About the Supplement Project Spotlight Series: This series by the HIV Implementation Science Coordination Initiative (ISCI) does a deep dive on research and findings from supplement projects funded by the National Institutes of Health (NIH) as part of the Ending the HIV Epidemic in the United States (EHE) Initiative. Keep reading to learn more about this process and click here for additional information on supplement project funding.

Healthcare systems that integrate community health workers (CHWs) into the care team have improved outcomes for chronic health conditions. As frontline public health workers who share lived experiences with the clients they serve, CHWs are trusted intermediaries between health systems and the community. They are uniquely equipped to help clients navigate healthcare systems by increasing the quality and cultural competence of services and addressing gaps in health outcomes in under-resourced communities.

Many studies have demonstrated the positive effect CHWs have on clients and healthcare systems, including in HIV care settings. CHWs improve linkage and retention in HIV care and increase medication adherence and undetectable viral load outcomes, which advances pillars of the Ending the HIV Epidemic in the US (EHE) initiative, underscoring their value to the HIV workforce. However, barriers like lack of funding from health systems, minimal training provided to CHWs, and unclear role responsibilities for CHWs within care teams prohibit effective integration of CHWs and limit their impact on HIV care.

Serena Rajabiun, PhD, co-developed an EHE supplement project to address barriers for CHWs in the Memphis Transitional Grant Area, which includes eight counties at the intersection of Arkansas, Tennessee, and Mississippi that receive Ryan White HIV/AIDS Program Part A funds. The project team included co-investigators Robin Lennon-Dearing, Melissa Hirschi, and Brandon Williams, as well as numerous community partners. The team worked with local stakeholders to adapt and implement a series of CHW trainings on engaging people in HIV care and to develop standard policies and practices for CHW roles. Together, Rajabiun, the co-investigators, and their community partners enhanced the integration of CHWs into HIV care provision, ultimately improving health outcomes for people living with HIV.

More About Community Health Workers

CHWs can have a wide variety of titles, including outreach worker, early intervention specialist, patient navigator, promotora, peer leader, community health advisor, health advocate, outreach educators, community health representatives, and peer health promoters. They provide a large range of services, such as culturally appropriate health education, informal guidance on health behaviors, advocacy for community health needs, translation services, transportation, and social support.

Studies examining outcomes of integrating CHWs in care teams demonstrate numerous advancements for healthcare services, including:

• • Increased health screening
  • Lower healthcare costs
  • Improved access to and use of healthcare services
  • More effective communication between community members and health providers
  • Improved adherence to treatment plans
  • Reduced need for emergency services

Identifying and Addressing Barriers to HIV Care Provision

The project team implemented the CHW HIV training series in two phases across three community-based organizations: Hope House, Friends for Life, and Christ Community Health Services.

Phase one took place from 2019 to 2020 with EHE funding through the Providence/Boston Center for AIDS Research. During this phase, the project team developed a community-based participatory workshop for 30 stakeholders including people living with HIV, CHWs, and HIV care providers. The workshop identified key barriers to and facilitators for improving viral suppression for people living with HIV. Participants also discussed training topics needed to better prepare CHWs in the Memphis Transitional Grant Area.

“It was important to bring the people who are most affected by HIV to the table to help design these trainings because they know what needs to be done,” said Rajabiun. “CHWs are particularly equipped to engage people in HIV care, even more so than physicians, nurses, and social workers because CHWs are from the community and have the community’s trust.”

To ensure the trainings met the needs of CHWs in HIV care settings across the Memphis Transitional Grant Area, the project team engaged Tennessee’s Shelby County Health Department in conversations on areas that need additional support.

“Memphis had an existing community health workforce through their early intervention specialists, but training was not standardized, and high turnover exacerbated inconsistencies in HIV care knowledge. Our project team simply came at the right time, since the health department was already thinking about integrating CHW trainings,” said Rajabiun.

With these insights, the project team began phase two, which ran from 2020 through 2022 and was funded with a second EHE supplement through the Providence/Boston Center for AIDS Research. Phase two focused on adapting and implementing a CHW training curriculum that Rajabiun initially developed through a previous project. The project team maintained major components of the original training curriculum, which was designed to develop core competencies for CHW roles generally and for CHW roles providing HIV care. To make the training as effective as possible, they adapted it to address prominent barriers CHWs face when providing HIV care in the Memphis Transitional Grant Area.

Tomekicia Wren, Hope House director of outreach and linkage, was part of the project team and facilitated conversations with CHWs to identify key barriers to providing HIV care.

“Some CHWs have been doing this work for 10, 15 years, so it was important to really dig in and figure out what we could do to address specific barriers they face when providing HIV care. What made this work particularly well was that we invited everyone to contribute to the conversation, since all voices are valuable in this process,” said Wren.

One of the major barriers they identified was a lack of information on navigating the intersection of aging and HIV, since CHWs reported having a large population of older clients. Because the project launched in 2020, the team also developed training components addressing COVID transmission and how to navigate structural racism through cultural humility, specifically within the context of police violence. By the end of the project, the team conducted six trainings with a total of 75 participants.

In addition to implementing trainings for CHWs, the project team conducted bimonthly coaching sessions that addressed topics like strengthening advocacy and managing mental health. During these sessions, CHWs strengthened skills they learned in trainings through discussing client cases with their supervisors, as well as collectively identifying strategies to address challenges with engaging and retaining clients. The project team also developed standard policies and practices for CHWs, including concrete job descriptions with corresponding wages and performance assessment tools.

Training Outcomes: Support for CHWs Benefits Clients and Community

After implementing the CHW interventions, the project team conducted an evaluation that examined major takeaways for CHWs and impacts on their clients. CHWs provided largely positive feedback with notable improvements in HIV care knowledge and practice, ultimately improving client health outcomes.

CHW Outcomes

The project team conducted surveys and individual interviews with the 75 CHWs to examine intervention outcomes. They analyzed three major elements: change in CHW confidence, training acceptability, and applicability to work.

Compared with results from the pre-training evaluation, CHW confidence in navigating and understanding different HIV-related topic areas increased across the board, highlighting clear initial benefits from the trainings.

CHWs also ranked the HIV-related topic areas by acceptability, which examined their level of satisfaction with the topic based on how closely it relates to client needs. They ranked all topics in the training as highly acceptable. Topics CHWs said were most relevant to their clients included cultural humility and power dynamics; trauma informed care; and the role of CHWs in advocating for clients in the organization and community.

CHWs similarly evaluated the applicability of training topics to their work environment. They provided high rankings for all training topics, again demonstrating their satisfaction with the training. The topics ranked as the most applicable included aging and HIV; cultural humility and power dynamics; addressing internal biases; and using a trauma informed care approach.

“Overall, the CHW trainings were very beneficial for the Memphis Transitional Grant Area. It happened at a time where CHWs were feeling unsupported and exhausted with a lack of resources, so the project had a positive impact,” Wren of Hope House said.

Supervisors for CHWs provided feedback as well, focusing specifically on improvements they noticed among the community health workforce after the trainings. Improvements that multiple supervisors mentioned include building stronger community relationships, learning innovative techniques to keep clients engaged, networking with colleagues to share best practices, and gaining new resources to share with clients.

Client Outcomes

Training CHWs in HIV care and standardizing policies and practices had a direct impact on their clients. The project team evaluated client impact through distributing pre- and post-training surveys to 45 clients, in addition to conducting individual interviews and analyzing clients’ medical chart data.

Client HIV health outcomes improved, with medication adherence increasing from approximately 91 to 92 percent, and viral suppression increasing from 90 to 92 percent. However, the positive impact CHWs had on clients is far more apparent when examining outcomes for social support, stigma, and empowerment.

Through discussing the importance of social supports in HIV care, the trainings prepared CHWs to talk to clients about support networks, ultimately helping strengthen clients’ use of social support networks. Support groups clients reported reaching out to include significant others, family, friends, and other people living with HIV. Clients also saw a statistically significant reduction in the level of stigma they experienced and increased feelings of empowerment, which was evaluated through an empowerment scale included in the client survey.

Empowering statements surveyed clients reported they strongly agree with include:

• • I can do things to take care of my family
  • I can make important decisions in my life
  • I can advocate for myself
  • I have access to basic resources I need to live a healthy life
  • I have access to resources to make decision for myself and family

These improved outcomes for both CHWs and their clients not only demonstrate the positive impact of the intervention itself, but also provide evidence that supporting and further integrating CHWs in HIV care will improve HIV outcomes over time.

“There are not a lot of studies out there that show how community health workers can improve outcomes over time, but this project does. It shows how community health workers are really helping people find resources and build up their self-efficacy and decision making, which I’m hopeful will encourage more support for CHWs,” said Rajabiun.

Digital Outcomes: A New Client Referral System

During the project, the project team and partners discussed the need for a standardized client intake form and streamlined referral system, leading them to adopt a new data system. Hope House and other community organizations worked with grant officers from the Ryan White HIV/AIDS Program to apply the Ryan White Integrated Statewide Eligibility web-based interface on top of their existing CAREWare database. This system digitizes the intake and referral process and enables clinics in the Memphis Transitional Grant Area to easily send, receive, and track referrals amongst each other.

“Sending and receiving referrals had been a barrier for years, but now we have a system we actually use, which is a really exciting product to come out of the EHE project,” said Wren. “This lays the groundwork for what we want community health work to look like in our city and how we want to do that collectively.”

Maximizing Impact: Opportunities to Expand CHW Training

Based on feedback given in the post-intervention evaluation and their own observations, the project team identified areas for improvement and expansion for future CHW trainings.

Additional topic areas identified:

• • HIV and incarceration
  • Addressing biases
  • How to approach mental health and substance use
  • Engaging sexual minority youth
  • Engaging Black women

The project team’s conversations with community stakeholders illuminated a particularly strong desire for additional trainings specific to mental health and substance use.

“We have been trying to find funding for CHW training to strengthen both screening and engagement with mental health and substance use treatment,” said Rajabiun. “The online training is still available for CHW and new staff, but we need funding in order to do more substantial training and capacity building.”

Wren shared a similar sentiment, acknowledging that the online training has been useful for new staff but can’t compare to the full CHW training series.

“Our community could have benefitted from even more of this training. These projects need to have actual funding streams for long-term support and resources to continue to do the work, so it doesn’t become a wild goose chase to get more funding,” said Wren.

Supervisors and leaders of the community organizations have committed to continuing to support CHWs. They expressed a desire to increase CHW salaries, offer more appealing benefits, and promote opportunities for trainings and conferences.

Rajabiun is also exploring additional opportunities to expand CHW trainings and support, specifically through conversations with the National Community Health Worker Association and community organizations in St. Louis, Missouri.

“There are a lot of groups out there that are interested in promoting CHW roles, so we’re trying to share this intervention more widely—it just takes time,” said Rajabiun. “We need to invest in health systems and invest in a community health workforce because they can engage people and build trust in a way other members of the HIV care team can’t. Supporting CHWs may sound like a big lift for health systems, but the reward in the end is worth it.”

Study team and partners (2020 – 2023):

• • University of Massachusetts, Lowell – Department of Public Health
    • Alicia Downes
    • Simone Philips
  • University of Memphis – School of Social Work
    • Robin Lennon-Dearing (co-investigator)
    • Melissa Hirschi (co-investigator)
    • Abigail Smack
  • Shelby County Health Department
    • Brandon Williams (co-investigator)
    • Sherry Cohen
    • Veronyca Washington
  • Community partners
    • Tomekicia Wren from Hope House
    • Chasity Bolton from Christ Community Health Services
  • St. Jude Children’s Research Hospital – EHE Committee
    • Ashley Ross

More on supplement projects: In support of the EHE Initiative, the NIH funded implementation science projects through its network of Centers for AIDS Research and the National Institute of Mental Health’s AIDS Research Centers. Research reported in this spotlight was supported under award number P30AI050410. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

More on the spotlight series: ISCI’s EHE Supplement Project Spotlight series does a deep dive on the research and findings from these projects, providing insight into how researchers, providers, and community members can scale up HIV prevention and treatment strategies. Visit HIV.gov to learn about the EHE initiative and check out the NIH website for more information on supplement projects.

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