Hospital Visit as Opportunity for Prevention and Engagement for HIV-Infected Drug Users

This study is a 3-arm randomized, prospective trial in which HIV-infected inpatients who
report substance use at screening will be randomized in 1:1:1 ratio to Patient Navigator
(PN) vs. Patient Navigator + Contingency Management (PN+CM) vs. Treatment as Usual (TAU).
Randomization will occur after screening, informed consent, baseline assessment and
collection of biological (blood) specimens. Participants assigned to the PN and PN+CM groups
will meet (ideally at bedside if the participant is still hospitalized at the time of
randomization) with the Patient Navigator interventionist and will complete up to 11
intervention sessions over the 6-month-long intervention period. Participants assigned to
the TAU group will receive care as it is typically offered in the inpatient setting.
Follow-up visits will be conducted at approximately 6 and 12 months post-randomization.

To minimize patient and staff burden, sites may implement a pre-screening procedure with
permission from their respective IRBs to determine which inpatients would meet the study's
AIDS-defining illness/CD4 count/viral load inclusion criteria. Pre-screening, screening,
enrollment, assessment, randomization and the initial intervention visit will (ideally)
occur during the participant's stay at an inpatient facility. Recognizing that participants
may be recruited at various stages of illness during their inpatient visit, however, this
may not be possible. To allow maximum flexibility, all activities that occur after the
screening informed consent may be completed after the patient has been discharged from the
hospital. The intervention duration will be 6 months with sessions ideally occurring weekly
during the first month, bi-weekly during months 2 and 3 and monthly during months 4- 6.
Follow-up visits will occur at approximately 6 and 12 months post-randomization. Therefore,
the total duration of individual participation in the study is approximately 12 months.

Prior to approaching patients to recruit them into the study, members of the medical teams
within each hospital (i.e., attending physicians, fellows, residents and nurse
practitioners) who are involved in patient care and who know the patients' HIV-infected
status will assess the medical stability of the patients. If a patient has expressed
interest in potentially participating in research and is deemed medically stable, then a
study staff member will meet with the patient at bedside to discuss the study. Strict
ethical guidelines regarding professional conduct and confidentiality will be enforced for
all study staff.

Prior to screening individuals to determine their eligibility to participate, the research
staff will briefly explain the study purpose, procedures, potential risks and benefits and
voluntary nature of participation. Individuals willing to be screened to determine
eligibility will provide written informed consent, including providing HIPAA authorization
for medical record abstraction. After signing the consent and HIPAA forms, participants will
be offered copies of the forms to keep for their records.

After the enrollment process (providing written informed consent and completing a locator
form) is complete and a brief rapport-building discussion between the interviewer and
participant has taken place, the research interviewer will administer the baseline
assessment through a handheld Computer Assisted Personal Interview (CAPI) device. The CAPI
system displays each assessment question on a computer monitor, allowing the interviewer to
read the questions and then enter the participants' responses directly into the computer.
The baseline assessment will include, but not be limited to questions on participant
demographics, HIV care, medication adherence, substance use and co morbid conditions such as
hepatitis, depression, etc.

Collection of Biologic Specimens:

We will collect blood specimens at the baseline, 6-month and 12-month follow-up visits to
evaluate the primary outcome, HIV virologic suppression, as well as to measure CD4 count,
and complete blood count (CBC). Blood specimen processing will be done by sites' local
laboratories. In the event that a blood specimen cannot be collected for any reason (e.g.,
vein is "dry", participant is lost to follow-up, etc.) or the result of a collected specimen
is not available (e.g., not enough specimen drawn, lab processing error, etc.), the study
team may abstract and use non-study lab results for the purpose of evaluating the HIV
virologic suppression outcome and measuring CD4 count and CBC. Participants randomized to
the intervention groups may also provide urine for drug screening.

Randomization:

Participants will be randomized in a 1:1:1 fashion to one of the 3 treatment groups.
Randomization will be stratified by site. The randomization procedure will be conducted in a
centralized process through the Data and Statistical Center (DSC2). After the baseline
assessment is successfully completed, a designated study staff member will perform the
randomization. Randomization for each participant is done over the Internet using the
Enrollment Module in AdvantageEDC (the study electronic data capture system).

Study Interventions:

The 3 treatment conditions/study groups are: 1) Patient Navigator intervention (PN), 2)
Patient Navigator plus Contingency Management (PN+CM) intervention and 3) Treatment as Usual
(TAU).

The patient navigator (PN) approach includes five functions: 1) establishing an effective
working relationship; 2) encouraging identification and use of strengths, abilities and
assets; 3) supporting client control over goal setting and the search for needed resources;
4) viewing the community as a resource and identifying informal sources of support; and 5)
conducting case management as an active community based activity. Specifically, patient
navigators will provide the following to all study participants randomized to the PN group:
1) four initial meetings, ideally having the first one during hospitalization and three
within the first 3 weeks of hospital discharge, and 2) after the initial four meetings,
patient navigators will meet with the PN group participants ideally twice monthly during
months 2 and 3 and once during months 4 - 6.

Study participants randomized to the patient navigator plus contingency management (PN+CM)
group will receive the patient navigation (PN) intervention as outlined above and in Section
11.2 of the sponsor protocol combine with contingency management (CM). For participants
randomly assigned to the PN+CM study group, patient navigators will: 1) effectively
communicate the incentive plan to the participant, 2) track each of the seven target
behaviors that may earn participant incentives, 3) verify occurrence of the target
behaviors, 4) deliver incentives according to the protocol, and 5) maintain a record of
incentives delivered.

Participants assigned to the treatment as usual (TAU) group will receive the standard
treatment provided at participating sites for linking patients to HIV and substance use
care.

Follow-up visits will be conducted at approximately 6- and 12-months post-randomization and
will involve follow-up CAPIs and blood collection.

Inclusion Criteria

Participating individuals must:

1. be admitted to a hospital and be HIV-infected at the time of recruitment

2. be at least 18 years old

3. meet one of the following: A) have an AIDS-defining illness during the current
hospital admission; or B) have the most recent CD4 count and viral load performed
within the past 6 months be <350 cells/uL and >200 copies/mL; or C) have the most
recent CD4 count and viral load performed within the past 12 months be <=500 cells/uL
and >200 copies/mL or unknown accompanied by the Site PI's discretion that the
patient a) is likely to currently have a viral load >200 copies/mL, b) is not
currently successfully/correctly taking antiretroviral therapy (ART) and c) needs to
be on ART

4. report (or have evidence in the medical record of) any opioid and/or stimulant and/or
heavy alcohol use within the past 12 months (Note: Medical record evidence may
consist of a) positive toxicology screen(s) for stimulants or heavy alcohol or b)
clinician notes indicating heavy use of alcohol, use of stimulants or non-prescribed
opioids or abuse of prescribed opioids.)

5. have a Karnofsky performance scale index score of >=60

6. provide informed consent

7. provide locator information

8. sign a HIPAA form / medical record release form to facilitate medical record
abstraction

9. report living in the vicinity and being able to return for follow-up visits

10. complete the baseline assessment, including blood draw

11. be able to communicate in English

Exclusion Criteria

Individuals will be excluded from the study if they:

1. do not meet any one or more of the above-described inclusion criteria

2. have significant cognitive or developmental impairment to the extent that they are
unable to provide informed consent

3. are terminated via Site PI decision with agreement from study Lead Investigator