Human immunodeficiency virus (HIV) infection has disproportionately persisted as a public health threat to adolescents and young adults (AYA) from minority communities in the United States. HIV has evolved into a chronic disease, which can be managed in the outpatient setting with antiretroviral therapy (ART) designed to achieve virologic suppression and life expectancy equivalent for uninfected individuals. However, for AYA, huge disparities exist compared to adults, with greater proportions unaware of their status, lower rates of care engagement, retention, and initiation and maintenance of ART, resulting in higher rates of virologic non- suppression, and development of sequelae including immunologic deterioration and transmission. Interventions designed to improve outcomes for youth living with HIV (YLHIV) are being sponsored by agencies including the Centers for Disease Control and Prevention and the National Institutes of Health, however, most target the early components of the continuum of care (identification, linkage, and ART initiation). Our research from the HIV Research Network shows that 30-40% of YLHIV are not virologically suppressed despite being in care, highlighting the need for novel interventions targeting the distal components of the care continuum. Community health nurse (CHN) interventions have been shown to increase access to appropriate resources, enhance health care utilization, and promote risk-reducing behavior among AYA. Use of short messaging service (SMS) messaging can further enhance clinical care by improving attendance at medical visits, medication adherence, and communication with the health care team. We have used these two modalities in randomized trials of youth with complex sexually transmitted infections (STIs) in low-income minority communities with high feasibility and acceptability amongst AYA and their families, remarkable improvements in visit completion, medication adherence, and reduction in recurrent STIs. The overarching goal of this project is to build on the evidence from this trial and to repurpose the intervention for YLHIV in the same community who are having challenges with care and medication non-adherence.
We aim to compare the effectiveness of a technology-enhanced community health nursing intervention (TECH-N 2 CHECK-IN) to a standard of care control group using a randomized trial design. The central hypothesis is that the intervention will result in higher rates of adherence to ART and virologic suppression. We have demonstrated our interdisciplinary team's capacity to follow urban AYA in the community, utilizing the combination of CHNs and outreach workers to optimize care according to national standards. TECH-IN 2 CHECK-IN aims to enroll 120 YLHIV followed at clinics specializing in HIV care in the Baltimore-Washington Metropolitan area who are challenged with treatment adherence and randomizing them to receive TECH-IN 2 CHECK-IN vs. standard of care. Results of this trial will inform best practices for engaging YLHIV by addressing the distal component of the continuum, critical to achieving the elusive 90-90-90 HIV goals.
Project Relevance Despite advances in HIV treatment, youth living with HIV (YLHIV) have profound challenges with adherence to care visits and antiretroviral therapy (ART), with 1/3 of YLHIV who are in care not reaching virologic suppression; however, few evidence-based interventions have been developed or studied that can improve these rates. We will repurpose a technology-enhanced community health nursing intervention (TECH-N) with demonstrated efficacy for improving care adherence and reducing risk behaviors among youth from similar racial/ethnic, socioeconomic status and community backgrounds into an HIV-focused intervention (TECH-N 2 CHECK-IN) and use a randomized controlled trial design to compare it to standard of care for YLHIV who are non-adherent to care and ART using data on medication adherence, virologic suppression, and cost- effectiveness. If successful, this study will provide critical data to support the need for comprehensive, higher intensity community-based nursing services that leverage mHealth to assist the subset of the mostly racial/ethnic minority YLHIV who are challenged by the complexity of HIV care and to introduce a novel strategy to move the United States closer to meeting our 2020 National Health Objectives by embracing the United Nations 90-90-90 goals focused on effective treatment of YLHIV to end AIDS.
