Peer navigators improve linkage to HIV care and retention in care in South African study

Adults recently diagnosed with HIV getting help from peers to address personal barriers to care together with SMS check-in messages, appointment and healthy living reminders had nearly twice the odds of being retained in care at one year follow-up compared to those getting standard of care at primary health clinics in South Africa according to findings presented last week at the Conference on Retroviruses and Opportunistic Infections (CROI 2017).

Dr Wayne Steward of the University of California San Francisco, presenting on behalf of the I-Care study, highlighted the value of this intervention as an important strategy to help meet UNAIDS 90-90-90 targets (90% of people with HIV diagnosed, 90% of diagnosed people on treatment and 90% of those on treatment with undetectable viral load).

While South Africa has the largest antiretroviral therapy (ART) programme in the world only an estimated 30 to 50% of ART-eligible individuals are in care, Dr Steward noted. Despite steps taken to improve access to antiretroviral treatment through expanded ART initiation and task shifting and monitoring at primary health clinics, complementary strategies are needed to better engage patients in care, he added.

A recent large study of the cascade of care in South Africa highlighted linkage to care after testing positive as the biggest weakness of treatment programmes trying to achieve UNAIDS targets. Less than half the population with HIV in the district studied had linked to care within eight years, yet 82% were aware of their HIV infection.

The I-Care study was a cluster randomised controlled trial conducted from 2014 to 2016 in South Africa’s North West province. The study tested two interventions to support linkage to care: SMS reminders, and SMS reminders plus peer navigation services to address barriers to HIV care. SMS is relatively easier to implement but less flexible with less personal support. Peer navigation, while more complex to implement, is more flexible and offers a more personal and robust source of support. Capitalising on social modelling by peers, patients can build skills to help manage the difficulties associated with living with HIV, Dr Steward noted.

Peers, receiving HIV care themselves at the clinics, are trained to help patients navigate HIV care and prevention. This required a minimum of monthly in-person meetings; phone and SMS contact as needed (minimum bi-weekly check-ins); and accompanying patients to clinic appointments as needed. Recruited through advertisements, peers were offered a small stipend.

A cluster-randomised design was used to assign primary health clinics in the Moses Kotane and Rustenburg sub-district of the North West Province, South Africa to three arms comprising:

• SMS two-way check-in messaging, appointment and healthy living reminders (6 clinics)
• SMS reminders plus peer navigation services (SMS+PN) to address personal barriers to care (7 clinics), and
• Standard of care (SOC) (4 clinics).

For inclusion, clinics had to have a catchment area of 6000 inhabitants or more and a minimum of 40 new HIV patients added to their caseload in the first four months of 2014.

From October 2014 to April 2015 752 (292 men, 460 women) recently HIV-diagnosed consenting adults were enrolled in the SMS, SMS+PN and SOC assigned clinics and followed for up to one year. Patients were identified at HIV diagnostic and CD4 receipt visits and screened through pre-ART and ART registers and had to be newly diagnosed within the prior 12 months. Approximately half were recruited within one week of diagnosis.

Retention in care was defined in those on ART as at least four care visits within 12 months with fewer than four months between visits; for those pre-ART: two or more visits in 12 months with a visit within two months of the anticipated return date.

At baseline, there were no differences in gender, age, ART eligibility or socio-economic characteristics in the arms. Pregnant women were more numerous in the SOC arm.

The overall mean number of clinic visits by arm were 5.52, 5.43 and 7.65, p < 0.01 for the SOC, SMS and SMS+PN arms, respectively and this difference in frequency translated into a difference in retention.

Overall, retention over 12 months was almost twice as likely in the SMS+PN arm compared to the SOC arm, OR: 1.83, (95% CI: 1.01-3.33). Whereas SMS and peer navigation significantly improved retention in women (0R: 2.13, (95% CI: 1.23-3.70), it made no difference to retention in men (OR: 1.48 (95% CI: 0.60-3.68).

Dr Steward suggested these findings possibly reflect the greater number of female peers recruited and able to give more time.

SMS services alone compared to SOC showed no significant differences in retention over 12 months.

Retention was associated with navigation time provided. For those getting three hours of navigation retention was almost 100%, compared to 45-50% for those getting one hour.

Dr Steward concluded the SMS+PN intervention substantially improved retention in care over a 12-month period. These findings point to the importance of using a social modelling approach to improve retention outcomes.