Promoting Sustained Viral Suppression Through Implementation of an Adapted Evidence-Informed Low-Barrier Care Model in a System of HIV Primary Care Clinics

The goal to end the HIV epidemic (EHE) in the United States cannot be achieved if people with HIV (PWH) do not achieve sustained viral suppression (VS). However, more than half of PWH in the US do not receive regular HIV care, due largely to social and structural factors like stigma and discrimination, poverty, and care complexity, as well as conditions like mental health and substance abuse. Additional approaches to care delivery, especially for PWH experiencing compounding barriers, are needed to close the gap in sustained care and VS. Low-barrier care (LBC) is a package of implementation and care engagement strategies developed specifically to address barriers experienced by PWH with complex needs and has been shown to significantly improve VS among this population. The original model of standalone LBC clinics, however, may have challenges in scalability due to feasibility and limited reach to PWH within large areas. In contrast, adapting LBC strategies for integration into existing HIV primary care sites has the potential to facilitate greater use of this promising model of HIV care while also engaging more PWH with unaddressed needs. The overarching goal of this proposal is to evaluate the implementation and effectiveness of adapted LBC strategies in a system of 12 HIV population-centered health homes (PCHHs) funded by the Chicago Department of Public Health (CDPH) using a pragmatic trial design. Guided by the EPIS framework, we will achieve this goal through three specific aims: (1) Facilitate adoption, adaptation, and implementation of LBC strategies by PCHHs using a learning collaborative. Learning collaboratives are widely used, evidence-based implementation strategies. Following best practices, a lead facilitator and subject matter experts will help PCHHs explore and prepare protocols for implementation of LBC strategies while trained practice coaches will provide technical assistance around implementation at each site. CDPH has strong interest in integrating LBC strategies into PCHHs and will both mandate PCHH participation in the learning collaborative and encourage LBC implementation through additional funding. We will assess the process of adoption and implementation of LBC strategies using mixed methods. (2) Evaluate site-specific and system-wide effectiveness of integrated LBC strategies at improving sustained care and VS. Using a single-arm, pre–post trial design, we will assess if rates of retention in care and VS improve in the two years following ramp-up of LBC strategies. We will also examine contextual factors and implementation fidelity using mixed methods to explain variability in outcomes across PCHHs. (3) Assess implementation cost and sustainment of LBC strategies among PCHHs. We will examine implementation costs over time and plans for sustainment using mixed methods. Our proposal directly responds to RFA-AI-21-024 and is consistent with the NIH Office of AIDS Research’s high priority of implementation science to improve HIV service delivery and reduce disparities in treatment. Results from this study will facilitate the use of LBC strategies in new settings to reach PWH with complex needs.