Navigation programs for people living with HIV/AIDS who experience homelessness: considerations for assessing performance and costs

Despite the advances in antiretroviral therapy (ART) a disproportionate number of people living with HIV (PLWH) remain limited in their access and use of health care and treatment, including racial/ethnic minorities, persons with mental health and substance use disorders and persons experiencing homelessness or unstable housing. Patient navigation programs have emerged as a potential effective and efficient use of resources to reach and engage these vulnerable populations as part of the HIV service delivery system. This dissertation contains three chapters that aim to identify and assess the performance and mechanisms for navigation programs working with PLWH who experience homelessness and co-occurring substance use and mental health disorders. Study 1, Developing a Reliable and Valid Composite Measure of Effectiveness for HIV Navigation Programs for PLWH who are homeless/unstably housed, describes the development of a multidimensional outcome measure to assess the performance of navigation programs for this population. The composite measure was comprised of seven indicator variables: linkage to care, retention in care and adherence to treatment, patient experience of care, physical and mental health related quality of life and housing stability. Using multivariate analyses, a 3 item measure of retention, adherence, and housing stability was found to have high goodness of fit and strong predictive association with viral suppression. Study 2, Classifying Components of HIV Navigation Programs for PLWH who are homeless/unstably housed, used a latent-class analysis to identify common patterns of activities, modalities of communication, location of work, and staff composition among highest utilizers of services. Results showed that types of activities, work setting and modality of contact were significantly associated with increased retention in care. No difference in activity, staffing patterns, work setting or modality of communication of navigation programs were found on viral suppression rates. Study 3, An Economic Evaluation of HIV Navigation Programs Working with PLWH who are Homeless/Unstably housed assessed costs and net benefits of these navigation programs overall and in subpopulations. Cost utility and net benefit analyses performed indicated that navigation programs for PLWH who are homeless/unstably housed are a potential efficient investment of resources at various willingness-to-pay thresholds. Navigation programs provide a myriad of services for PLWH who are homeless/unstably housed and must be flexible in their approach to address the multiple medical and psychosocial needs of this population. The results of this dissertation provide information for improving the design, measuring performance and costs and benefits of navigation programs as part of the HIV service delivery system for PLWH who experience homelessness.2020-06-30T00:00:00

Reducing Chronic Malnutrition in Peru: A Proposed National Strategy

This paper proposes a national strategy to reduce the prevalence of chronic malnutrition in Peru. It is intended for senior decision-makers in the government, and researchers on food and nutrition policy, in order to, a) emphasize the importance of the problem and the feasibility of its solution, and b) suggest how resources should be allocated, and services organized, with a view to achieving the goal of reduced chronic malnutrition. It is also intended as a guide to senior program managers, to identify the essential elements of an integrated program to meet that goal. All the elements of the proposed strategy have been suggested before, and some have even been incorporated into national planning documents. However, an integrated strategy has not until now been implemented on a national scale, whether due to lack of technical capacity, administrative constraints, or lack of political will. Compared with many other countries financial resources are not the major constraint in Peru. The government devotes significant resources to food and nutrition assistance. Yet, much of it goes to programs that are poorly designed and targeted. If redirected such resources would be sufficient to fund the proposed strategy.peru

The role of patient navigators in building a medical home for multiply diagnosed HIV-positive homeless populations

Context: People living with human immunodeficiency virus (HIV) (PLWH) who are most at risk for falling out of HIV primary care and detectable viral loads include homeless and unstably housed individuals and those codiagnosed with behavioral health disorders. The patient-centered medical home (PCMH) is a model that promotes provision of comprehensive, patientcentered, accessible, coordinated, and quality care for patients. This initiative provided patient navigation to HIV-positive homeless and unstably housed individuals codiagnosed with a mental health or substance use disorder as a means to create an adapted PCMH to meet the specific needs of this population. Objective: The purpose of this analysis was to characterize the roles and responsibilities of patient navigators as part of an effort to create a medical home for homeless and unstably housed PLWH with behavioral health comorbidities. Design: Eighty-one in-depth interviewswith clinic staff and 2 focus groups with patient navigatorswere conducted. Content analysis was performed to identify key roles and responsibilities of the patient navigators. Results: Patient navigators played an important role in creating a PCMH by working with clients to schedule and complete appointments, develop comprehensive care plans, forging critical relationships with providers both within and outside of health care systems, providing holistic support to increase patient self-management, and assisting in achieving housing stability. Conclusions: It may be necessary to adapt the traditional PCMH model to effectively meet the social, behavior health, and medical needs of homeless and unstably housed PLWH with behavioral health comorbidities. A patient navigator who can invest time in supporting and connecting these patients to needed services may be a key component in creating an effective PCMH for this population. These findings highlight the roles and tasks of patient navigators that may contribute to developing a PCMH specific to homeless and unstably housed PLWH with mental health and substance use comorbidities. Implementation of such a model has the potential to improve health outcomes (such as retention in care and viral suppression) for particularly vulnerable PLWH and thereby reduce the burden of HIV infection

Using Implementation Science to Promote Integration and Sustainability of Community Health Workers in the HIV Workforce

Background:Community health worker (CHW) interventions are an evidence-based practice adopted by health care settings to increase retention in care and viral suppression for people living with HIV (PLWH) from racial/ethnic minority communities. However, disparate funding, unclear roles vis a vis other care team members, limited training and promotion opportunities, and a lack of standards for wages and tasks limit the ability to effectively use CHWs as part of the health care team. Guided by the Exploration, Preparation, Implementation, and Sustainment and Reach, Effectiveness, Adoption, Implementation, and Maintenance frameworks, this study describes the key determinants for CHW integration and sustainability at 3 agencies in Shelby County, TN, to improve viral suppression and reduce disparities among rural and urban people living with HIV.Setting:Memphis Transitional Grant Area (TGA) which includes 8 rural and urban counties in west Tennessee, Arkansas, and Mississippi.Methods:Seventeen key informants were identified using purposeful and snowball sampling techniques, including community and agency leadership staff, frontline staff, and faith leaders.Results:Key determinants of CHW integration include establishing clear and standardized CHW roles within and across organizations, facilitating interorganizational networks, and leveraging funds for livable CHW wages and sustainable positions. Training strategies that strengthen the CHW workforce include content related to trauma-informed care, managing stress, and cultural humility.Conclusion:Several inner and outer settings and innovation and bridging factors affect CHW positions. Data collected will inform the implementation and sustainment of future policies and interventions intended to improve HIV care continuum outcomes and reduce disparities for PLWH

Associations of internalized and anticipated HIV stigma with returning to work for persons living with HIV.

IntroductionEmployment is particularly beneficial for persons living with HIV (PLWH). However, PLWH experiencing internalized stigma or anticipating that they may experience stigma may be less likely to seek employment due to additional barriers associated with HIV. The purpose of this study was to understand the associations between internalized and anticipated stigma and employment barriers for PLWH.MethodsParticipants (N = 712) from 12 sites across the United States were recruited and interviewed about barriers to employment, HIV stigma, and several other factors related to health. A series of unadjusted and adjusted linear regression models were conducted using cross-sectional data.ResultsAdjusted models suggest that greater anticipated stigma was related to increased employment barriers (β = 0.12, p = 0.04). Mental and physical health functioning also positively predicted employment barriers (β = -0.18, p DiscussionEmployment among PLWH has beneficial impacts on HIV-related health outcomes. This study suggests that anticipated stigma may limit and individual's willingness to seek out employment, or may cause them to leave employment. Internalized stigma may not play as large of a role in employment as anticipated stigma for PLWH. HIV-related stigma reduction interventions focused on community-level and employers are essential to improve employment opportunities for PLWH

Ending the HIV Epidemic: One Southern Community Speaks

Memphis, Tennessee and its surrounding counties have been profoundly affected by the HIV epidemic. Using a participatory research approach this study identified from a community perspective: 1) the barriers and facilitators for providing support to achieve viral suppression to the most at-risk groups living with HIV in the Memphis Transitional Grant Area and 2) opportunities to strengthen the health care system through the use of community health workers (CHWs) to do outreach and engage with people living with HIV. Themes of barriers include intersectional stigma, HIV criminal laws, abstinence-only sex education, housing, transportation, and limited access to HIV case management and mental health services. Strategies to address these barriers included HIV education to youth in schools and community-wide campaigns, more testing sites, involving faith leaders, funding for housing options, innovative transportation services, rapid start of culturally appropriate HIV medical treatment, intensive case management services, and mental health counseling. Two opportunities to utilize CHWs to address the barriers identified in this geographic area are as policy advocates and as an integrated member of the HIV primary care team. The findings of this study can inform a strategy to build the CHW workforce which may have widespread implications for ending the HIV epidemic in this geographic area and across the United States

It Comes in Steps and Stages: Experiences of People Living with HIV in Achieving Employment.

People living with HIV who are seeking jobs experience unique barriers to obtaining employment at the individual, group, and community levels. Traditional employment assistance programs can provide support but may not be tailored to some people living with HIV who often experience barriers to work related to their social needs (such as housing instability) or their lack of consistent engagement in the workforce. To understand how people living with HIV return to work, in-depth interviews were conducted with 43 participants enrolled in interventions coordinating HIV care with housing and employment services at eight sites across the US. Four themes emerged on strategies to increase employment: (1) assessing and responding to employment needs that align with their socio-economic environment; (2) using social networks among family and friends for referrals and support; (3) engaging with navigators who are able to connect clients to skills building opportunities and job resources; and (4) addressing the system barriers such as helping with unmet basic needs (e.g. transportation), finding employers who can accommodate workers with income limits associated with public benefits, and helping immigrants, transgender individuals, and people experiencing homelessness secure legal documentsthat facilitate entry into employment by reducing stigmatized identities