Project nGage

Project nGage seeks to improve retention in care for young Black men who have sex with men (YBMSM) who are already linked to care. Project nGage uses a support intervention approach that offers participants an initial 90-minute session with a social work interventionist (SWI) and a participant support confidant (SC), which includes discussion and collaboration between the SWI, SC, and participant to develop a tailored care and support plan for the participant to identify and overcome barriers to care. The SWI then offers four follow-up sessions to each participant at regular intervals to discuss progress on the care and support plan. Project nGage was evaluated in a randomized controlled trial from 2012 to 2015: participants in the intervention were more likely to have at least three HIV primary care visits in the last 12 months than those who received usual care.

Chicago, IL

Implementation Guide
False
Evidence-Based Intervention
Icon for Intervention Type
Support service delivery model
Icon for HIV Care Continuum
Retention in HIV medical care
Icon for Ending the HIV Epidemic in the U.S. Strategy
Treat
Icon for Focus Population
Gay, bisexual, and other men who have sex with men (MSM); Black gay and bisexual men; Youth ages 13 to 24; Young adults ages 25 to 34
Icon for Priority Funding
Non-RWHAP: NIMH
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Community health center, including Federally Qualified Health Centers (FQHCs)
Need Addressed

Project nGage focuses on YBMSM with HIV between the ages of 16 and 29, who typically experience worse health outcomes across the HIV care continuum compared to other groups, and who may struggle to access necessary social support and ancillary services.1 Despite the disproportionate impact YBMSM face, there are few interventions explicitly designed to increase their retention in care or medication adherence. Originally developed by researchers from the University of Chicago, Project nGage draws on several theoretical frameworks, including information-motivation-behavioral skills theory, motivational interviewing, and cognitive behavioral therapy, to inform the design of the participant sessions. The intervention uses a client-centered approach to identify and overcome barriers to care while also providing social support to participants, which may be a particularly important element of interventions for YBMSM.

“The philosophical underpinnings for Project nGage are that social networks and social support are critical for improving and maintaining people’s health and well-being.”

Core Elements
Initial 90-minute session

The initial 90-minute session contains several distinct components. Three people attend this session: the participant, the SWI, and the SC. The SWI and participant work together and draw on the results of an algorithm to identify the optimal person in the participant’s life (e.g., friend, family member) to serve in the support confidant role. This identified SC then joins the 90-minute session. The SWI discusses the importance of HIV care and social support with the SC and the participant, known as the “SC-index dyad,” during the first 20 minutes. During the next portion of the session, which lasts 40 minutes, the SWI and the SC meet one-on-one to identify strategies to provide effective social support to the participant. Finally, all three work together to create a customized “care and support plan” to identify barriers, solutions for overcoming them, and an approach to improve retention in care and ART adherence for the participant.

Telephone booster sessions

The SWI follows up with the participant at four intervals: 2, 5, 8, and 11 months after the initial interview. These follow-up booster sessions take place over the phone and focus on implementation of the previously established care and support plan. Project nGage also offers the same sessions to selected SCs, which allows for provision of additional tips on offering support to the participant. The SWI also works to identify any problems associated with the care and support plan, including risk of relationship strain or abuse between the SC and the participant.

Outcomes

Project nGage was originally evaluated in a randomized controlled trial from 2012 to 2015 at five federally qualified health centers (FQHCs) in Chicago, IL. Ninety-eight YBMSM with a mean age of 23.8 years were randomized to the Project nGage treatment arm (n=45) or a “treatment as usual” (TAU) arm (n=53). The evaluation found that Project nGage participants were significantly more likely to be retained in care and to self-report optimal ART medication adherence than the TAU participants. There were no significant differences in viral suppression between the two groups.

Category Information
Evaluation data Participant surveys, electronic health record data
Measures
  • Self-reported ART medication adherence (90% adherence defined as optimal)
  • Retention in care (at least three HIV primary care visits within the past 12 months)
  • Viral suppression (≤ 200 copies/mL)
Results
  • Intervention participants were more likely to have at least three HIV primary care visits in the last 12 months than the TAU arm (OR 3.01, 95% CI 1.05, 8.69). *
  • Intervention participants were more likely to self-report optimal ART medication adherence (OR 2.91, 95% CI 1.10, 7.71).*

* statistically significant

Source: Bouris A, Jaffe K, Eavou R, et al. Project nGage: Results of a randomized controlled trial of a dyadic network support intervention to retain young Black men who have sex with men in HIV care. AIDS Behav. 2017;21(12):3618-3629.

“Identifying, engaging, and bringing supportive network members into care may improve HIV care continuum outcomes among YBMSM, a vulnerable and underserved population.”

Planning & Implementation
  • Novel intervention design. While some interventions for people with HIV focus on creating new forms of social support, such as care navigation services, Project nGage’s novel design focused on using existing supportive relationships in participants’ lives to improve retention in care. Project nGage drew on different supportive figures, including parents, relatives, friends, and romantic partners, to play the SC role for individual participants, therefore allowing more flexibility. It also used a theory-based design to develop the modes of support, specifically drawing on information-motivation-behavioral skills theory with additional insight from motivational interviewing and cognitive behavioral therapy.
  • Setting and recruitment. Participants from the original Project nGage pilot were recruited from five FQHCs in Chicago, IL using a combination of flyers and face-to-face recruitment. These participants already had fairly high rates of retention, medication adherence, and viral suppression due to their engagement in care in the FQHC setting.
  • Staff and training. A social worker served in the SWI role, the position with the most direct engagement with the participants and the SCs. The pilot used REDCap for data collection for the follow-up surveys with Project nGage participants. Staff involved in pilot implementation received a structured survey training from the University of Chicago Survey Lab to prepare for data collection.
Sustainability

As one of the first social network support interventions for YBMSM, Project nGage is a promising model for future interventions. Project nGage may also promote long-term sustainability because it relies on participants’ existing social networks to identify SCs, which may be less costly for new implementations compared to intensive case management or other support intervention models. 

As of 2021, Project nGage is being evaluated as part of large, randomized controlled trial in both Chicago and Alabama to explore the generalizability and sustainability of the intervention in more detail, including what the translation of the intervention might look like from an urban setting like Chicago to a rural setting like Alabama.2

Lessons Learned
  • It is important to distinguish different categories of SC. The SC selection process was a success in the pilot with nearly all participants identifying at least one possible SC; there were also no abuses or conflicts of interest after the SC relationships were established. However, the evaluation identified a gap in understanding whether “friend or roommate” SC relationships in the pilot might have had a romantic or sexual component. Programs wanting to implement Project nGage may wish to explore this question because partner or romantic relationships may differ from “friend or roommate” relationships in terms of the available support for participants.
  • Staff encountered challenges working with a dyad, rather than a single participant. First, project staff must quickly build a strong relationship based on empathy and genuine positive regard with both the client and their SC. Without this type of rapport, it would be difficult to engage and retain YBMSM and their SCs for the duration of the study. In addition, scheduling two people for one intervention appointment can be a challenge. Open and flexible communication is essential, but at the same time, this communication should be balanced so as not to over-burden participants with too much project contact, i.e., intervention sessions, boosters, and data collection appointment reminders. This communication must also be done in a way that establishes a clear boundary between the research study and regular clinic services.
Resources & Tools
Contact
School of Social Service Administration, Chicago Center for HIV Elimination, University of Chicago
Alida Bouris, PhD
Co-Director
Departments of Internal Medicine and Public Health Sciences, Biological Sciences Division, Chicago Center for HIV Elimination, University of Chicago
John Schneider, MD, MPH
Director

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