The Power of Peers and the Team to

Link and Re-Engage Women of Color

Living with HIV in Medical Care

National Lat inx HIV/Hep C Conference

M a y 1 8 , 2 0 1 8

Presenters

AIDS United

Alicia Downes, ITAC, Senior Program Manager

Howard Brown Health

Lasheena Miller

LeSherri James

Co-authors:

• Jane Fox, MPH, DEC Co-PI

• Alexis Marbach, MPH, DEC Senior Program Manager

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Objectives

• Describe the components of the standardized

intervention

• Identify through vignettes lessons learned from

implementation at the three funded clinical sites, with an

in-depth focus on Howard Brown Health

• Strategize ways to leverage the relationship between

peers and case managers at your agency/clinic practice

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Project Background

• Four-year Cooperative Agreement with HRSA Special

Projects of National Significance (SPNS)

• Funding amount of $3 million/year, with $2.4 million

going to implementing sites

• Replicates four previously-implemented SPNS initiatives

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Interventions being replicated

AIDS United

Implementation and Technical Assistance Center (ITAC)

Select & Fund

12 Sites

Provide

TA

Coordinate

Experts

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Boston University

Dissemination and Evaluation Center (DEC)

• Adapt and design 4 intervention

models for replication.

• Design and implement multi-site

evaluation

• Studying both patient outcomes

(including retention in care and viral

suppression) and implementation

findings (what works in practice and

what facilitates/hinders

implementation)

• Publish and disseminate final

adapted interventions and study

findings

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HIV Care Continuum:

Background and Data Overview

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Project Background

• Four-year Cooperative Agreement with HRSA’s

Special Projects of National Significance (SPNS)

• Funding amount of $3 million/year, with $2.4 million

going to implementing sites

• Replicates four previously-implemented SPNS

initiatives

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Viral Suppression among Clients Served by the

Ryan White HIV/AIDS Program, by Race/Ethnicity,

2010 and 2016—United States and 3 Territoriesa

Hispanics/Latinos can be of any race.Viral suppression: ≥1 OAHS visit during the calendar year and ≥1 viral load reported, with the last viral load result <200 copies/mL.a Guam, Puerto Rico, and the U.S. Virgin Islands.Source: HRSA. Ryan White HIV/AIDS Program Services Report (RSR) 2016. Does not include AIDS Drug Assistance Program data.

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Viral Suppression among Key Populations Served

by the Ryan White HIV/AIDS Program, 2010 and

2016—United States and 3 Territoriesa

Hispanics/Latinos can be of any race.Viral suppression: ≥1 OAHS visit during the calendar year and ≥1 viral load reported, with the last viral load result <200 copies/mL.a Guam, Puerto Rico, and the U.S. Virgin Islands.

Source: HRSA. Ryan White HIV/AIDS Program Services Report (RSR) 2016. Does not include AIDS Drug Assistance Program data.

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Viral Suppression among Clients Served by the

Ryan White HIV/AIDS Program, by Gender, 2010

and 2016—United States and 3 Territoriesa

Viral suppression: ≥1 OAHS visit during the calendar year and≥1 viral load reported, with the last viral load result <200 copies/mL.

a Guam, Puerto Rico, and the U.S. Virgin Islands.

Source: HRSA. Ryan White HIV/AIDS Program Services Report (RSR) 2016. Does not include AIDS Drug Assistance Program data.

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Peer Linkage and Re-Engagement:

Intervention Overview

Intended for organizations, agencies,

and clinics considering a short-term

intensive peer-focused model to

increase linkage of newly diagnosed

and re-engagement of known HIV-

positive women of color.

4 month intervention to achieve the

following outcomes:

• attendance to two medical care

visits with a prescribing provider;

• completion of one lab visit; and

• completion of one visit with a case

manager.

PEER LINKAGE AND RE-ENGAGEMENTFor Women of Color

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What’s in a name?

• Peers: People living with HIV

• Role:

– Case finding and outreach

– Make reminder phone calls

– Prepare and attend medical appointments with clients

– Provide transportation

– Adherence education

– Emotional support

– Provide referrals

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Peer Linkage Model

Generate list of clients identified as ‘not in care’

Peer navigators and outreach staff check EMR to confirm ‘not in care’ status and gather contact information for follow up

PatientHealthcare Provider

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Outreach meetings with outreach staff and healthcare providers on ‘not in care list’

Patients contacted by outreach staff for linkage and re-engagement

Patient care visit scheduled

Peer Linkage and Re-Engagement:

Selected Sites

Howard Brown Health

• Located in Chicago, IL

• Newly opened clinic in the Englewood Community, with

high rates of HIV

• Intentionally enrolling both cis and transgender women

• Peers have led the creation of support groups and are

conducting community outreach to increase enrollment

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AIDS Care Group

• Located in Chester, PA

• Largest FQHC in South Eastern PA

with the majority of HIV cases

• Third poorest city of its size in the

nation

• By providing Saturday clinic peers

and staff are able to re-engage

WOC and provide meals

• On-site pharmacy

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Meharry

Medical College

• Located in Nashville, TN• One of the nation's oldest and largest historically black

academic health science centers • Peer services delivered from the Wellness Center, a

hospital based outpatient clinic• Wraparound services are provided to women through

Meharry’s Hospital System

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Peer Linkage and Re-Engagement:

Cohort Level Data

Enrollment Across Peer Linkage

Sites

[Participant

Form

pending] Active Withdrawn

Moved out

of service

area

Completed

study Total

AIDS Care Group 0 60 1 0 1 62

Meharry

Wellness Center 1 45 4 4 0 54

Howard Brown

Health Center 0 31 1 0 0 32

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Demographic Variables Across the Peer

Linkage CohortAge

Continuous variables reported as: Mean

± SD, Median (IQR), Range

42.44 ± 12.57

43 (32 - 52)

19 - 73

Currently, which do

you consider yourself

to be?

Categorical variables

reported as: N(%)

Male 0 (0)

Female 131 (90.34)

Transgender 11 (7.59)

Other (specify): 3 (2.07)

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Top needs reported by participants

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• Transportation

• Housing assistance (e.g. permanent, temporary,

emergency shelter, residential treatment facilities)

• Applying for benefits (SSI, SSD, insurance, etc.)

• Substance use treatment and/or mental health

treatment/counseling

• Medication assistance (paying for medication, help with

prescriptions)

• Assistance getting medical care

Howard Brown’s Experience

Implementing the Peer Linkage Intervention

• Network of Federally Qualified

Health Centers (FQHCs) across

the City of Chicago

• “Exists to eliminate the disparities

in healthcare experienced by

lesbian, gay, bisexual and

transgender people through

research, education and the

provision of services that promote

health and wellness.”

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Rates of Persons Living with Diagnosed HIV in Chicago 2015

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HBH 63rd Clinic Services

• Primary Care

• Behavioral Health

• Community Outreach

• HIV Care

• Peer Support

• PrEP/PEP

• Hepatitis Services

• Sexual Assault Survivor

Services

• Dental

• Pediatrics

• Insurance Navigation

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Implementation at 63rd St.

• Morning huddle before the start of clinic

• Medical providers buy-in

• Monthly emails sent to HBH Southside sites

• EMR has a peer linkage desktop which is used to route

eligible clients to peer interventionist

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Partnerships

• Identify agencies providing similar services– AFC, CDPH, Planned Parenthood

• Identify CBO’s servicing target population: – Local beauty salons/barbershops

– Women’s Recovery Homes/Transitional Housing Programs

• In the Spirit Transformational Living, Primo

– Libraries

– The Meow University

– Colleges

• Kennedy King College, Olive Harvey College

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Outreach/Events

• Peer Intervention Team collaborates with HBH

Outreach Team to engage and provide services to

target population

– Free confidential HIV screenings, safer sex kits,

pamper kits, coat drives

• Events

– Black Wellness Event

– Black Women's Expo

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Implementation Successes

• Howard Brown Health marketing

• Welcoming/Inviting Environment

– Waiting room and exam room are decorated with pictures,

statues and the walls are painted in bright colors

• Staff mirror the clients we are serving

• Well trained peer

– Peers are able to complete MAP applications and make other

referrals based upon clients needs

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Implementation Challenges

• New Clinic, New Patient Population, Old Reputation

• Stigma

– “The gay clinic”, “The HIV clinic”

• Distrust

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What would you do……………..

• What strategies would you apply to leverage community

relationships?

• What strategies would you apply to leverage

relationships within the clinic/agency practice?

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Case Study & Discussion

Joyce

• 32-year-old woman who was on the out of care list.

• Last medical appointment was 6/24/17

• Her CD4 was 320 and viral load 875,000

• She lives with her family

• Has shared that she received a utility notice to

disconnect services

• She is 2 weeks behind on her rent

• She feels her family treats her differently since she told

them about her HIV status 2 years ago

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Myka

• 22-year-old African American Transwomen

• Diagnosed since 2006

• Last medical appointment was April 2017

• CD4 225 and viral load 625,000

• Moved back to Chicago to help her mother.

• Unemployed and hopes to move into her own an apt

March 1, 2018

• Diagnosed with Depression, Major RCR unspecified

• Interested in hormone therapy only

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Lessons Learned, Resources, & Next

Steps

Lessons Learned at Howard Brown

Health

• Early diagnosis and treatment is important for ALL

populations.

• An understanding of each patient’s needs is essential for

effective linkage and retention.

• We can learn something valuable from each and every

patient.

• Strong partnerships between ASOs, public health depts,

social services providers are vital in enhancing the

continuum of care.

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Lessons Learned Across Peer Linkage

Cohort

• Hiring and onboarding of Peers is key to success.

- Including supporting staff transition from state and federal benefits to gainful employment

• Clear, strong, and consistent communication between team members and the larger clinic team is crucial to working with women who are at risk for falling out of care or have struggled to link.

• Case management needs to be in place prior to implementation.

• Peers need space to have private, confidential conversations with clients.

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Lessons Learned Across Peer Linkage

Cohort, continued

• Mobility outside of the clinic is an effective strategy for

finding and engaging with clients.

• Cultural competency:

– Immigrant population brings a different challenge.

• Power of a story:

– Relatability

– Extra layer of emotional support for clients.

• Multiple factors impact linkage and retention in care.

– No one size fits all.

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Resources Currently Available

• The intervention manuals are available for download

on the TARGET Center site

– https://nextlevel.careacttarget.org/

• Training Manuals Coming Soon

– Anticipated release, Fall of 2018

– Will also be posted on TARGET Center site

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Looking ahead: Care and Treatment

Interventions (CATIs)

• Continue monitoring

implementation at sites

and multi-site outcomes

evaluation.

• Analyze and summarize

interim findings

• Update adapted

interventions

• Release final

interventions as CATIs

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Questions?

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