Contingency Management and Pre-Exposure Prophylaxis Adherence Support Services (CoMPASS): A hybrid type 1 effectiveness-implementation study to promote HIV risk reduction among people who inject drugs

Implementing a pre-exposure prophylaxis (PrEP) promotion intervention among persons who inject drugs: Perspectives from community and research implementation partners

BACKGROUND

Clinical guidelines recommend pre-exposure prophylaxis (PrEP) to prevent HIV among persons who inject drugs (PWID), yet few are reached by this evidence-based intervention. To address this challenge, we are conducting a clinical trial to evaluate the impact of contingency management (CM) with stepped care to PrEP adherence and support services (PASS) among PWID. We sought to elicit perspectives from community- and research-based implementation partners on barriers and facilitators to implementing this intervention package as well as describe perspectives around evidence-based research practices in general.

METHODS

In October 2023, we conducted three focus groups with community-based site staff (n = 8), site leadership (n = 6), and research coordinators (n = 6) involved in delivering and implementing the intervention. The Promoting Action on Research Implementation in Health Service (PARIHS) implementation science framework construct (evidence, context, and facilitation opportunities) informed qualitative data collection and analysis.

RESULTS

Regarding evidence, focus group participants had a mix of previous experience or backgrounds in behavioral and interventional research with pre-existing research experience and embedded research infrastructure described as implementation facilitators. Participants described initially mixed views towards CM but became more positive as participants engaged in trial implementation. Regarding context within the community-based setting, focus group participants acknowledged challenges in promoting PrEP among PWID given competing social needs as well as individual and service priorities. Participants described turnover and burnout among staff delivering the intervention in addition to providing regular day-to-day services as major barriers to implementation. Regarding future intervention facilitation opportunities, participants suggested integrating interventional activities into off-site services like outreach as well as increasing the number of CM sessions. To facilitate site engagement and localized practice improvement, site leadership emphasized the need for consistent research team presence and detailed correspondence of results at the conclusion of research.

CONCLUSION

Focus group participants identified barriers and facilitators to implementing and sustaining CM-based PrEP promotion interventions within community-based settings. Efforts should be made to anticipate and address staff capacity and turnover when implementing HIV prevention interventions within community settings. Additionally, integrating CM-based PrEP promotion programs into off-site services and operations to reach PWID could be an opportunity to increase reach.

Perspectives on Clinical Pharmacist-Delivered Contingency Management to Promote Smoking Abstinence Among Individuals with HIV: A Qualitative Study

Contingency management (CM), an evidence-based behavioral strategy that rewards positive behavior change including tobacco cessation, is rarely offered to support people with HIV (PWH) who smoke. In this study, we explored perspectives among patients and research staff engaged in a multi-site randomized clinical trial involving clinical pharmacist-delivered CM within HIV clinics. Between February and September 2023, we conducted 1:1 interviews with 12 PWH randomized to receive CM and one focus group with 8 staff (i.e., clinical pharmacists and research coordinators). Qualitative data collection and analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) implementation science framework to understand barriers and facilitators related to evidence (perspectives on CM for smoking cessation), context (HIV clinics), and facilitation (promoting effectiveness and sustainability). Regarding evidence, PWH and staff had limited prior experience with CM and supported the use of exhaled carbon monoxide to promote accountability. PWH and staff thought CM was useful in bolstering internal motivation, but differed on ideal target behaviors (i.e., cessation vs. reduction). Regarding context, clinical pharmacist-delivered tobacco treatment within HIV clinics was viewed favorably, with mixed perspectives regarding optimal visit schedules and utility of remote CM. Regarding facilitation, PWH and research staff discussed strategies to increase participant engagement and retention such as incorporating behavioral counseling services. PWH endorsed application of CM beyond smoking cessation and for people without HIV. Future efforts should consider expanding the use of CM to target smoking cessation and related health behaviors and tailoring the intervention to individual needs and goals.

Readiness to implement contingency management to promote PrEP initiation and adherence among people who inject drugs: results from a multi-site implementation survey

BACKGROUND

Contingency management (CM), an incentive-based intervention to encourage target behaviors, effectively promotes medication adherence. However, efforts to extend CM to HIV pre-exposure prophylaxis (PrEP) have been lacking. As part of a randomized clinical trial to promote HIV Prevention among people who inject drugs (PWID), we examined the readiness of staff in community-based organizations serving PWID to implement CM for PrEP uptake and adherence in this population.

METHODS

From April to August 2022, we conducted a survey of staff from four community-based organizations providing HIV testing, harm reduction, and outreach services in the northeastern United States. We assessed knowledge and attitudes regarding PrEP for PWID on five-point Likert scales (e.g., Poor to Excellent, Not at all to Extremely). Using a modified version of the Contingency Management Beliefs Questionnaire, we assessed the degree to which attitudes about CM for HIV prevention influenced interest in its adoption on a scale from "1-No influence at all" to "5-Very strong influence". We explored endorsement patterns, along with average values of individual items and subscale scores.

RESULTS

Among 271 staff invitations, 123 (45.4%) responded. The majority (88.6%) of respondents reported prior PrEP awareness, with a mean self-rated knowledge of 2.98 out of 5 (SD = 1.1). Attitudes towards PrEP, including its relevance to and importance for clients (both means = 4.3), efficacy (mean = 4.5), and safety (mean = 4.2), were positive. Items related to practicality and confidence in providing PrEP-related care had relatively lower ratings. Respondents endorsed influential generalized (mean = 2.1) and training-related (mean = 2.5) CM implementation barriers less frequently than positive attitudes towards CM (mean = 3.6). Staff favored adding CM to existing services (mean = 3.8), and highly endorsed it as "useful for targeting HIV prevention with PrEP" (mean = 3.7).

CONCLUSIONS

Respondents generally supported the use of CM to promote HIV prevention among PWID and favored adding it to their existing services. Though respondents understood the value of both PrEP and CM to support HIV prevention activities, findings corroborate research citing relative lack of knowledge and confidence regarding PrEP management among clients, potentially detracting from implementation readiness.

TRIAL REGISTRATION NUMBER

NCT04738825.

A Review of Implementation Strategies to Enhance PrEP Delivery for People Experiencing Housing Insecurity: Advancing a Multifaceted High-Touch, Low-Barrier Approach

PURPOSE OF REVIEW

This review summarizes key implementation strategies to advance oral and long-acting PrEP delivery for unstably housed people in the United States.

RECENT FINDINGS

People experiencing homelessness and housing instability face barriers to PrEP uptake and adherence including lack of safe medication storage, competing basic needs, insurances issues, and/or mental health or substance use disorders. Recent advancements in HIV treatment and prevention provide evidence on high-touch, low-barrier implementation approaches to address these challenges. We compiled these approaches into a multi-component implementation strategy, "SHELTER", which includes: low-barrier primary care, case management, incentives, outreach, care coordination, multidisciplinary provider collaboration, data tracking, and robust provider-patient relationships. The US has fallen short of our Ending the Epidemic targets, in part due to challenges in PrEP delivery for people experiencing housing instability. SHELTER provides a comprehensive approach for considering critical components of HIV prevention for this population that can be used in future oral and long-acting PrEP programs.

Integrating stakeholder feedback into the design of a peer-delivered primary care wellness program: A rapid qualitative study

BACKGROUND

Individuals seen in Primary Care with behavioral health concerns who decline behavioral health treatment may benefit from the support of peers (consumers in recovery from behavioral health concerns employed to support other consumers). Whole Health STEPS is a new intervention for Veterans in Primary Care with behavioral health concerns which combines essential elements of peers' role and the Whole Health model using a stepped-care design. We incorporated stakeholder feedback in the Whole Health STEPS design to improve fit with Veterans, peers, and primary care settings.

METHODS

We conducted semi-structured qualitative interviews with VA staff using questions derived from the Consolidated Framework for Implementation Research (CFIR). Participants were recruited via a maximum variation strategy across a national sample and interviewed between January 2021-April 2021. The analytic design was a rapid qualitative analysis. Interviews addressed design decisions and potential barriers and facilitators to future implementation. Then, we made adaptations to Whole Health STEPS and catalogued changes using the Framework for Adaptations and Modifications-Enhanced (FRAME). A VA peer conducted the interviews, participated in analyses, assisted with design modifications, and co-wrote this paper.

RESULTS

Sixteen staff members from 9 VA primary care peer programs participated (8 peers and 8 supervisors/administrators). Feedback themes included: capitalizing on peer skills (e.g., navigation), ensuring patient-centered and flexible design, and making it easy and efficient (e.g., reducing session length). Understanding the structure of primary care peers' roles and their interactions with other programs helped us identify role conflicts (e.g., overlap with Whole Health Coaches and Health Behavior Coordinators), which led to design modifications to carve out a unique role for Whole Health STEPS. Staff also made recommendations about marketing materials and training tools to support Whole Health STEPS roll out.

CONCLUSIONS

Feedback from frontline staff, including peers, in the design process was crucial to identifying essential modifications that would not have been possible after initial trials without re-evaluating efficacy due to the extent of the changes. Whole Health STEPS was adapted to fit within a range of program structures, emphasize peers' unique contributions, and streamline delivery. Lessons learned can be applied to other interventions.

A Driver in Health Outcomes: Developing Discrete Categories of Transportation Insecurity

Research suggests that transportation is an important social determinant of health, because the ability to get around is consequential for accessing health care and nutritious food and for making social connections. We used an inductive mixed-methods approach and a quantitative k-means clustering approach to identify 5 categories of transportation insecurity using the validated 16-item Transportation Security Index. The resulting 5-category measure distinguished among respondents with qualitatively different experiences of transportation insecurity. Analyzing data from 2018 that were representative of the US adult population aged 25 years or older, we demonstrated a nonparametric association between transportation insecurity and 2 different health measures (self-rated health and depressive symptoms). There was a threshold relationship between self-rated health and any level of transportation insecurity. High transportation insecurity had a very strong relationship with depressive symptoms. The categorical Transportation Security Index will be useful for clinicians who wish to screen for transportation-related barriers to health care. It will also facilitate research investigating the influence of transportation insecurity on health outcomes and provide the basis for interventions designed to address health disparities.

Promoting alcohol treatment engagement post-hospitalization with brief intervention, medications and CBT4CBT: protocol for a randomized clinical trial in a diverse patient population

BACKGROUND

Alcohol use disorder (AUD) commonly causes hospitalization, particularly for individuals disproportionately impacted by structural racism and other forms of marginalization. The optimal approach for engaging hospitalized patients with AUD in treatment post-hospital discharge is unknown. We describe the rationale, aims, and protocol for Project ENHANCE (ENhancing Hospital-initiated Alcohol TreatmeNt to InCrease Engagement), a clinical trial testing increasingly intensive approaches using a hybrid type 1 effectiveness-implementation approach.

METHODS

We are randomizing English and/or Spanish-speaking individuals with untreated AUD (n = 450) from a large, urban, academic hospital in New Haven, CT to: (1) Brief Negotiation Interview (with referral and telephone booster) alone (BNI), (2) BNI plus facilitated initiation of medications for alcohol use disorder (BNI + MAUD), or (3) BNI + MAUD + initiation of computer-based training for cognitive behavioral therapy (CBT4CBT, BNI + MAUD + CBT4CBT). Interventions are delivered by Health Promotion Advocates. The primary outcome is AUD treatment engagement 34 days post-hospital discharge. Secondary outcomes include AUD treatment engagement 90 days post-discharge and changes in self-reported alcohol use and phosphatidylethanol. Exploratory outcomes include health care utilization. We will explore whether the effectiveness of the interventions on AUD treatment engagement and alcohol use outcomes differ across and within racialized and ethnic groups, consistent with disproportionate impacts of AUD. Lastly, we will conduct an implementation-focused process evaluation, including individual-level collection and statistical comparisons between the three conditions of costs to providers and to patients, cost-effectiveness indices (effectiveness/cost ratios), and cost-benefit indices (benefit/cost ratios, net benefit [benefits minus costs). Graphs of individual- and group-level effectiveness x cost, and benefits x costs, will portray relationships between costs and effectiveness and between costs and benefits for the three conditions, in a manner that community representatives also should be able to understand and use.

CONCLUSIONS

Project ENHANCE is expected to generate novel findings to inform future hospital-based efforts to promote AUD treatment engagement among diverse patient populations, including those most impacted by AUD.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05338151.