UM Study in JAMA: Patient Navigation, Even with Financial Incentives, Does Not Improve HIV Outcomes
A large study by researchers from 14 institutions, including the University of Miami Miller School of Medicine, has found that a short-term structured patient-navigation intervention, even with financial incentives, shows no long-term improvement in HIV viral suppression when compared with conventional treatment for substance-abusing HIV patients who require hospitalization.
The study report, “Effect of Patient Navigation With or Without Financial Incentives on Viral Suppression Among Hospitalized Patients with HIV Infection and Substance Use,” was published online by the Journal of the American Medical Association.
The goal for people living with HIV is viral suppression achieved through adherence to medication and doctor visit schedules that have a well-documented positive impact on patient outcomes. Nonetheless, patient statistics reveal that as many as 70 percent may have uncontrolled HIV virus in their blood, and that many are hospitalized, often due to substance abuse, with conditions preventable through HIV treatment.
“Substance users who are HIV positive and end up hospitalized may need intervention to ensure appropriate attention to HIV care to maximize their own health and reduce the chance of HIV transmission,” said Daniel J. Feaster, Ph.D., associate professor in the Biostatistics Division of the Department of Public Health Sciences, who was second author of the paper.
A total of 801 individuals were recruited for the study, called Project HOPE (Hospital Visit as Opportunity for Prevention and Engagement for HIV-infected Drug Users), while inpatients at hospitals in Miami, Atlanta, Baltimore, Boston, Birmingham, Chicago, Dallas, Los Angeles, New York City, Philadelphia and Pittsburgh.
Participants were randomly assigned to either six months of patient navigation (care coordination with case management), six months of patient navigation plus financial incentives, or treatment as usual. Patient navigation included up to 11 sessions of case management over 6 months. Financial incentives (up to $1,160) were provided for achieving targeted behaviors aimed at reducing substance use, increasing engagement in HIV care, and improving HIV outcomes. Treatment as usual was the standard practice at each hospital for linking hospitalized patients to outpatient HIV care and substance use disorders treatment. HIV viral load was measured at study entry and at 6 and 12 months.
The study results showed that patient navigation, with or without financial incentives, provided no lasting improvement in HIV viral suppression over that achieved using treatment as usual.
“Patient navigation and financial incentives provided a short-run increase in engagement to care and viral suppression, but the primary outcome at six months after treatment completion was not significantly different,” said Feaster.
Researchers offered several possible explanations for the lack of positive results. Participation in treatment for substance use disorders was low across groups, with no decrease in overall substance use and severity of use. And although patient navigators sought to engage participants with available substance use disorders treatment services, several study sites had limited harm-reduction services.
Also, many study participants had multiple comorbidities and social disadvantages in addition to substance use disorders, including poverty, racism, unstable housing, HIV-related stigma and high rates of incarceration.
“Looking forward, more-intensive and longer-lasting interventions are needed to simultaneously address HIV and substance use disorder,” said Feaster. “One of the things that everyone can agree on is that we want to stop the spread of HIV. Research has shown that the best course for an individual who has HIV is to pursue active HIV treatment as quickly as possible. This strategy will minimize the damage that HIV inflicts on individuals through both inflammatory processes and attack on the immune system.”
“Exploring interventions in hard-to-engage populations, such as substance users, is of utmost importance in Miami, the metropolitan area that has the highest HIV infection case rate in the U.S,” said one of Feaster’s coauthors, Allan E. Rodriguez, M.D., professor of clinical medicine and Director of Behavioral/Social Science and the Community Outreach Core of the Miami Center for AIDS Research. “Perhaps a longer intervention, such as a year, would have had a better outcome.”
The key, Feaster explains, is for HIV-infected individuals to 1.) know they are HIV-positive, 2.) be linked to HIV services, 3.) be initiated on the best treatment for them as quickly as possible and 4.) receive ongoing HIV treatment and services. This sequence is sometimes referred to as the Seek, Test, Treat and Retain paradigm.
“HIV-positive individuals who are also substance abusers frequently experience difficulty with all four of these steps in the HIV care continuum,” said Feaster. “They generally know that they are HIV positive, and most have been linked to HIV care, but for many reasons they have fallen out of care. When they arrive at the hospital with a complication related to HIV, it is an ideal time to try to intervene and improve their future outcomes.”
The study’s first author was Lisa Metsch, Ph.D., formerly on the Miller School faculty and now Chair of the Department of Sociomedical Sciences at the Columbia University Mailman School of Public Health. The national study coordinator and the paper’s third author was Lauren Gooden, Ph.D., who earned her doctorate in epidemiology from the Department of Public Health Sciences. Gooden is assistant professor in Metsch’s department and Director of Columbia’s Sociomedical Sciences Miami Research Center, which is housed in the Miller School’s Department of Public Health Sciences and is the site of ongoing collaboration among the four researchers.