Rapid start antiretroviral therapies for improved engagement in HIV care: implementation science evaluation protocol.

BACKGROUND: In 2020, the Health Resources and Services Administration's HIV/AIDS Bureau funded an initiative to promote implementation of rapid antiretroviral therapy initiation in 14 HIV treatment settings across the U.S. The goal of this initiative is to accelerate uptake of this evidence-based strategy and provide an implementation blueprint for other HIV care settings to reduce the time from HIV diagnosis to entry into care, for re-engagement in care for those out of care, initiation of treatment, and viral suppression. As part of the effort, an evaluation and technical assistance provider (ETAP) was funded to study implementation of the model in the 14 implementation sites. METHOD: The ETAP has used implementation science methods framed by the Dynamic Capabilities Model integrated with the Conceptual Model of Implementation Research to develop a Hybrid Type II, multi-site mixed-methods evaluation, described in this paper. The results of the evaluation will describe strategies associated with uptake, implementation outcomes, and HIV-related health outcomes for patients. DISCUSSION: This approach will allow us to understand in detail the processes that sites to implement and integrate rapid initiation of antiretroviral therapy as standard of care as a means of achieving equity in HIV care.

Outcomes and costs of publicly funded patient navigation interventions to enhance HIV care continuum outcomes in the United States: A before-and-after study.

BACKGROUND: In the United States, patients with HIV face significant barriers to linkage to and retention in care which impede the necessary steps toward achieving the desired clinical outcome of viral suppression. Individual-level interventions, such as patient navigation, are evidence based, effective strategies for improving care engagement. In addition, use of surveillance and clinical data to identify patients who are not fully engaged in care may improve the effectiveness and cost-effectiveness of these programs. METHODS AND FINDINGS: We employed a pre-post design to estimate the outcomes and costs, from the program perspective, of 5 state-level demonstration programs funded under the Health Resources and Services Administration's Special Projects of National Significance Program (HRSA/SPNS) Systems Linkages Initiative that employed existing surveillance and/or clinical data to identify individuals who had never entered HIV care, had fallen out of care, or were at risk of falling out of care and navigation strategies to engage patients in HIV care. Outcomes and costs were measured relative to standard of care during the first year of implementation of the interventions (2013 to 2014). We followed patients to estimate the number and proportion of additional patients linked, reengaged, retained, and virally suppressed by 12 months after enrollment in the interventions. We employed inverse probability weighting to adjust for differences in patient characteristics across programs, missing data, and loss to follow-up. We estimated the additional costs expended during the first year of each intervention and the cost per outcome of each intervention as the additional cost per HIV additional care continuum target achieved (cost per patient linked, reengaged, retained, and virally suppressed) 12 months after enrollment in each intervention. In this study, 3,443 patients were enrolled in Louisiana (LA), Massachusetts (MA), North Carolina (NC), Virginia (VA), and Wisconsin (WI) (147, 151, 2,491, 321, and 333, respectively). Patients were a mean of 40 years old, 75% male, and African American (69%) or Caucasian (22%). At baseline, 24% were newly diagnosed, 2% had never been in HIV care, 45% had fallen out of care, and 29% were at risk of falling out of care. All 5 interventions were associated with increases in the number and proportion of patients with viral suppression [percent increase: LA = 90.9%, 95% confidence interval (CI) = 88.4 to 93.4; MA = 78.1%, 95% CI = 72.4 to 83.8; NC = 47.5%, 95% CI = 45.2 to 49.8; VA = 54.6, 95% CI = 49.4 to 59.9; WI = 58.4, 95% CI = 53.4 to 63.4]. Overall, interventions cost an additional $4,415 (range = $3,746 to $5,619), $2,009 (range = $1,516 to $2,274), $920 (range = $627 to $941), $2,212 (range = $1,789 to $2,683), and $3,700 ($2,734 to $4,101), respectively per additional patient virally suppressed. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess patients against themselves at baseline and not against standard of care during the same time period. CONCLUSIONS: Patient navigation programs were associated with improvements in engagement of patients in HIV care and viral suppression. Cost per outcome was minimized in states that utilized surveillance data to identify individuals who were out of care and/or those that were able to identify a larger number of patients in need of improvement at baseline. These results have the potential to inform the targeting and design of future navigation-type interventions.

Health information technology interventions and engagement in HIV care and achievement of viral suppression in publicly funded settings in the US: A cost-effectiveness analysis.

BACKGROUND: The US National HIV/AIDS Strategy (NHAS) emphasizes the use of technology to facilitate coordination of comprehensive care for people with HIV. We examined cost-effectiveness from the health system perspective of 6 health information technology (HIT) interventions implemented during 2008 to 2012 in a Ryan White HIV/AIDS Program (RWHAP) Special Projects of National Significance (SPNS) Program demonstration project. METHODS/FINDINGS: HIT interventions were implemented at 6 sites: Bronx, New York; Durham, North Carolina; Long Beach, California; New Orleans, Louisiana; New York, New York (2 sites); and Paterson, New Jersey. These interventions included: (1) use of HIV surveillance data to identify out-of-care individuals; (2) extension of access to electronic health records (EHRs) to support service providers; (3) use of electronic laboratory ordering and prescribing; and (4) development of a patient portal. We employed standard microcosting techniques to estimate costs (in 2018 US dollars) associated with intervention implementation. Data from a sample of electronic patient records from each demonstration site were analyzed to compare prescription of antiretroviral therapy (ART), CD4 cell counts, and suppression of viral load, before and after implementation of interventions. Markov models were used to estimate additional healthcare costs and quality-adjusted life-years saved as a result of each intervention. Overall, demonstration site interventions cost $3,913,313 (range = $287,682 to $998,201) among 3,110 individuals (range = 258 to 1,181) over 3 years. Changes in the proportion of patients prescribed ART ranged from a decrease from 87.0% to 72.7% at Site 4 to an increase from 74.6% to 94.2% at Site 6; changes in the proportion of patients with 0 to 200 CD4 cells/mm3 ranged from a decrease from 20.2% to 11.0% in Site 6 to an increase from 16.7% to 30.2% in Site 2; and changes in the proportion of patients with undetectable viral load ranged from a decrease from 84.6% to 46.0% in Site 1 to an increase from 67.0% to 69.9% in Site 5. Four of the 6 interventions-including use of HIV surveillance data to identify out-of-care individuals, use of electronic laboratory ordering and prescribing, and development of a patient portal-were not only cost-effective but also cost saving ($6.87 to $14.91 saved per dollar invested). In contrast, the 2 interventions that extended access to EHRs to support service providers were not effective and, therefore, not cost-effective. Most interventions remained either cost-saving or not cost-effective under all sensitivity analysis scenarios. The intervention that used HIV surveillance data to identify out-of-care individuals was no longer cost-saving when the effect of HIV on an individual's health status was reduced and when the natural progression of HIV was increased. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess sites against themselves at baseline and not against standard of care during the same time period. CONCLUSIONS: These results provide additional support for the use of HIT as a tool to enhance rapid and effective treatment of HIV to achieve sustained viral suppression. HIT has the potential to increase utilization of services, improve health outcomes, and reduce subsequent transmission of HIV.

Modified Antiretroviral Treatment Access Study (MARTAS): A Randomized Controlled Trial of the Efficacy of a Linkage-to-Care Intervention Among HIV-Positive Patients in Ukraine.

Between October 2015 and March 2018, we conducted the Modified Antiretroviral Treatment Access Study (MARTAS), a nurse-delivered case management intervention to improve linkage-to-care for persons recently tested HIV positive. Adult participants from nine urban clinics in three regions of Ukraine were randomized to either MARTAS or standard of care (SOC) using individual, parallel, two-arm design. The main study outcome was linkage-to-care (defined as registration at an HIV clinic) within a 3-month period from enrollment in the study. Intention-to-treat analysis of MARTAS (n = 135) versus SOC (n = 139) showed intervention efficacy in linkage to HIV care (84.4% vs. 33.8%; adjusted RR 2.45; 95% CI 1.72, 3.47; p < 0.001). MARTAS is recommended for implementation in Ukraine and may be helpful in other countries with similar gaps in linkage-to-care. Clinicaltrials.gov registration number: NCT02338024.

"I don't have to do this all by myself": Systems Navigation to Ensure Continuity of HIV Care for Persons Leaving Prison.

Ensuring continuity of and retention in care after release from prison is critical for optimizing health outcomes among people living with HIV. As part of a large federal initiative, we conducted qualitative interviews (n = 24) with individuals living with HIV and recently released from prison in four states to understand their experiences in different navigation interventions to improve access to HIV care post-release. Interventions were delivered only in prison, only in the community, or in both settings. While the interventions varied by design, overall, participants appreciated the breadth of support received from interventionists, including health system navigation, case management and social support. Even when individuals leaving prison were returning to clinics that they were familiar with, systems navigation supported continuity of care. Our findings elucidate why navigational support was instrumental, and underscore the value of a variety of types of navigation programs in facilitating continuity of care and reintegration post-prison.

"Closing the Loop" Developing State-Level Data Sharing Interventions to Promote Optimum Outcomes Along the HIV Continuum of Care.

This manuscript describes the experiences of three state departments of health (SDoH) that successfully launched data sharing interventions involving surveillance and/or patient data collected in clinics to improve care outcomes among people living with HIV. We examined 58 key informant interviews, gathered at two time points, to describe the development and implementation of data sharing interventions. We identified three common themes across states' experiences: creating standard practices, fostering interoperability, and negotiating the policy environment. Projects were successful when state teams adapted to changing circumstances and were committed to a consistent communication process. Once implemented, the interventions streamlined processes to promote linkage and retention in care among low-income populations living with HIV. Despite using routinely collected data, key informants emphasized the labor-intensive process to develop and sustain the interventions. Lessons learned from these three state experiences can help inform best practices for other SDoH that are considering launching similar interventions.

The Effect of Patient Navigation on the Likelihood of Engagement in Clinical Care for HIV-Infected Individuals Leaving Jail.

OBJECTIVES: To compare the effectiveness of patient navigation-enhanced case management in supporting engagement in HIV care upon release from jail relative to existing services. METHODS: We randomized 270 HIV-infected individuals to receive navigation-enhanced case management for 12 months or standard case management for 90 days following release from jail between 2010 and 2013. Participants were interviewed at 2, 6, and 12 months after release. We abstracted medical data from jail and city health records. RESULTS: Patient navigation-enhanced case management resulted in greater linkage to care within 30 days of release (odds ratio [OR] = 2.15; 95% confidence interval [CI] = 1.23, 3.75) and consistent retention over 12 months (OR = 1.95; 95% CI = 1.11, 3.46). Receipt of treatment for substance use disorders in jail also resulted in early linkage (OR = 4.06; 95% CI = 1.93, 8.53) and retention (OR = 2.52; 95% CI = 1.21, 5.23). Latinos were less likely to be linked to (OR = 0.35; 95% CI = 0.14, 0.91) or retained in (OR = 0.28; 95% CI = 0.09, 0.82) HIV care. CONCLUSIONS: Patient navigation supports maintaining engagement in care and can mitigate health disparities, and should become the standard of care for HIV-infected individuals leaving jail.

Impact of AIDS Education and Training Centers on the US HIV Medical Workforce.

OBJECTIVES: To examine the extent to which the AIDS Education and Training Centers (AETCs) are increasing the number and racial/ethnic diversity of HIV medical providers, in accordance with the US National HIV/AIDS Strategy (NHAS). METHODS: We used administrative data from funding year 2012-2013 to describe AETC trainee characteristics, including the types of medical providers trained, compared with national estimates of available US medical providers to estimate the proportion of providers trained for every 1000 available providers by professional group and race/ethnicity. RESULTS: AETCs trained 56 127 unique trainees, of whom 64.1% were medical providers and 45.5% were racial/ethnic minorities. Compared to national proportions, participation in AETC training was higher among racial/ethnic minorities. The proportions of racial/ethnic minority groups trained differed across regional AETCs. CONCLUSIONS: AETCs support NHAS goals by expanding the HIV medical workforce and strengthening the skills of minority medical providers to deliver high quality HIV care. Public Health Implications. Some AETCs made greater contributions to training different types of racial/ethnic minorities, which indicates varied approaches are needed to best target these efforts in communities heavily impacted by HIV.

Recall of Nadir CD4 Cell Count and Most Recent HIV Viral Load Among HIV-Infected, Socially Marginalized Adults.

Lower nadir CD4 cell counts and higher HIV viral loads are associated with increased risks of adverse events in the progression of HIV disease. In cases where medical records are inaccessible or incomplete, little evidence is available regarding whether nadir CDR cell count or HIV viral load is reliably reported in any patient population. We compare survey data collected from 207 HIV-infected individuals detained in San Francisco jails to data collected from electronic medical records (EMR) kept by the jails and community health providers. The sensitivity of self-reported nadir CD4 cell count less than 200 was 82 % [95 % confidence interval (CI) 68, 88], and the sensitivity of reporting an undetectable most recent HIV viral load was 93 % (95 % CI 84, 97). This suggests that in a highly socially marginalized population, nadir CD4 cell count and most recent HIV viral load are recalled accurately when compared to EMR.

eHealth-Enhanced Peer Navigation for Substance Use Treatment and HIV Prevention Service Linkage for Young Adults Surveilled by the Criminal Legal System: Protocol for a Pilot Randomized Trial Study.

BACKGROUND: In the United States, the proportion of criminal legal-involved (CLI) adults with a substance use disorder reaches 72%, and ~150,000 persons with HIV pass through a carceral setting annually, which represents 16% of the HIV-infected population nationally. Despite the high need for substance use treatment and HIV prevention services, few carceral settings successfully link CLI individuals to treatment upon release. Young adults represent 41.9% of the adults incarcerated in the United States and have the highest HIV incidence rates nationally. Peer patient navigation has successfully increased community-based care linkage for people living with HIV leaving jail; yet, peer-led navigation for HIV prevention among HIV-negative CLI populations is undeveloped and untested. eHealth approaches to substance use and HIV prevention services hold promise because they improve access to effective intervention services, particularly for younger people. OBJECTIVE: This paper describes a protocol for a pilot randomized controlled trial that aims to improve linkage to substance use treatment and HIV prevention services using peer navigation and a codeveloped eHealth technology adjunct. METHODS: The three aims of this study are to (1) adapt an existing evidence-based navigator model and incorporate codeveloped eHealth technology to refer and link young adults (18 to 29 years) surveilled by the criminal legal system to substance use and pre-exposure prophylaxis (PrEP) services; (2) refine and test the intervention with criminal legal-involved young adults (CLI-YAs); and (3) assess the feasibility, acceptability, and impact of the intervention. Data to inform the intervention will be collected via system partner interviews (n=4) and focus groups with CLI-YAs (n=24). Next, an open trial (n=10) will be conducted. The intervention will be refined via interviews with participants and facilitators, and a randomized pilot trial (n=75) will be conducted to assess the feasibility, acceptability, and preliminary impact of the eHealth-enhanced navigation on substance use and PrEP services linkage. Exit interviews conducted with a subsample of intervention participants (n=10), the navigator (n=1), and system partners (n=4) will assess intervention acceptability and suggestions for improvement. A community of practice, a group of system partners with an interest in working toward solutions to common problems, will inform each phase of the study. RESULTS: The project is currently ongoing. The project was funded in September 2022. Internal review board approval was received on March 21, 2022. The first results from early study aims are expected to be published in 2025. CONCLUSIONS: This study provides an opportunity to reduce HIV acquisition and improve access to substance use treatment in a systemically marginalized group: young CLI-YAs. The results will contribute to the development and testing of a future multilevel randomized controlled trial. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54815.

Helping clinicians deliver consistent HIV prevention counseling to their HIV-infected patients.

The delivery of HIV risk assessment and behavioral counseling by clinicians in HIV clinical settings is one component in a comprehensive "positive prevention" strategy to help patients reduce their transmission risk behavior. Clinicians engage in behavioral prevention inconsistently, however, depending on whether patients are new to a practice or are established in regular care and on their attitudes and characteristics of their practices. We analyzed clinician reports of behavioral prevention delivered before and after participation in a large federal demonstration project of positive prevention interventions. The interventions that were part of this project were successful in increasing behavioral prevention among both new and returning patients. Prior to study interventions, clinicians reported counseling 69% of new patients and 52% of returning patients. In follow-up interviews 12 months after receiving training, clinicians reported delivering prevention messages to 5% more new patients and 9% of returning patients (both p<0.01). After 12 months, clinicians were more likely to engage in behavioral prevention if other providers in their sites were also involved. Clinicians agreeing that behavioral prevention was part of the clinic's mission were more likely to conduct it. The interventions were successful in mitigating the influence of provider attitudes precluding prevention delivery. Intervention strategies can help clinicians more consistently deliver behavioral prevention messages to their HIV-infected patients.

HIV Disclosure Practices to Family Among Mexican and Puerto Rican Sexual Minority Men with HIV in the Continental USA: Intersections of Sexual Orientation and HIV Stigma.

Disclosing a seropositive HIV status still is a complex process of assessing the risks, benefits, and potential personal and interpersonal outcomes associated with disclosure, such as stigma, rejection, or emotional support. We examined HIV disclosure practices to family and intersectional stigma related to HIV and sexual orientation among Latino sexual minority men (LSMM) of Mexican and Puerto Rican origin with HIV in the continental USA. Guided by Framework Analysis, we present data from 54 interviews with 33 LSMM participants in HIV care engagement interventions, and 21 project staff implementing the interventions. LSMM disclosed their HIV status to family seeking support. They applied stigma management techniques to manage the information communicated to family about their HIV status, including selective disclosure to some family members, conveying strategic information about the significance of having HIV, non-disclosure, or partial disclosure, silence and deceptions. LSMM HIV disclosure practices to family encompassed appraisals of intersectional stigma related to their sexual orientation and HIV, assessing the potential outcomes of disclosure, and the preservation of family ties.

"It Comes in Steps and Stages": Experiences of People Living with HIV in Achieving Employment.

People living with HIV who are seeking jobs experience unique barriers to obtaining employment at the individual, group, and community levels. Traditional employment assistance programs can provide support but may not be tailored to some people living with HIV who often experience barriers to work related to their social needs (such as housing instability) or their lack of consistent engagement in the workforce. To understand how people living with HIV return to work, in-depth interviews were conducted with 43 participants enrolled in interventions coordinating HIV care with housing and employment services at eight sites across the US. Four themes emerged on strategies to increase employment: (1) assessing and responding to employment needs that align with their socio-economic environment; (2) using social networks among family and friends for referrals and support; (3) engaging with navigators who are able to connect clients to skills building opportunities and job resources; and (4) addressing the system barriers such as helping with unmet basic needs (e.g. transportation), finding employers who can accommodate workers with income limits associated with public benefits, and helping immigrants, transgender individuals, and people experiencing homelessness secure legal documentsthat facilitate entry into employment by reducing stigmatized identities.

Impact of San Francisco's New Street crisis response Team on Service use among people experiencing homelessness with mental and substance use disorders: A mixed methods study protocol.

Mobile crisis services for people experiencing distress related to mental health or substance use are expanding rapidly across the US, yet there is little evidence to support these specific models of care. These new programs present a unique opportunity to expand the literature by utilizing implementation science methods to inform the future design of crisis systems. This mixed methods study will examine the effectiveness and acceptability of the Street Crisis Response Team (SCRT), a new 911-dispatched multidisciplinary mobile crisis intervention piloted in San Francisco, California. First, using quantitative data from electronic health records, we will conduct an interrupted time series analysis to quantitatively examine the impacts of the SCRT on people experiencing homelessness who utilized public behavioral health crisis services in San Francisco between November 2019 and August 2022, across four main outcomes within 30 days of the crisis episode: routine care utilization, crisis care reutilization, assessment for housing services, and jail entry. Second, to understand its impact on health equity, we will analyze racial and ethnic disparities in these outcomes prior to and after implementation of the SCRT. For the qualitative component, we will conduct semi-structured interviews with recipients of the SCRT's services to understand their experiences of the intervention and to identify how the SCRT influenced their health-related trajectories after the crisis encounter. Once complete, the quantitative and qualitative findings will be further analyzed in tandem to assist with more nuanced understanding of the effectiveness of the SCRT program. This evaluation of a novel mobile crisis response program will advance the field, while also providing a model for how real-world program implementation can be achieved in crisis service settings.

Supporting the integration of HIV testing into primary care settings.

OBJECTIVES: We examined the efforts of the US network of AIDS Education and Training Centers (AETCs) to increase HIV testing capacity across a variety of clinical settings. METHODS: We used quantitative process data from 8 regional AETCs for July 1, 2008, to June 30, 2009, and qualitative program descriptions to demonstrate how AETC education helped providers integrate HIV testing into routine clinical care with the goals of early diagnosis and treatment. RESULTS: Compared with other AETC training, HIV testing training was longer and used a broader variety of strategies to educate more providers per training. During education, providers were able to understand their primary care responsibility to address public health concerns through HIV testing. CONCLUSIONS: AETC efforts illustrate how integration of the principles of primary care and public health can be promoted through professional training.

Messages HIV clinicians use in prevention with positives interventions.

Prevention with Positives (PwP) is a component of the US HIV prevention strategy that targets HIV-infected persons who are aware of their seropositive status. This paper examines the use of prevention messages by clinical providers during the PwP intervention period of the US Health Resources and Services Administration's Special Projects of National Significance program. Quantitative approaches were used to learn which prevention topics were most discussed and qualitative interviews were also utilized to better understand the clinician perspective in providing prevention counseling. At 12-month follow-up, there was a significant increase in the percent of patients receiving all PwP counseling messages (p<0.01). Providers reported discussing safer sex with 91% of patients when sexually transmitted infection (STI) screening was conducted during a visit, an increase from baseline (83.5%). The percent of providers reporting they regularly explained the risk of superinfection to their clients also increased from 75% at baseline to 90% at 12-month follow up (p<0.001). Qualitative data suggest that providers prioritize individual care over public health approaches to PwP in counseling. Discussing superinfection offered providers a way to discuss HIV prevention from a non-judgmental clinical perspective while focusing on a patient-centered philosophy of care. However, the threat of superinfection may not be the best counseling option. Examples such as STI screening, giving messages to reduce the number of sexual partners and adherence to medication, are more evidence-based approaches to changing HIV transmission risk behavior and may be more important in PwP. Findings suggest that in order for HIV care providers to incorporate HIV prevention discussions into their practice, acceptable approaches to speaking about risk behavior and prevention of HIV transmission must be developed.

Understanding patient acceptance and refusal of HIV testing in the emergency department.

BACKGROUND: Despite high rates of patient satisfaction with emergency department (ED) HIV testing, acceptance varies widely. It is thought that patients who decline may be at higher risk for HIV infection, thus we sought to better understand patient acceptance and refusal of ED HIV testing. METHODS: In-depth interviews with fifty ED patients (28 accepters and 22 decliners of HIV testing) in three ED HIV testing programs that serve vulnerable urban populations in northern California. RESULTS: Many factors influenced the decision to accept ED HIV testing, including curiosity, reassurance of negative status, convenience, and opportunity. Similarly, a number of factors influenced the decision to decline HIV testing, including having been tested recently, the perception of being at low risk for HIV infection due to monogamy, abstinence or condom use, and wanting to focus on the medical reason for the ED visit. Both accepters and decliners viewed ED HIV testing favorably and nearly all participants felt comfortable with the testing experience, including the absence of counseling. While many participants who declined an ED HIV test had logical reasons, some participants also made clear that they would prefer not to know their HIV status rather than face psychosocial consequences such as loss of trust in a relationship or disclosure of status in hospital or public health records. CONCLUSIONS: Testing for HIV in the ED as for any other health problem reduces barriers to testing for some but not all patients. Patients who decline ED HIV testing may have rational reasons, but there are some patients who avoid HIV testing because of psychosocial ramifications. While ED HIV testing is generally acceptable, more targeted approaches to testing are necessary for this subgroup.

Supporting Community Partners in Reducing HIV-Related Health Disparities: Technical Assistance Across a Spectrum of Intensity.

The HIV epidemic remains a public health threat in the U.S., and the dissemination and implementation of evidence-based prevention and care programs are critical to addressing significant HIV health disparities. The provision of technical assistance (TA) to program providers and evaluators is key for uptake of these programs. The University of California San Francisco Prevention Research Center (UCSF PRC) model for TA delivery uses topics and strategies adapted to address HIV health disparities for a global audience. This model specifically matches TA requests to a TA provider who has expertise in that area upon receiving a request through various communication channels. Areas of expertise include research methods, community engagement strategies, interventions, and Implementation Sciences. Our evaluation of diverse TA services indicates that on-demand TA is effective for light-touch requests and well-suited for moderate to intensive requests. The model is a promising, broad-reaching, and responsive alternative for providing TA to a multitude of HIV workforce recipients.

Key Elements and Mechanisms of a Peer-Support Intervention to Reduce Loneliness and Isolation among Low-Income Older Adults: A Qualitative Implementation Science Study.

This paper describes the evaluation of a longitudinal peer-support program developed to address loneliness and isolation among low-income, urban community-dwelling older adults in San Francisco. Our objective was to determine barriers, challenges, and successful strategies in implementation of the program. In-depth qualitative interviews with clients (n = 15) and peers (n = 6) were conducted and analyzed thematically by program component. We identified barriers and challenges to engagement and outlined strategies used to identify clients, match them with peers, and provide support to both peers and clients. We found that peers played a flexible, non-clinical role and were perceived as friends. Connections to community resources helped when clients needed additional support. We also documented creative strategies used to maintain inter-personal connections during the COVID-19 pandemic. This study fills a gap in understanding how a peer-support program can be designed to address loneliness and social isolation, particularly in low-income, urban settings.