Peer navigation helped HIV-positive inmates achieve sustained viral suppression after they were released from jail, according to results from a randomized clinical trial.

In the trial, William E. Cunningham, MD, MPH, professor of medicine and public health at the University of California, Los Angeles, and colleagues linked HIV-infected men and transgender women to lay peers who were trained to counsel them on the HIV care continuum, including how to link or re-engage and remain in care and how to adhere to ART upon their release.

The study was conducted among patients who were recently released from Los Angeles County jail, the largest jail system in the United States. The results were published in JAMA Internal Medicine.

The peer navigation intervention prevented declines in viral suppression after 12 months, whereas a control group of patients who received standard transitional case management saw a decline in viral suppression. Cunningham and colleagues said it was the first time an intervention was shown to sustain viral suppression over 12 months in a randomized trial.

“No prior interventions to our knowledge have shown a sustained level of viral suppression after jail release among people living with HIV reentering the community,” they wrote.

According to the researchers, around 14% of people with HIV pass through the U.S. correctional system each year, and HIV is three to five times more prevalent in incarcerated people than in the general population. Inmates with HIV in the U.S. have access to care while incarcerated and often achieve viral suppression, but retention in care can be poor upon release and many do not remain virally suppressed, Cunningham and colleagues said.

The researchers noted two studies showing poor outcomes in recently released inmates with HIV: an observational study in Texas in which just 30% filled ART prescriptions 60 days after release, and a randomized clinical trial in Texas and North Carolina that showed how an intervention involving, among other things, giving study participants cell phones to receive reminders about medication, failed to improve viral suppression 6 months after release.

For the Linking Inmates to Care in LA (LINK LA) trial, Cunningham and colleagues enrolled 356 eligible participants and randomly assigned them to either peer navigation or standard transitional case management. Peer navigators “were selected for having experiences in common with incarcerated people living with HIV (such as prior incarceration, being a patient retained in HIV care, and/or prior substance abuse recovery),” Cunningham and colleagues wrote. They initiated relationships with participants while they were still incarcerated.

The primary outcome of the study was viral suppression — a viral load under 75 copies/mL. According to the researchers, 250 participants completed the study. Among those in peer navigation, 49.6% were virally suppressed at 12 months compared with 36% in the control group, an unadjusted difference of 13.6% (95% CI, 1.34%-25.9%; = .03). The calculated adjusted difference was 22% (95% CI, 3%-41%; = .02)

In a related commentary, Lisa R. Metsch, PhD, professor of sociomedical sciences, Tracy Pugh, MHS, graduate research assistant — both at the Columbia University Mailman School of Public Health — and Grant Colfax, MD, director of Marin Health and Human Services in California, called the study “an important and welcome advance in elucidating what it takes to improve HIV outcomes in populations where other interventions have largely failed.”

“In the United States, there are few behavioral interventions proven to support clinically meaningful and sustained virologic suppression, and still fewer that demonstrate reduced mortality or increased quality of life,” they wrote.

“The efficacy of the intervention in preventing declines in viral suppression after release from jail [is] both statistically and clinically significant. Indeed, the number needed to treat to realize the benefit of the intervention is seven, a favorable result compared with other biomedical and behavioral interventions. Unfortunately, the authors do not provide a cost analysis, and adopting, scaling and sustaining a 12-session intervention may be a challenge for public health programs.” – by Gerard Gallagher


Author: Cunningham WE, et al. JAMA Intern Med. 2018;doi:10.1001/jamainternmed.2018.0150.
Metsch LR, et al. JAMA Intern Med. 2018;doi.10.1001/jamainternmed.2018.0096.