retention with the team.
  • Personal Health Navigator (2 staff, 100% FTE each): Builds a trusting relationship with clients; identifies clients’ needs and barriers to accessing HIV medical care; provides appropriate interventions dependent upon clients’ needs; facilitates the educational sessions with clients; and empowers clients through identification of their strengths. 
  • Outreach Staff (2 staff, 50% FTE each): Establishes referral relationships with area clinics, healthcare providers, and social service agencies.

Partnership with community-based organizations (CBOs). Identify CBOs with a history of working with people of Mexican descent and people with HIV, who have developed trust within that community. Partner with organizations with the capacity to expand their HIV testing within the Mexican population, and to identify men who have sex with men and transgender women. Co-locate a personal health navigator to work at each of the partner CBOs. Embedding staff within each of the organizations allows for more seamless referral and linkage processes.

Establish referral relationships with healthcare providers and the health department to help recruit clients. Conduct outreach to area clinics, healthcare providers, state HIV personnel, and social service agencies to inform them about the intervention and how it can help keep their clients engaged in care. Explain the benefits of making referrals to the intervention and the process by which the personal health navigator will receive referrals.

Sustainability

When planning for and promoting sustainability, assess organizational capacity to add intervention activities and roles into existing structures, services, and programs. While implementing the intervention, the study team found that both community-based organizations were assessing which intervention elements could be sustained. The HIV nonprofit organization maintained the personal health navigator position and is using a transnational framework and content from the one-on-one educational sessions to engage with clients. They were equipped to sustain parts of the intervention because they were already offering case management services.

Lessons Learned
  • Difficulties were encountered in building referral networks. Local agencies and clinics had concerns regarding serving as a referral source for the intervention. Some believed the intervention to be a duplication of their efforts, whereas others believed it would increase their workloads, and possibly impact their funding. Staff invested considerable time delivering presentations and meeting with agencies and clinics to share how their clients were benefiting from engagement in the intervention. 
  • Staff turnover at area clinics necessitated the continuous delivery of presentations about the intervention. It is important to ensure that organizational staff have prior knowledge of the intervention and established relationships with the intervention team. 
  • Personal health navigators were often unable to meet with clients in person, because clients often spent long spans of time working out of state and had little free time due to work schedules. To address this, personal health navigators contacted clients by phone and text messages and delivered the one-on-one educational sessions via phone.
  • Recruitment of Mexican men who have sex with men was difficult. Mexican men who have sex with men were initially one of the intervention’s priority populations; however, the study team recognized that some Mexican men may not identify as men who have sex with men, or will only do so after a period of trust has been established. To ensure men who have sex with men were not being excluded based on a low level of self-identification, the priority population was broadened to include the wider Latino male population.
Contact
Florida State University
Lisa Hightow-Weidman, MD, MPH
University of North Carolina at Chapel Hill
Clare Barrington, PhD, MPH

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