Navigation programs for people living with HIV/AIDS who experience homelessness: considerations for assessing performance and costs
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Despite the advances in antiretroviral therapy (ART) a disproportionate number of people living with HIV (PLWH) remain limited in their access and use of health care and treatment, including racial/ethnic minorities, persons with mental health and substance use disorders and persons experiencing homelessness or unstable housing. Patient navigation programs have emerged as a potential effective and efficient use of resources to reach and engage these vulnerable populations as part of the HIV service delivery system. This dissertation contains three chapters that aim to identify and assess the performance and mechanisms for navigation programs working with PLWH who experience homelessness and co-occurring substance use and mental health disorders. Study 1, Developing a Reliable and Valid Composite Measure of Effectiveness for HIV Navigation Programs for PLWH who are homeless/unstably housed, describes the development of a multidimensional outcome measure to assess the performance of navigation programs for this population. The composite measure was comprised of seven indicator variables: linkage to care, retention in care and adherence to treatment, patient experience of care, physical and mental health related quality of life and housing stability. Using multivariate analyses, a 3 item measure of retention, adherence, and housing stability was found to have high goodness of fit and strong predictive association with viral suppression. Study 2, Classifying Components of HIV Navigation Programs for PLWH who are homeless/unstably housed, used a latent-class analysis to identify common patterns of activities, modalities of communication, location of work, and staff composition among highest utilizers of services. Results showed that types of activities, work setting and modality of contact were significantly associated with increased retention in care. No difference in activity, staffing patterns, work setting or modality of communication of navigation programs were found on viral suppression rates. Study 3, An Economic Evaluation of HIV Navigation Programs Working with PLWH who are Homeless/Unstably housed assessed costs and net benefits of these navigation programs overall and in subpopulations. Cost utility and net benefit analyses performed indicated that navigation programs for PLWH who are homeless/unstably housed are a potential efficient investment of resources at various willingness-to-pay thresholds. Navigation programs provide a myriad of services for PLWH who are homeless/unstably housed and must be flexible in their approach to address the multiple medical and psychosocial needs of this population. The results of this dissertation provide information for improving the design, measuring performance and costs and benefits of navigation programs as part of the HIV service delivery system for PLWH who experience homelessness.