Integrating a Resilience Framework to Assess Implementation of a Novel HIV Care Re-Engagement Model in NYC.

BACKGROUND: The Bottom Up Project, a collaboration of clinical, community, and academic partners, consists of 7 major steps that leverage a health information exchange, a system for sharing patient health information, with real-time alerts to mobilize peer outreach workers to find and re-engage persons with HIV disconnected from care. Bottom Up faced implementation challenges in its start-up phase and produced effective responses leading to Project maturation, which we explore using a novel implementation science framework incorporating resilience. METHODS: We conducted semistructured interviews with implementation staff (N = 6) and meeting minutes and protocols document reviews (N = 35). The Consolidated Framework for Implementation Research and a novel resilience framework guided thematic and process analyses. The resilience framework consisted of the following 3 resilience types: absorptive to cope with adversity, adaptive to adjust as short-term solutions, and transformative to structurally change. RESULTS: The Project experienced 20 major challenges, 2-5 challenges per step. Challenges were multilevel and of chronic and crisis intensities. Implementers overcame challenges by leveraging multilevel factors that were absorptive, adaptive (most common), and transformative. DISCUSSION: Bottom Up matured by practicing consistency and flexibility. The Project maintained core operations while under crisis-level stress by strategically simplifying or "downshifting" activities. Transformational responses suggest that specific initiatives can catalyze organizational change. CONCLUSIONS: Bottom Up implementation demonstrates using diverse tactics to respond to challenges, thereby shaping Project development and in turn organizations. Applying resilience to Consolidated Framework for Implementation Research helps build awareness of active and dynamic processes promoting or impeding the growth and success of intervention-oriented Projects.

Are Financial Incentives Appropriate Means of Encouraging Medication Adherence Among People Living With HIV?

BACKGROUND: Financial incentives have been shown to improve antiretroviral (ARV) adherence for people living with HIV, but scholars have argued that this commodifies treatment and have debated the ethics of doing so. This article summarizes research on ethical processes and factors involved in an intervention that successfully improved ARV adherence among socially vulnerable people living with HIV. METHODS: Thirty qualitative interviews were conducted with intervention participants and field notes documenting organizational processes were analyzed. The protocol utilized a preexisting framework to assess the ethics of using financial incentives to motivate adherence. RESULTS: Financial incentives supported an ethical service provision framework by (1) establishing and strengthening client agency, (2) revising organizational protocols to prioritize adherence, and (3) promoting resource redistribution. CONCLUSIONS: Financial incentives, when embedded in wrap-around services, innovative client-centered organizational processes, and a justice orientation, constitute an ethical intervention requiring ethical investigation.

Integrating Financial Incentives for Viral Load Suppression into HIV Care Coordination Programs: Considerations for Development and Implementation.

CONTEXT: Interventions that support durable viral load suppression (VLS) among people living with HIV (PLWH) who face barriers to treatment adherence are needed to maintain optimal individual health, prevent new HIV infections, and advance health equity. Efficacy trials indicate that financial incentives (FIs) are a promising strategy for promoting VLS, although less is known about their implementation in "real-world" settings. This article describes considerations for the development and implementation of FI interventions identified in existing literature, and how they informed the scale-up of a multilevel treatment adherence support program designed to increase VLS among PLWH in New York City. PROGRAM: The Undetectables VLS Program comprises a social marketing campaign and a "tool kit" of evidence-based HIV treatment adherence strategies, including quarterly FIs ($100) that patients receive for achieving or maintaining an undetectable viral load (<200 copies/mL; also referred to as VLS). The intervention was developed and pilot tested by Housing Works Community Healthcare and the University of Pennsylvania from 2014 to 2016. Initial findings from the pilot evaluation showed a statistically significant positive effect on VLS. IMPLEMENTATION: The New York City Department of Health and Mental Hygiene contracted with 7 agencies across New York City to scale up The Undetectables Program over a 3-year period (2016-2019) by integrating the program into existing services for PLWH. EVALUATION PLANS: Quality indicators (eg, percentage of clients who received an FI each quarter; percentage of clients who were virally suppressed at 90 days postenrollment) will be used to measure program performance and impact over time. DISCUSSION: Recommendations for implementing FIs for PLWH include packaging FIs with client-centered, evidence-based adherence strategies, incorporating FIs into existing service delivery systems, and obtaining organization-wide buy-in to facilitate their implementation. Implementation science research is needed to identify strategies to effectively implement and sustain evidence-based FI interventions.

Effectiveness of a Viral Load Suppression Intervention for Highly Vulnerable People Living with HIV.

We examine the effect of the Undetectables Intervention (UI) on viral loads among socially vulnerable HIV-positive clients. The UI utilized a toolkit that included financial incentives, graphic novels, and community-based case management services. A pre-post repeated measures analysis (n = 502) through 4 years examined longitudinal effects of the intervention. Logistic models regressed social determinants on viral loads. Finally, in-depth qualitative interviews (n = 30) examined how UI shaped adherence. The proportion of virally suppressed time-points increased 15% (from 67 to 82% pre to post-enrollment, p < 0.0001). The proportion of the sample virally suppressed at all time-points increased by 23% (from 39 to 62% pre to post-enrollment, p < 0.0001). African Americans and the homeless were the most likely to be unsuppressed at baseline, but, along with substance users, benefitted the most from UI. The intervention shaped adherence through two pathways, by: (1) establishing worth around adherence, and (2) increasing motivation to become suppressed, and maintain adherence.

"It's my Room and my Life": Housing's Influence on Medication Adherence for HIV-positive Women Released from Incarceration.

A high prevalence of homelessness among women with HIV released from incarceration (WHRI) poses significant challenges to antiretroviral therapy. This research examines the pathways through which housing shapes adherence for previously homeless WHRI. In-depth semi-structured interviews were conducted with 43 WHRI in a supportive transitional housing program. Interviews were analyzed using grounded theory. Housing triggered subjective and material processes that increased adherence. Subjectively, housing increased empowerment, boosted cognitive and emotional re-engagement with post-carceral life, and established health-seeking behavior norms. Materially, housing increased reintegration into community life, reduced exposure to chaos and risk, and increased access to services. Our results suggest how a modified Theory of Planned Behavior (TPB) framework explains adherence by exploring subjective and material facets of TPB. Attitudes were described by subjective re-engagement and material reintegration; norms were established through subjective meaning-making and engagement in services; self-efficacy improved through subjective empowerment and reduction in the material risk environment.

Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review.

BACKGROUND: Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking "upstream" economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual's control that affect housing and residential environments and the health resources or risk exposures such contexts provide. OBJECTIVES: We examined the available empirical evidence on the association between housing status (broadly defined), medical care, and health outcomes among people with HIV and analyzed results to inform future research, program development, and policy implementation. SEARCH METHODS: We searched 8 electronic health and social science databases from January 1, 1996, through March 31, 2014, using search terms related to housing, dwelling, and living arrangements and HIV and AIDS. We contacted experts for additional literature. SELECTION CRITERIA: We selected articles if they were quantitative analyses published in English, French, or Spanish that included at least 1 measure of housing status as an independent variable and at least 1 health status, health care, treatment adherence, or risk behavior outcome among people with HIV in high-income countries. We defined housing status to include consideration of material or social dimensions of housing adequacy, stability, and security of tenure. DATA COLLECTION AND ANALYSIS: Two independent reviewers performed data extraction and quality appraisal. We used the Cochrane Risk of Bias Tool for randomized controlled trials and a modified version of the Newcastle Ottawa Quality Appraisal Tool for nonintervention studies. In our quality appraisal, we focused on issues of quality for observational studies: appropriate methods for determining exposure and measuring outcomes and methods to control confounding. RESULTS: Searches yielded 5528 references from which we included 152 studies, representing 139,757 HIV-positive participants. Most studies were conducted in the United States and Canada. Studies examined access and utilization of HIV medical care, adherence to antiretroviral medications, HIV clinical outcomes, other health outcomes, emergency department and inpatient utilization, and sex and drug risk behaviors. With rare exceptions, across studies in all domains, worse housing status was independently associated with worse outcomes, controlling for a range of individual patient and care system characteristics. CONCLUSIONS: Lack of stable, secure, adequate housing is a significant barrier to consistent and appropriate HIV medical care, access and adherence to antiretroviral medications, sustained viral suppression, and risk of forward transmission. Studies that examined the history of homelessness or problematic housing years before outcome assessment were least likely to find negative outcomes, homelessness being a potentially modifiable contextual factor. Randomized controlled trials and observational studies indicate an independent effect of housing assistance on improved outcomes for formerly homeless or inadequately housed people with HIV. Housing challenges result from complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health. The broad structural processes sustaining social exclusion and inequality seem beyond the immediate reach of HIV interventions, but changing housing and residential environments is both possible and promising.

Surviving the aftershock: postearthquake access and adherence to HIV treatment among Haiti's tent residents.

In this research we examined how the conditions of Haiti's tent communities, inhabited by those displaced by the January 10, 2010, earthquake, shaped access and adherence to highly active antiretroviral treatment (HAART) for Haitians with HIV. Conditions in the encampments were marked by unhygienic and cramped living spaces, exposure to the elements, a lack of privacy, unavailability of food and clean water, and a dependence on poorly functioning aid agencies. These conditions shaped access and adherence to HAART by (a) exacerbating the stigma of being HIV positive and undermining mental health; (b) presenting logistical challenges to accessing medical care, storing pills, and ingesting them safely and privately; and (c) sustaining a political economy of aid characterized by unequal treatment in major HAART-dispensing centers, unequal circulation of international funds, and the emergence of alternative medical institutions within encampments that could improve future treatment. Policy and intervention implications are discussed.

Moving from fact to policy: housing is HIV prevention and health care.

A growing body of empirical evidence shows strong correlations between improved housing status and reduced HIV risk behaviors, improved access to health care for persons living with HIV/AIDS, and better health outcomes. These findings support the provision of housing assistance for low-income persons living with HIV/AIDS: as a basic human right; as a necessary component of systems to enable individuals to manage their HIV/AIDS care and treatment; and as an exciting new tool to end the AIDS crisis in America by reducing the number of new HIV infections. This paper provides a public policy framework for consideration of the research reported in this special issue of AIDS and Behavior, and offers suggestions for using research to move policy and practice towards a true public health response to the housing needs of persons at risk for or living with HIV/AIDS.