Enhanced Access to HIV Care for Drug Users in San Juan, Puerto Rico
The overall goal of this project is to implement and evaluate a community-level, structured approach to enhance HIV care access and retention for drug users in San Juan, Puerto Rico. The "Enhanced HIV Care Access and Retention Intervention" will: 1) identify drug users living with HIV who either do not know their HIV status and/or are not engaged in HIV care; 2) provide direct HIV care services through a mobile health van; and 3) support identified HIV-infected drug users with patient navigators to enhance their ability to engage in HIV care and substance abuse treatment, to initiate antiretroviral therapy, and maintain adherence to their treatment regimens. The structural enhanced care approach will be evaluated through a randomized roll-out design, a refinement of the stepped-wedge design. The community-level success of the intervention will be assessed by evaluating virologic suppression (primary biological outcome), increased attendance to HIV care visits, uptake of antiretroviral therapy, adherence to HIV treatment regimens, and decreased substance use (as secondary behavioral outcomes) in an independent cohort of HIV-positive individuals drawn from each of the neighborhoods included in the intervention. We will also evaluate the implementation process and cost of the enhanced care approach including implications for cost-effectiveness, feasibility of expansion, and sustainability.
Behavioral: Enhanced HIV Care Access and Retention Intervention
Behavioral: HIV Testing Campaign
Behavioral: Treatment Re-engagement Campaign
Behavioral: Patient Navigator Linkage to Care and Substance Abuse Treatment Team
Behavioral: Mobile Care Clinic
|Study Design:||Allocation: Randomized
Endpoint Classification: Efficacy Study
Intervention Model: Crossover Assignment
Masking: Open Label
Primary Purpose: Treatment
|Official Title:||Enhanced Access to HIV Care for Drug Users in San Juan, Puerto Rico|
- HIV Virologic Suppression [ Time Frame: Every 6 months for up to 36 months ] [ Designated as safety issue: No ]Assessment of success of the intervention will be measured by testing whether there is a significant change in virologic suppression associated with the intervention.
- Increasing HIV care visit attendance [ Time Frame: Every 6 months for up to 36 months ] [ Designated as safety issue: No ]
- Uptake of antiretroviral therapy [ Time Frame: Every 6 months for up to 36 months ] [ Designated as safety issue: No ]
- Adherence to HIV treatment regimens [ Time Frame: Every 6 months for up to 36 months ] [ Designated as safety issue: No ]
- Decreasing substance use [ Time Frame: Every 6 months for up to 36 months ] [ Designated as safety issue: No ]
- Consistency of enrollment in the intervention and receipt of intervention services across neighborhoods over time [ Time Frame: 36 months ] [ Designated as safety issue: No ]
- Cost of delivering the intervention and of other medical services received [ Time Frame: 36 months ] [ Designated as safety issue: No ]
|Study Start Date:||August 2013|
|Estimated Study Completion Date:||April 2017|
|Estimated Primary Completion Date:||April 2017 (Final data collection date for primary outcome measure)|
Experimental: Enhanced HIV Care Access and Retention Intervention
Through the Enhanced HIV Care Access and Retention Intervention, the five neighborhoods will receive the 4 components of the intervention: 1) HIV Testing Campaign; 2) Treatment Re-engagement Campaign; 3) Patient Navigator Linkage to Care and Substance Abuse Treatment Team; and 4) Mobile Care Clinic. The neighborhoods will receive the intervention at different times throughout the study period, but once the intervention is initiated in a neighborhood it will continue being implemented in that neighborhood until the end of the study period.
Behavioral: Enhanced HIV Care Access and Retention Intervention
Through the Enhanced HIV Care Access and Retention Intervention, the five neighborhoods will receive the 4 components of the intervention: 1) HIV Testing Campaign; 2) Treatment Re-engagement Campaign; 3) Patient Navigator Linkage to Care and Substance Abuse Treatment Team; and 4) Mobile Care Clinic. In addition to these intervention components, study participants will receive screening and access to treatment for other physical and mental co-morbidities, general primary health care, and social/psychosocial services addressing unstable housing, food insecurity, interpersonal violence, legal issues. All HIV-positive IDUs identified either through the HIV Testing Campaign or the Treatment Re-engagement Campaign will be enrolled in the HIV Care Cohort. The HIV Care Cohort will be comprised of the HIV-positive injectors who are receiving direct services in the Mobile Care Clinic. The 4 intervention components are detailed below:Behavioral: HIV Testing Campaign
When the intervention is initiated in a neighborhood, HIV rapid testing will begin and continue in a particular neighborhood from the time that the neighborhood's intervention begins until the end of the study period. Anyone testing HIV positive will be seen and counseled by a member of the Patient Navigator Team.Behavioral: Treatment Re-engagement Campaign
Simultaneously with the introduction of the HIV Testing Campaign, a patient navigator team will approach HIV-positive IDUs identified as not having seen their HIV care provider in the last 6 months. In addition, known HIV-positive IDUs within the designated neighborhoods will be approached for service enrollment and meet with a patient navigator.Behavioral: Patient Navigator Linkage to Care and Substance Abuse Treatment Team
The patient navigator team will provide informational support to the HIV-positive injectors, motivate them to attend HIV care visits and engage in substance abuse treatment, encourage their use of and adherence to antiretroviral therapies, and work with them to overcome any barriers to attendance at HIV care visits and substance abuse treatment. All clients of the patient navigator will become part of the HIV Care Cohort; they will have been identified either in the HIV Testing Campaign or the Treatment Re-Engagement Campaign.Behavioral: Mobile Care Clinic
Participants who choose to receive services in the study mobile HIV care clinic will receive an initial appointment and the patient navigator will ensure that the client attends it. At the initial visit, clients will have a medical history taken, be examined and have blood drawn to measure CD4 and viral load. The mobile care clinic doctor will also prescribe medications for the client at the subsequent visit which will be scheduled as soon as lab results are available and interpreted, approximately one week later. The mobile HIV care clinic van will provide health services to the general IDU population within each intervention neighborhood to avoid any stigmatization of the HIV positive clients.
No Intervention: Control / Neighborhood(s) not receiving the intervention
The neighborhood(s) not receiving the intervention will act as a control while the intervention is initiated and implemented in other neighborhoods. All neighborhoods will receive the intervention but at different times throughout the study period. Once the intervention is initiated in a neighborhood, that neighborhood will continue receiving the intervention until the end of the study period.
The overall goal of this project is to implement and evaluate a community-level, structured approach, the "Enhanced HIV Care Access and Retention Intervention" for drug users in San Juan, Puerto Rico. It will bring HIV care directly to five San Juan neighborhoods in which a high proportion of HIV-positive injection drug users (IDUs) reside. The enhanced care intervention is comprised of 4 components: A) a neighborhood-level HIV Testing Campaign to identify HIV-positive drug users who are not aware of their HIV status, B) a Treatment Re-engagement Campaign using patient navigators for out-of-care HIV-positive IDUs, C) a Patient Navigator Linkage to Care and Substance Abuse Treatment team for both newly diagnosed and out of care HIV-positive IDUs and D) a Mobile HIV Care Clinic staffed by HIV clinicians to facilitate linkage into and retention in care. The intervention will be evaluated using a randomized roll-out design, a refinement of the stepped-wedge design.
The intervention will be rolled-out at 6-month intervals in each of the five neighborhoods. The order in which neighborhoods will receive the intervention will be determined randomly. Once a neighborhood begins to receive the intervention, it will continue receiving the intervention throughout the remaining period of the study. The number of individuals served by the intervention who enter into care, their appointment adherence, viral loads and health service and substance abuse treatment utilization will be documented. The success of the intervention will be determined by examining the proportion of virologic suppression over time in an independent assessment cohort of approximately 400 HIV-positive drug-using individuals drawn from the five neighborhoods included in the intervention. The primary evaluation outcomes of this study are to see whether the intense saturation of our intervention results in persons in the assessment cohort being offered and receiving intervention services and the impact on their viral load.
Exposure to the intervention will be evaluated by the assessment cohort as the intervention strategy is rolled out in each of the 5 intervention neighborhoods. Eligible participants (defined below) will be scheduled for a baseline appointment, and asked to bring documentation of their HIV status if available. At the baseline visit, participants will: 1) review and sign the consent form; 2) complete a rapid HIV test; 3) provide blood to assess CBC (including CD4 and plasma HIV RNA; and 4) complete a behavioral assessment using an audio computer assisted interview (ACASI). Participants recruited into the assessment cohort will be counseled on the importance of HIV care and risk reduction practices following existing standards within Puerto Rico. At the end of the baseline visit, participants will be compensated for their time and travel costs and reminded about the next scheduled visit in six month's time. Participants will then be followed at six month intervals for a period of 30 months (and 36 months for neighborhood 5). At each assessment points they will be asked to complete the behavioral assessment using an ACASI and to have their blood drawn for CD4 and viral load.
|Contact: Paco C. Castellon, M.P.H.||firstname.lastname@example.org|
|Iniciativa Comunitaria de Investigacion, Inc.||Not yet recruiting|
|Hato Rey, Puerto Rico, 00918|
|Contact: Glenda Davila Torres, M.D. 787-250-8629 email@example.com|
|Principal Investigator: Jose Vargas Vidot, M.D.|
|Puerto Rico Department of Health||Not yet recruiting|
|Rio Piedras, Puerto Rico, 00922|
|Contact: Sandra Miranda De Leon, M.P.H. 787-763-0240 firstname.lastname@example.org|
|Principal Investigator: Sandra Miranda De Leon, M.P.H.|
|Principal Investigator:||Lisa Metsch, Ph.D.||Columbia University|
|Principal Investigator:||Jorge Santana, M.D.||University of Puerto Rico Medical Sciences Campus|
|Principal Investigator:||Sandra Miranda De Leon, M.P.H.||Puerto Rico Department of Health|
|Principal Investigator:||Daniel Feaster, Ph.D.||University of Miami|
|Principal Investigator:||Bruce Schackman, Ph.D.||Joan & Sanford I. Weill Medical College of Cornell University|
|Principal Investigator:||Jose Vargas Vidot, M.D.||Iniciativa Comunitaria de Investigacion, Inc.|
|Study Director:||Paco C. Castellon, M.P.H.||Columbia University|