Peer Navigation Helps Released Inmates Maintain HIV Suppression

William Cunningham, MD, MPH

HIV-positive inmates who receive healthcare navigation services from peer mentors stand a better chance at maintaining long-term viral suppression after their release from incarceration, according to a new study.

Researchers from the University of California, Los Angeles, studied 356 soon-to-be-released HIV-positive inmates at the Los Angeles County Jail. Half of the enrollees participated in a program called LINK LA. Those enrollees met every other week for 24 weeks with trained peer navigators who helped them set goals and solve problems associated with their post-incarceration healthcare. Counseling continued after release, and the peer navigators accompanied each patient on two physician visits. The other half—the control group–received a list of housing referrals and doctor’s appointments, but no other services.

Among the peer navigation group, 49% had achieved viral suppression at release, and the same percentage still had the virus under control 12 months after release. Meanwhile, among patients in the control group, 52% had viral suppression at release, but only 30% still had the virus under control after 12 months.

Forty-two percent of the study enrollees were black, 31% were Latino, 85% were male, and 15% were transgender women.

William Cunningham, MD, MPH, the study’s principal investigator and a professor of medicine at UCLA’s David Geffen School of Medicine, said the human element of the peer navigation program is critical.

“Evidence strongly suggests having a human navigator who is trained to carry out a behavioral intervention makes a world of difference,” Cunningham told MD Magazine. “A number of other studies have attempted a variety of smartphone-based interventions and none have shown a sustained effect on viral suppression over 12 months, as we did.”

Cunningham said the study wasn’t designed to identify which specific elements of the program were most effective, but he noted that the peer navigators can offer services a smartphone app cannot, such as helping to facilitate better communication between the patient and his physician. However, Cunningham also noted that smartphone apps could potentially play a role in helping the peer navigator do her or his job.

Though this was only a small program carried out at a single facility, Cunningham said he believes this type of approach could be rolled out at other municipal jails, and at larger facilities elsewhere. He and his fellow researchers are already looking at ways the program could be tailored to fit other jails and prisons.

“It most likely needs to be adapted for these purposes, but when it is, it needs to be tested scientifically before being adopted nationwide,” he said. “Other investigators around the US are trying this and other approaches at present.”

One critical element of making such a program work will be getting buy-in from jails and prisons, since this approach is predicated upon counseling beginning prior to release. For the study, Cunningham and his team worked closely with the Los Angeles Sheriff’s Department, which operates the county jail, as well as LA’s Department of Public Health and Department of Health Services.

“As with any collaboration among large complex institutions, of course it required a lot of work to align our interests, comply with all regulator requirements, and perform the study,” he said. “But, the knowledge gained and the outcomes achieved made it all worth it.”

The program also requires funding. Cunningham said he is currently working on a cost-benefit analysis that will make the case for why these programs are cost-effective. However, he said a simple analysis shows the high potential benefits. Just in this one small study, the program helped control the virus for a long period of time in more than 100 high-risk patients. He said newly released inmates often engage in drug use and unprotected sex in the period immediately following release, creating a high risk of transmission if those patients don’t have their HIV under control.

“You can see how there is potential for enormous public health benefit from this, despite the costs,” he said. “We already spend millions testing low-risk populations and conducting campaigns to promote condom use, often in low-risk populations that may not have anywhere near the yield of a program like this.”

The study, “Effectiveness of a Peer Navigation Intervention to Sustain Viral Suppression Among HIV-Positive Men and Transgender Women Released From Jail,” was published this month in JAMA Internal Medicine.