Peer Linkage and Re-engagement of Women of Color with HIV

From 2016 through 2019, three clinics—AIDS Care Group, Howard Brown Health, and Meharry Medical College—participated in a Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) initiative to implement peer linkage and re-engagement interventions for women of color with HIV. Integrating peers into HIV primary care teams has been effective in better engaging women of color in care.

Sharon, PA

Chicago, IL

Nashville, TN

Emerging Intervention
Outreach and reengagement activities
Linkage to HIV medical care; Retention in HIV medical care; Viral suppression
Treat
Women of color
RWHAP SPNS
Hospital or hospital-based clinic; University-based clinic
Need Addressed

Women of color, especially transgender women of color, make up a disproportionate share of new HIV infections and face barriers to HIV care. Strategies that use peer-based approaches to link and engage women of color have been effective in improving outcomes.  

Core Elements
Recruitment of clients

Eligible clients for this intervention may be identified through many sources, including external referrals. Women of color who have been out of care for at least six months and women of color with newly diagnosed HIV are eligible. Additional clients who would benefit from the intervention can be identified by the care team (including clinical, administrative, and support staff), referrals from other partners, and outreach activities.

Intensive peer support

Peers should meet with eligible clients to explain the intervention, their role in the care team, and to develop a care plan that incorporates both clinical and non-medical needs. Peers work alongside case management to connect clients to needed supports like transportation services, elder care, or child care. They also offer enhanced support such as coaching, accompanying clients to appointments, and ongoing check-ins and communication. This intervention is intended to offer six to 12 months of intensive engagement (on average at least six encounters) before a client makes the transition into standard care and working with HIV case managers. . Peers generally have a caseload of 30–35 clients at a time. 

 

Clinical and administrative supervision of peers

Peers need ongoing support from clinical and administrative staff to ensure that they discuss challenges and successes with clients and other team members, and manage work-life balance. When starting a program or bringing in new team members, the supervision schedule should include weekly administrative meetings on work expectations, specific job responsibilities, performance and trainings; biweekly clinical supervision meetings to discuss burnout and setting clear boundaries with clients; and regular case conferencing meetings with the clinical team, case managers, peers, and supervisors.


“Focus on health promotion in general, not just HIV. So, yes, it's important you get your Pap smears, you get your mammograms. Yes, it's important that you have the support in taking care of all of the other chronic things, too. It's not just HIV, I think having and expanding where the care coordinators could sponsor or work with the group of women—having a girls' night out where they just do something either collectively or, you know, have a spa day. Something of that sort where the emphasis is not on HIV. It's on them being a woman.”

Outcomes

Across the three demonstration sites, a total of 196 clients received services through this intervention from 2016 through 2019.

Categories Information
Evaluation Data  Data from the sites’ electronic medical record (EMR) systems
Measures

Number of clients who:

  • Were connected to HIV case managers
  • Were linked to care within 90 days
  • Were retained in care (had two medical appointments at least 90 days apart in 12 months)
  • Had reached viral suppressed at six and 12 months after enrollment
Results*
  • 58% of client had a case manager (up from 23% at baseline)
  • 96% of clients were linked to care
  • 73% of clients were retained in care
  • 81% of clients reached viral suppression at six and 12 months after enrollment (53% virally suppressed at baseline)

*Available data on 173 clients. For baseline viral suppression values data available on n=133.

Planning & Implementation
  • Key staff roles for this intervention included one full-time or two part-time peers, and some time allotted for a clinical supervisor, an administrative supervisor, and a quality improvement specialist/data manager. 
  • Peers were recruited from the client population or community partners, and received training and support on job responsibilities and setting expectations with clients. 
  • Peers come from diverse backgrounds and may not have health care-specific training. Peers should receive training on job roles and responsibilities, and using technology, including electronic medical records. If feasible, allowing new staff  to “shadow” experienced peers or other clinic staff provides a great learning opportunity. 
  • Peers may use various methods for outreach, including clinic-sponsored phones, texting, email, social media, and in-person outreach. Check rules and regulations around outreach, safety, and liability to ensure that expectations for the peer role comply with institutional standards. Staff should also complete annual training on the Health Insurance Portability and Accountability Act.
  • Peers function most effectively when they are integrated into the care team. Clinical and support staff should be oriented to the intervention and engaged in a feedback loop with peers. Consider integrating peers into case conferencing meetings, daily huddles, and other regular communications to ensure that their perspectives are considered and respected by the rest of the care team.  
  • Provide peers with opportunities for professional development in the organization and/or leadership opportunities in the community.
  • Activities were supported by the Dissemination of Evidence Informed Interventions (DEII) dissemination and evaluation center and the DEII technical assistance center.
Sustainability
  • Organizations have continued to support peer positions through RWHAP Part A and Part B funding as community health workers, early interventions services, and case management. They continue to explore other options to support peers as members of the HIV care team through program income. This funding has also enabled expansion of peer roles to work with other populations including youth.
  • Peers continue to serve the clinical team providing referrals and supporting clients in both HIV medical care and behavioral health services.
Lessons Learned
  • Peers need a private, confidential space to meet with clients, and will need access to electronic medical records to document activities, access lab results for client education, and monitor appointments. Peers will also need to have a work supplied phone and/or computer to conduct outreach and receive communication from clients and the care team.  
  • An internal champion, such as a physician or support services director, can be a powerful advocate for this intervention and can help ensure that peers are fully integrated into the care team. 
  • Clients should be transitioned into standard care after they complete the goals set in their treatment plans, which include two visits with a primary care provider, a visit with a case manager, and completion of lab work. This took an average of seven months for clients who were engaged in case management, but could be as long as 12 months depending on the client needs. Consider “bundling” case management and peer visits, so clients do not have to come in to the clinic multiple times. Ensure that clients are comfortable with case management before transitioning into standard care.
  • Consider opportunities to expand or continue the peer service role. For example, one site transitioned a peer to an expanded community health worker role funded by RWHAP Part A, and another expanded the peer role to include outreach and testing activities.

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