The intervention was designed for people who inject drugs who have HIV infection and who are either just being diagnosed or have been in treatment before but are not doing well in treatment. Either they've dropped out of treatment or they're still taking their medication, but they aren't doing well; they aren't virally suppressed as we say.
So the intervention was designed to help those people get into care, so that most importantly from our perspective, the goal was to reduce transmission to people who they shared needles with, who they could transmit HIV infection to.
We conducted the study in these three countries in part because these three countries have HIV epidemics that are largely driven by injection drug use.
That was one of the major criteria. The second, an additional one, was that the countries that participated in this trial had to have a sufficient incidence or prevalence of HIV infection in this population to make it feasible to do this study.
The two components of the intervention are systems navigation and psychosocial counseling.
Systems navigation is simply assisting people to engage in health care—both, in this circumstance, HIV care, so antiretroviral therapy; and substance use treatment, specifically medication-assisted treatment.
The psychosocial counseling was focused on problem solving and using techniques such as motivational interviewing to be able to help them address some of the key barriers in their own lives to managing their own health and engagement in health care.
We did not provide directly any antiretroviral therapy. Instead, people were referred to local clinics, where they were able to receive the treatment. And the same was true for medication-assisted treatment. We did not provide it directly; instead, we were referring to the local health care system.
The people that were providing the intervention, like the navigators and the counselors, had a variety of range of education levels, from a bachelor's degree all the way up to physicians, depending on the context. And that was part of our goal, was that someone with relatively little education would be able to provide the intervention, so that when if a country wanted to implement this when we were done, they would be able to do so at relatively low cost.
The next steps with the intervention are in sort of two different directions.
One direction is that although we did very well getting a large proportion of the population initiated on antiretroviral therapy and staying on antiretroviral therapy, we had somewhat less than desirable results on the level of viral suppression among the population. So we want to do a better job of getting them virally suppressed.
A second part is a larger emphasis on the medication-assisted treatment. That was a smaller piece, and we think it needs to be expanded a little bit. And a third element is additional social support. The people that had a friend or a family member supporting them through the intervention did better than those that did not have that social support. So we think that we can devise a way to encourage that social support.
In many ways, this is actually easier to implement in other contexts than in the United States, and that has everything to do with our complicated health care system.
The challenge in the United States is that things like systems navigation are not easily reimbursable in our insurance system.
We really need to encourage our health care infrastructure, our insurance companies, and that sort of thing to understand the benefit of these sort of simple interventions that could really make a difference in people's lives