Proyecto Compadre: Using Implementation Science to Tailor Peer Navigation for Latino Men in the US-Mexico Border Region

Abstract

Background:

Latino MSM in San Diego have poor HIV testing and prevention outcomes compared to non-Latino white men. Peer navigation (PN) is a promising evidence-based intervention to reduce disparities but needs tailoring for Latino MSM.

Settings:

This paper presents findings on tailoring PN for Latino MSM at health centers near the US-Mexico border.

Methods:

Using the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework, we conducted mixed-methods implementation science study. In Phase I, we conducted interviews with Latino men(n=15), focus groups with staff(n=7), and surveys with all to understand the EPIS factors associated with HIV testing and care linkage. In Phase II, we conducted 31 web-based surveys with Latino men and staff to rank intervention and implementation strategies from Phase I. Quantitative data were analyzed descriptively, integrated with qualitative data, and reviewed by our community-academic partnership to develop an implementation model.

Results:

Latino men(N=15) were 94% Spanish speaking, 67% gay-identified, 27% US-born, and their suggestions were to have navigators use peer referral to address barriers like stigma; utilize the Latino social network to expand reach, leverage social media for peer-led intervention, and disseminate HIV information. Staff(N=26) were 77% Spanish speaking, 35% gay-identified, 96% trained in cultural competency, and suggested including culturally-appropriate HIV educational materials in Spanish, status and identity neutral programs, administrative/supervisorial/training structure for PNs, and PN compensation and team integration. Overall, results emphasized a need for a formalized PN model centered on referrals and utilizing existing Latino community social networks.

Conclusion:

Findings can be packaged for future implementation of PN programs for Latino MSM.

INTRODUCTION

Latino gay, bi-sexual, and other men who have sex with men (MSM) in the US experience HIV prevention disparities. HIV testing is a critical entry point into prevention and linkage to care, yet an estimated 17% of Latinos are unaware of their HIV infection,¹ and are at the the greatest risk for late HIV diagnosis (AIDS within 1 year of diagnosis).² Implementation barriers related to engaging Latino MSM with HIV prevention (testing) and care include stigmatized use of HIV services and PrEP, Latino MSM readiness along the change continuum, concerns about negative consequences of service use (i.e., confidentiality), and Latino MSM and provider knowledge about services.^3,4 Strategies are needed to address these persistent socio-structural barriers (i.e., language, insurance, stigma) and facilitate successful engagement in HIV prevention practices for Latino MSM.^5,6

Peer-led implementation strategies, such as peer navigation, enlist members of a specific group to influence and support members to change behaviors and norms conducive to a healthier lifestyle.⁷ Peers have access to hidden populations that may lack access to conventional health programs.⁸ Peer-driven messaging is effective in engaging MSM in intervention content by utilizing peers’ established rapport and trust to disseminate information about HIV testing and prevention, while offering social support⁹ and reducing the negative impacts of medical mistrust and stigma.^10,11 Peer-led strategies among MSM have increased uptake of HIV testing,^12-18 improved HIV knowledge, and reduced condomless anal sex.^19,20 The utilization of peers as leaders in patient navigation programs has been identified with improved engagement/linkage of HIV-infected individuals with care.²¹ There is a paucity of peer-led HIV testing strategies for Latino MSM, but Latino MSM who report social support from peers report frequent and less delayed HIV testing, less unrecognized HIV infection, and less risky sexual behaviors.^22,23

We conducted an implementation research study in San Diego (SD) County that engaged Latino MSM, HIV staff at various points of the service delivery chain, and an academic-community partnership between a large state university and a large Federally Qualified Health Center (FQHC). The community organization is a federally funded, multi-site, non-profit organization providing accessible health services across San Diego County. We used the the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework²⁴ in the study design, measurement, and analysis of barriers and facilitators to accessing and providing HIV testing and care to develop a peer navigation (PN) implementation strategy called Proyecto Compadre (“Project Good Friend”). This paper presents preliminary findings from the collaborative development of Proyecto Compadre, a peer-mediated, social media, social networ, patient-focused implementation strategy aimed to promote HIV testing and PrEP/HIV care linkage for Spanish-speaking, Latino MSM in SD County.

METHODS

Design and Data Collection.

We conducted a pilot EHE mixed-methods implementation research study with Latino MSM and staff divided into two phases. Phase I focused on understanding the relevant inner and outer context, innovation, and bridging determinants of the EPIS Framework²⁴ associated with the effective implementation of HIV testing and PrEP/HIV care linkage among Latino MSM. We conducted 7 focus groups (FGs) with organizational staff, 15 key informant interviews (KIIs) with Latino men (data saturation was reached) and 4 KIIs with peer navigators. Phase I specifically mapped the current HIV prevention services (provided or used), community and mobile outreach efforts, peer-led services, and care coordination/wrap-around services. Prior to the qualitative assessments, we administered brief, 20-minute paper-based surveys on socio-demographics, co-morbidities and HIV prevention and treatment (Latino men only), and work experience (staff only). In Phase II, we conducted 31 brief, web-based surveys with both Latino men and staff to rank the full list of implementation strategies from each group based on qualitative data from Phase I. They ranked each strategy on a likert scale (strongly agree to strongly disagree) separately in terms of feasibility (staff only) and acceptability, and from 1 to 10 in terms of importance of implementation. Feasibility was defined as the extent to which the implementation straegy is practical or possible to use, and measured if the strategy was perceived to be implementable, possible, doable, and easy to manage.^25,26 Acceptability was defined as the extent to which the implementation strategy is attractive, agreeable, or palatable, and measured if they approved the strategy, found it appealing, liked the idea, and welcomed it. Strategies were ranked in order of importance, then acceptability and feasibility (staff only) were considered in the ranking. The research team (organizational leadership and investigators) then considered the prioritized rankings from each group within the implementation context. Finally, we conducted web-based FGs (2 with Latino MSM and 2 with organizational staff) to tailor the prioritized Proyecto Compadre implementation strategies for Latino MSM and the organizational context. Academic-community partnership meetings reviewed findings and informed the development of the logic model informed by the EPIS framework in response to local and organizational needs.

Recruitment.

Latino men were recruited via direct community-based recruitment, provider referral, and clinic-based recruitment in South and Southeast SD County. Eligibility criteria included self-identifying as Latino/Hispanic, ≥18 years old, and either: 1) HIV+ and engaged in HIV care, 2) HIV- and engaged in PrEP care, or 3) HIV- (or status unknown) and not engaged in HIV testing or PrEP. Organizational staff were recruited via email invitation, and were provided protected time to participate. Staff eligible to be included consisted of HIV frontline staff, peer navigators, managers, supervisors, and care providers.

Data Analysis.

Quantitative data from Phase I were analyzed descriptively using STATA 15.1.²⁷ Phase II survey data of implementation strategy feasibility (Staff only), acceptability, and importance rankings were then averaged within groups (Latino MSM/Staff), compared, and a final list of strategies was devised. Findings were presented to leadership and top ranking strategies within each group and those that overlapped between groups were assessed for inclusion in the multifaceted implementation strategy based on implementation context.

Qualitative data from Phase I and II were preliminarily analyzed by creating templated summaries,²⁸ in which: 1) neutral domains were created from each FG/KII question, 2) the team of investigators applied and revised the domains with 2 FG/KII each, and 3) then applied the revised domains to all of the FG/KIIs. Templated summaries were revised for key themes around barriers and facilitators to HIV testing and care linkage and ways to tailor evidence-based practices and implementation strategies for Latino men. Using preliminary findings, the academic-community partnership of the Proyecto Compadre team convened to discuss appropriate health behavior theory, evidence-based interventions, and implementation inputs to inform the logic model.

RESULTS

Table 1 describes the socio-demographic and other characteristics of Latino men and organizational staff. Latino men (N=15) averaged 39 years old, 67% were at least high school-educated, 81% had an annual income at or below $29,000, 94% preferred to speak Spanish, 27% were US-Born, 67% identified as gay, and 53% were HIV-negative. Staff (N=26) were mainly Latinx (69%) and spoke Spanish (77%). Staff were well trained in cultural competency, serving transgender populations, motivational interviewing, trauma-informed care, and HIV prevention and care.

Table 1.

Characteristics of Latino men and organizational staff

	Latino Men (n=15)		Staff (n=26)
	n	%	n	%
SOCIO-DEMOGRAPHICS
Age [mean(std dev.)]	39.47	(10.53)	39.32	(10.75)
25-34	6	40	11	42
35-44	4	27	8	31
45-54	3	20	4	15
55-61	2	13	2	8
Missing			1	4
≥ High School Diploma	10	67	26	100
Annual income
≤ $29,000	12	81		-
Missing	3	20		-
Gender
Male	15	100	14	54
Female		-	12	46
Ethnicity
Hispanic/Latinx	15	100	18	69
Non-Hispanic White		-	5	19
Asian/Pacific Islander; Black/African American; Other		-	3	12
Speaks Spanish	14	94	20	77
US-Born	4	27	19	73
Sexual orientation
Gay or Lesbian	10	67	9	35
Straight or heterosexual	4	27	17	65
Bisexual	1	7
HIV status
Positive	6	40	4	15
Negative	8	53	21	81
Don't know	1	7	0	0
Prefer not to say	0	0	1	4
No Medical Insurance	7	47		-
Lived in the street (prior 12 months)	5	33		-
Food Insecure (prior 12 months)	4	27		-
STAFF CHARACTERISTICS
Staff Category
Clinic staff	16	61	4	15
Healthcare provider		-	3	12
Management		-	3	12
Other		-	4	15
Received Training In:
Cultural competency		-	25	96
Working with transgender patients		-	19	73
Professional development skills		-	18	69
Motivational interviewing		-	17	65
Trauma-informed care		-	17	65
Medications for HIV		-	16	62
Treatment adherence counseling		-	15	58
PrEP		-	13	50
RANKINGS [ranking from 1 to 6]
Referral to Social & Ancillary Services (i.e., mental health)	[1]			-
Peer Navigation (PN) Program	[2]		[4]
PN Recruitment via Social Media	[3]			-
PN Recruitment via In-Person Network	[4]			-
Culturally Tailored HIV Material	[5]		[1]
Community HIV Campaign	[6]		[2]
PN Training Program		-	[5]
Recruiting logisitics (social media; in-person; incentivized)		-	[6]
Train All Staff re: HIV Referral		-	[3]

Source: Proyecto Compadre (2019-2020)

In terms of the feasibility (staff only), acceptability, and importance of implementations strategies, Latino men and staff both positively ranked a formal PN program (2 and 4, respectively), culturally tailored HIV material (5 and 1, respectively), and a community HIV campaign around South SD County (6 and 2, respectively). Latino men also positively ranked referrals to social and ancillary services (i.e., mental health care; 1), and peer recruitment via social media and in-person networks (3 and 4, respectively). Staff also positively ranked training all staff in HIV referral, PN training program, and establishing a comprehensive recruitment strategy to include social media, in-person, and incentivized recruitment methods (ranked 3, 5, and 6, respectively).

Table 2 describes the rankings of the implementation strategies and highlights the strategies that were retained, organized by EPIS factors. Outer context strategy suggestions include: PN program and information dissemination. Latino men described a PN implementation strategy that leverages peer trust and referral to address intersectional stigma, medical mistrust, and discrimination in accessing HIV services, and uses the Latino social network to expand reach. Latino men emphasized the need for a community HIV campaign with tailored, publically accessible, and discreet HIV messaging to disseminate information. Latino men also recommended a social media intervention to leverage facilitators to testing in the outer context of EPIS. This strategy would create and strengthen social networks to disseminate information around HIV testing and prevention. Key suggestions identified culturally competent HIV educational material as an innovation factor. Staff described the need for culturally tailored HIV educational materials in Spanish, at a sixth grade reading level, and sexual orientation neutral given significant stigma in the Latino community. Inner context factor suggestions consisted of a formalized PN program structure. Staff described the need for an organizationally integrated PN program with a supervisorial structure, PN training, and fair PN compensation and team integration.

Table II.

Recommended Components for a Community-Vetted Peer Navigation (PN) Implementation Strategy for Latino MSM in San Diego, CA

Implementation Strategies	Barrier/Facilitator Addressed or Leveraged and Example Quotations
Peer-Led Intervention	Barriers Addressed: Intersectional Stigma, Medical Mistrust, Discrimination (Outer Context: Service Environment/Policies)
Peer Recruitment and Referral	"If…a flyer or something reached us by a relative or acquaintance who is already going to the clinic, then we feel secure that it is well-established and a place with open doors where we trust to go and ask questions" (Latino male, Phase I )
Peers Build Trust and Reduce Stigma	"Diffusion of information is important because people are scared to go to a clinic or they feel shame because they don't speak English, they don't have documents [(legal status)], or don't know what will happen…[we] need to let people know not to worry about it" (Latino male, Phase I )
Peers Utilize Latino Social Network	"[Have] other Latinos referring them so that they know it's safe and confidential. Using the Latino social network" (Latino male, Phase I )
Disseminate Information	Barriers Addressed: Lack of HIV Prevention and Care Information (Outer Context: Availability and Accessibility of Public Health Information)
Community HIV Campaign	"All the information that I have seen about HIV [and] PrEP [is] in the clinics…I have not seen any ads on the street or in transportation" (Latino male, Phase I )
Tailored Messaging	"Creating a viral message, an attractive campaign…using language that is easy to understand…Staff who are in the field are used to using big words and people sometimes are not at that level, and they get scared" (Latino male, Phase II )
Public & Discrete Messaging	"Use something that is informative, and that offers…anonymity; like a QR code…I see it in public transportation, on the street…I take it without no one seeing me and [without] feeling judged" (Latino male, Phase II )
Social Media Platforms	Barriers Addressed: Expanded Reach and Diffusion of Innovation (Bridging Factor: Network/Communication Channels)
Social Media Recruitment and Intervention	"Creating the Facebook page…from men to men…the administrator will input prevention messages, it could be a good way to engage clients with services…an informal platform to make friends and talk to clients like if they were friends" (Latino male, Phase II )
Dating Apps Recruitment and Intervention	"I suggest using…[the] Grindr app or other dating [with] an announcement like "the virus doesn't kill, but your fear of getting tested does,"…it is a reality, the virus doesn't kill us, but the fear of receiving care is what leads people not to treat HIV on time" (Latino male, Phase II )
Tailored HIV Educational Material	Barriers Addressed: Need for Linguistically and Culturally Appropriate Material (Innovation Factor: Culturally, Linguistically Competent; Relevant Intervention Content)
Spanish Language	"The vast majority of clients that we see, especially in South Bay, are mono-lingual Spanish speakers who obviously feel more comfortable with any type of service in Spanish" (Staff, Phase I )
Reading Level	"It's best that the material is set at like a sixth grade level…and it's a lot of phrasing…that even some native English speakers get confused with before even translating it into Spanish" (Staff, Phase I )
Sexual Orientation Stigma	"They want the services but they do not want it to be openly homosexual, to have even more confidentiality. There's a stigma attached to just being openly gay with a lot of Latinos. So that's a very big issue." (Staff, Phase II )
PN Program Structure	Barriers Addressed: Need for PN Management, PN Representation, and Team Integration (Inner Context: Staffing, Organizational Characteristics)
Dedicated PN Manager	"We don't have a dedicated staff position to run our peer navigation program…so talking about organizational structure, if we had resources…that could fund a dedicated staff position or even a small team to actively recruit,…navigate, and train, and make sure none of our [PNs] are falling through the cracks" (Staff, Phase I )
PN Reflect Population	"If…they don't have a social security number, then that limits them from being a peer volunteer and stipends and all that…But maybe…include peers that actually reflect our population." (Staff, Phase II )
PN Pay and Team Integration	"If we were to get a volunteer with incentives or hire a peer navigator, having benefits and…ideally, paying them and keeping them as part of the team." (Staff, Phase II )

Source: Proyecto Compadre (2019-2020)

Figure 1 describes the EPIS-based logic model that aided the development of the Proyecto Compadre components. Determinants to HIV testing and prevention for Latino men within the outer context included²⁹ the public charge law (a regulation endangering immigration status based on using social benefits). Barriers to testing included the lack of HIV information, intersectional stigma, medical mistrust, being uninsured, untreated mental health problems, Spanish mono-lingual status, and lack of reach of Latino men.^30-32 Facilitators included social support (check-in calls, birthday parties, support groups), word-of-mouth (peer referral) which gave men trust in the referral, culturally competent care, dissemination of information, and using social media to enhance reach and access to care. In the inner context, the organization developed a COVID-19 home-based testing program, but still lacks a PN model and case management for HIV-negative clients and a strategy for social media recruitment, and faces workforce difficulties retaining trained PNs. Bridging factors included strong community-academic partnerships for implementation.

Figure I.

Proyecto Compadre Peer-Led Social Media, Social Network Implementation Science Logic Model. Notes: 1. The current report focuses on the exploration and preparation phases (first two columns); 2. Legend: PN=Peer Navigation; HIVST=HIV self-testing; MH=Mental Health

Implementation Strategy Bundle.³³

Proyecto Compadre is a multifaceted PN implementation strategy that comprises: 1) Peer-Led Intervention Strategy, 2) Social Media Recruitment and Dissemination Strategy, 3) Tailored HIV educational material, and 4) PN Program Structure.

Mechanisms.

Organizational coordination includes managing a PN program, hiring and training PNs and PN Coordinator, optimizing HIV self-testing and referrals to care, and community stakeholder buy-in. PN and peer influence is hypothesized to increase perceptions of social support, reduce stigma, reduce medical mistrust, and enhance HIV prevention norms. Proyecto Compadre is hypothesized to increase accessibility to HIV and mental health (MH) information, linkage to care, and reduce socio-structural barriers.

Outcomes.

Implementation outcomes include reach (characteristics of tested vs. non-tested, recruitment rate of Latino MSM and PNs, qualitative measures), effectiveness (HIV testing productivity, qualitative measures), and implementation (acceptability, fidelity). Clinical and services outcomes include HIV testing (% repeat-/testers, unmet MH need (access to MH provider with MH need), and linkage to care (PrEP, HIV, MH).

DISCUSSION

Using the EPIS framework, we identified outer, inner, bridging, and innovation determinants to inform selection of a multifacted PN implementation strategy. Findings have three key implications for ending the HIV epidemic among Latino MSM in SD County. First, our PN implementation strategy for Spanish-speaking Latino MSM includes key elements that address outer context determinants identified in our Phase 1 assessment of being peer-led, utilizing Latino social networks and social media for enhanced reach and information dissemination, and culturally tailoring intervention material. The ranking system used in Phase 2 identified important, acceptable, and feasible implementation strategies. The PN program was selected as the primary strategy based on the ranking system, but is a multifaceted implementation strategy that requires additional implementation strategies to address the mulit-level barriers to HIV testing and care for Latino MSM (i.e., language barriers, stigma, etc.). Additionally, the ranking system enabled us to identify potential synergies among organizational staff, Latino MSM, and organizational implemenation context. The PN implementation strategy will engage navigators in disseminating intervention content about HIV testing and prevention to their peers by leveraging their established rapport and trust, while offering social support and reducing the negative impacts of medical mistrust and stigma. The PN strategy can serve as a liason service to identify and address other needs, like mental health (in this case), in addition to HIV specific services. Referral to these social and ancillary services was identified as a priority for Latino men and addressing these socio-structural barriers to testing can increase the number of individuals reached and retained by HIV services. The PN strategy centers individuals that need the most support to access HIV testing and care linkage. Peers are more likely than professionals to influence health behaviors of fellow group members, and have better access to hidden populations who may lack access to conventional health programs.^7,8 Findings from this study are specific to Spanish-speaking Latino MSM in SD County who are regular social media users, especially as Latino sub-groups in other US regions experience variable barriers to testing and care utilization.^34-36 However, if efficacious, Proyecto Compadre can be modified for other Latino sub-groups paying attention to the unique cultural (Puerto Ricans, Dominicans, etc.) and implementation contexts. One limitation is that participant recruitment was via referral by peers and agencies, potentially limiting tranferability of findings to those reachable by traditional referral mechanisms. However, we offset this limitation by including Latino MSM not currently engaged in HIV prevention/care.

Second, we selected critical implementation strategies at the organizational level (inner context), including creating PN jobs, developing a PN training certificate program, and systematizing a social media recruitment and intervention approach. Staff specified the need to include an administrative/supervisorial structure for PNs and social media recruitment, which would allow for consistent PN recruitment, integration, and retention. Additionally, engaging trainings for PNs are imperative to address ethical/confidentiality issues and support PN implementation fidelity. Finally, staff stated that they needed culturally-appropriate Spanish-language HIV educational materials, as most clientle prefer to access services in Spanish (innovation factors). These strategies align with EPIS inner context and innovation factor considerations by managing organizational coordination to facilitate key implementation outcomes like HIV testing and care linkage reach and effectiveness.

Third, our community- academic partnership (bridging factor) highlighted critical facets for a continued and successful collaboration to EHE for Latino MSM. These partnerships are the basis of providing infrastructure and a common goal between researchers at academic institutions and CBOs. Proyecto Compadre is the first of its kind to leverage the power of peer influence, social media, and social networks to address HIV testing and MH, advancing HIV prevention science and addressing care disparities among Spanish Speaking Latino MSM.

In conclusion, we developed and adapted a PN implementation strategy to mitigate key barriers and leverage key facilitators to HIV testing and PrEP/HIV care linkage for Latino MSM.