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Project Engage: Snowball Sampling and Direct Recruitment to Identify and Link Hard-to-Reach HIV-Infected Persons Who Are Out of Care

Wohl, Amy Rock MPH, PhD*; Ludwig-Barron, Natasha MPH*; Dierst-Davies, Rhodri MPH, PhD*; Kulkarni, Sonali MD, MPH*; Bendetson, Jesse BA*; Jordan, Wilbert MD; Bolan, Robert MD; Smith, Terry MPA§; Cunningham, William MD; Pérez, Mario J. MPH*

JAIDS Journal of Acquired Immune Deficiency Syndromes: June 1st, 2017 - Volume 75 - Issue 2 - p 190–197
doi: 10.1097/QAI.0000000000001312
Implementation Science

Introduction: Innovative strategies are needed to identify and link hard-to-find persons living with HIV (PLWH) who are out of care (OOC). Project Engage, a health department–based project in Los Angeles County, used a mixed-methods approach to locate and provide linkage for PLWH who have limited contact with HIV medical and nonmedical services.

Methods: Incentivized social network recruitment (SNR) and direct recruitment (DR) was used to identify eligible OOC alters for a linkage intervention that included HIV clinic selection, appointment and transportation support, reminder calls/texts, and clinic navigation.

Results: Between 2012 and 2015, 112 alters were identified using SNR (n = 74) and DR (n = 38). Most alters were male (80%), African American (38%), and gay (60%). Sizable percentages were homeless (78%), had engaged in sex work (32%) in the previous 6 months, had injected drugs (47%), were incarcerated in the previous 12 months (50%), and had only received HIV care during the previous 5 years while incarcerated (24%). SNR alters were more likely than DR alters to be African American, uninsured, unemployed, homeless, sex workers, injection drug users, recently incarcerated, and have unmet service needs. Alters linked to care within 3 (69%), 4–6 (5%), and 7–12 months (8%), and 72% were retained at 6–12 months. The percent virally suppressed increased (27% vs. 41%) and the median viral load decreased (P = 0.003) between linkage and follow-up at 6–12 months.

Discussion: The alternative approaches presented were effective at locating marginalized HIV-positive persons who are OOC for linkage and retention. The SNR approach was most successful at identifying alters with serious social challenges and gaps in needed medical/ancillary services.

*Division of HIV and STD Programs, Los Angeles County Department of Public Health, Los Angeles, CA;

OASIS Clinic, MLK-OC, Los Angeles, CA;

LA LGBT Center, Los Angeles, CA;

§AIDS Project Los Angeles, Los Angeles, CA; and

UCLA Department of Medicine and School of Public Health, Los Angeles, CA.

Correspondence to: Amy R. Wohl, MPH, PhD, Division of HIV and STD Programs, Los Angeles County Department of Public Health, 600 S. Commonwealth Avenue, Suite 1920, Los Angeles, CA 90005 (e-mail:

Supported by California HIV/AIDS Research Program and US Centers for Disease Control and Prevention.

Presented at the Conferences in IAPAC, June 8–10, 2014, Miami FL; APHA, November 15–19, 2014, New Orleans, LA; National HIV Prevention Conference, December 6–9, 2015, Atlanta, GA.

The authors have no conflicts of interest to disclose.

Received July 01, 2016

Accepted January 17, 2017

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