Supporting the Growth of Domestic HIV Implementation Research in the United States Through Coordination, Consultation, and Collaboration: How We Got Here and Where We Are Headed

Building the Road to End the HIV Epidemic Through Coordinating and Capacity-Building Hubs to Enhance the Science of HIV Implementation REsearch (CHESHIRE): Reflections and Directions

BACKGROUND

Because implementation remains the biggest challenge to Ending the HIV Epidemic in the United States (EHE), since 2019, the National Institutes of Health (NIH) has funded 248 supplements to identify best practices for delivering evidence-based HIV interventions. NIH also funded a coordination center [Implementation Science (IS) Coordination Initiative "ISCI"] and 9 consultation hubs ("Hubs") to provide technical assistance and cross-project information sharing, measure harmonization, and data synthesis. This article describes this unique capacity-building model, lessons learned from the first 5 years, and opportunities created by this infrastructure.

METHODS

Beginning in FY20, Hubs were assigned 7-9 funded supplement projects in EHE priority jurisdictions. Primary Hub services included direct coaching, multiproject meetings, communities of practice, and technical webinars. ISCI and the Hubs met monthly to reflect on project support, discuss ways to enhance HIV IS broadly, and assess projects' use of Hub services.

FINDINGS

Hub engagement strategies included grouping projects by HIV intervention type, setting data reporting expectations early, and tailoring engagement based on EHE team IS expertise. Support and coordination provided by the Hubs and ISCI have developed generalizable IS knowledge from local knowledge (e.g., publications and tools). The network of ISCI, the Hubs, and EHE projects have also led to infrastructure for conducting multisite HIV implementation research.

IMPLICATIONS FOR DI SCIENCE

The Hub model is a novel, systemwide approach for rapidly improving IS capacity in a field. Implementation of this model will continue to be refined through an ongoing evaluation and as the funding transitions to regular, nonsupplement NIH funding mechanisms.

Leveraging Implementation Science to End the HIV Epidemic in the United States: Progress and Opportunities for Federal Agencies

ABSTRACT

Implementation science has emerged and matured as an essential field for HIV treatment and prevention, designed to bridge the gap between research and practice by identifying opportunities to overcome barriers to implementation of effective interventions, and to accelerate the replication and scale-up of HIV care innovations. In this article, we describe activities and collaborations among the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the National Institutes of Health to optimize the impact of national federal funding opportunities aimed at identifying effective and replicable HIV care and prevention interventions, improving HIV health outcomes, and reducing HIV incidence in the U.S. These activities are outlined in the context of the Ending the HIV Epidemic in the U.S. Initiative, which was enacted across U.S. Department of Health and Human Services agencies, providing new funding and outlining an operational plan to further guide federal agencies in their specific roles and funding areas.In describing these activities and opportunities, we aim to demonstrate how implementation science is being increasingly leveraged to accelerate progress towards ending HIV through scale-up and dissemination efforts. Continued collaboration through federal implementation science will be instrumental in reaching Ending the HIV Epidemic goals.

Two Pilots of an Implementation Science Training Program for HIV Prevention and Care Service Providers: Lessons Learned and Future Directions

BACKGROUND

Development, implementation, and dissemination of HIV-related implementation strategies require partnerships with affected communities, government agencies, and HIV service organizations. Implementation science (IS) training for partners is needed to ensure they can benefit from, and equally contribute to, implementation research (IR). Building IS knowledge and expertise in real-world practice increases providers' ability to offer evidence-based HIV interventions and effectively implement them at scale to achieve the goals of the national Ending the HIV Epidemic (EHE) initiative.

METHODS

National Institutes of Health funds the Implementation Science Coordination Initiative (ISCI) and the Sociostructural Implementation Science Coordination Initiative (SISCI) to support studies in the conduct of rigorous HIV IR through technical assistance, development of IS tools, and trainings for researchers and implementers. As part of these efforts, we created and evaluated 2 pilot IS training courses for HIV service providers: the Practitioner-Oriented Implementation Science Education (POISE) and the Implementation Practitioner Training (IPT). We discuss the importance of training for implementers, the development of our curriculum, lessons learned, and future directions for IS trainings.

CONCLUSIONS

Implementers play a critical role in IR, because they are the beneficiaries of the knowledge produced and are responsible for effectively implementing HIV interventions to achieve EHE goals. Few training courses in IS are specifically designed to meet the needs of those implementing HIV evidence-based interventions and little is known about how to design and deliver them to maximize training benefit. Both training pilots increased participants' ability to apply IS to their work. Participant input provides valuable feedback to improve future training.

Generating Evidence for Effective HIV Implementation at Scale: The Value and Feasibility of a Network for Implementation Science in HIV

ABSTRACT

The Network for Implementation Science in HIV (NISH) was established to conduct multisite research to study real-world implementation of evidence-based HIV interventions across US contexts, and to generate generalizable knowledge around implementation strategies to support the achievement of Ending the HIV Epidemic goals. NISH sites represent diverse Ending the HIV Epidemic priority jurisdictions and include participation of multiple units within those sites (eg, multiple clinics and community-based organizations) and bring together research teams from multiple backgrounds within implementation science and the HIV service sector. We argue and provide examples of how NISH studies have and can contribute to the context versus generalizability debate, generate power in numbers, and synthesize, develop, and test implementation strategies that advance both effectiveness and equity. To date, the network has conducted observational studies exploring ongoing implementation and determinants across contexts, and the identification and codesign of strategies to be leveraged in future work. The next stage of network evolution is to leverage this infrastructure to test implementation strategies through nimble study designs built for fast-changing evidence and implementation environments. We argue that the initial successes of NISH warrant future investment to efficiently capitalize on developed infrastructure and optimize science that can effectively be scaled up to address our most critical questions to end the HIV epidemic and support communities most affected.

Strengthening the US Health Workforce to End the HIV Epidemic: Lessons Learned From 11 Ending the HIV Epidemic Jurisdictions

BACKGROUND

Supplements were awarded under the National Institutes of Health, ending the HIV epidemic (EHE) initiative to foster implementation science through community-engaged research. The objective of this study was to synthesize lessons learned, identify areas of research sufficiently studied, and present an agenda for future research on HIV health workforce development from a collaboration across 9 EHE projects in 11 jurisdictions in the United States.

METHODS

EHE supplement recipients completed a semistructured questionnaire to identify shared lessons learned about common themes of workforce development using the Consolidated Framework for Implementation Research and Expert Recommendation for Implementing Change frameworks. Data were synthesized to identify shared lessons learned, topic areas no longer in need of research, and next steps.

RESULTS

Project teams emphasized several strategies including clarifying roles and responsibilities, the need for dynamic training, and stigma mitigation as strategies to enhance the implementation of HIV prevention and treatment services. Strengthening organizational support through supportive supervision structures, ensuring sustainable funding, preventing turnover, addressing salary constraints, and establishing clear promotion and educational pathways were identified as useful workplace development strategies. Supplements identified lessons learned about deploying community engagement strategies to ensure communities were aware of HIV prevention and treatment services. Several areas sufficiently studied that can be deprioritized were identified and discussed.

CONCLUSION

A research agenda for workplace development moving forward is discussed with several recommendations to improve the implementation of HIV prevention and treatment programs.

Progress and Priorities to End the HIV Epidemic by 2030: Combined Lessons From 120 US Implementation Research Projects

ABSTRACT

Five years into the US national Ending the HIV Epidemic (EHE) plan, it is a critical time to examine what has been learned and what still needs to be studied to achieve its 2030 goals of reducing new HIV infections by 90%. While much has already been gained from the 250+ individual National Institutes of Health-funded implementation research projects and the capacity building provided by the Implementation Science Coordination Initiative (ISCI) and 9 regional consultation hubs (RCHs), identifying generalizable implementation science lessons requires the synthesis of findings across multiple sites, studies, and/or contexts. This supplemental issue of JAIDS emphasizes collaborative papers that summarize shared HIV implementation knowledge from multiple EHE-funded research projects. The 24 papers herein represent work from 111 EHE supplement projects and 7 R01s happening in 40 EHE priority jurisdictions, as well as from ISCI, all RCHs, and federal partners. We identified the following 4 overarching themes: infrastructure for HIV implementation research, methods for conducting HIV implementation research with specific communities, implementation strategies to help deliver HIV-related interventions, and training in implementation science for the HIV workforce. Insights shared in this issue provide a clear pathway for the next phase of EHE, in which research infrastructure must remain robust, workforce investments must prioritize sustainability, and partnerships must continue to bridge local innovation with systemic change.

HIV Trends in Metropolitan US Cities From 2014 to 2021: Baseline Data for the Ending the HIV Epidemic Initiative

Objective. To examine baseline trends for the 2019 Ending the HIV Epidemic in the United States (EHE), which aims to reduce HIV incidence by 90% by 2030 in the 57 counties and states responsible for half of incident infections, and to provide a counterfactual comparator for future evaluation of the initiative's midpoint. Methods. We used 2014‒2021 metropolitan statistical area (MSA) data to compare HIV diagnostic rate trends between MSAs subsuming EHE regions (n = 46) and other MSAs (n = 76). A difference-in-difference analysis illustrated potential early-stage programmatic effects. Results. From 2014 to 2021 across 122 MSAs, 305 413 HIV cases were diagnosed with a mean annual MSA-level diagnostic rate change of ‒6.7% (range = ‒66.1‒466.7%). MSA-level diagnostic rate changed by ‒21.3% (range = ‒50.8%‒14.8%) amongst MSAs including EHE regions and by 2.1% (range = ‒66.1%‒466.7%) in other MSAs. In a difference-in-difference analysis, the HIV diagnostic rate change from 2020 to 2021 was 3.1 cases per 100 000 people-years (P = .03) greater in EHE regions compared to the baseline HIV diagnostic rate change of ‒0.8 cases per 100 000 people-years (P < .01) across all MSAs. Conclusions. Although MSAs including EHE regions experienced greater reductions in HIV diagnoses from 2014 to 2021, high interregional variability requires exploration. These trends provide a baseline for subsequent EHE programmatic evaluations. (Am J Public Health. 2025;115(2):217-220. https://doi.org/10.2105/AJPH.2024.307890).

Innovation and implementation determinants of HIV testing and linkage-to-care in the U.S.: a systematic review

OBJECTIVE

To identify innovation and implementation determinants of HIV testing, diagnosis, and linkage-to-care in the U.S.

DATA SOURCES AND STUDY SETTING

Between November 2020 and January 2022, a broad search strategy was employed in three literature databases: Ovid MEDLINE, PsycINFO, and Web of Science.

STUDY DESIGN

A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

DATA COLLECTION/EXTRACTION METHODS

A team of master's and Ph.D.-level researchers screened eligible studies against the inclusion criteria and extracted the data using COVIDENCE software in pairs with consensus performed by a senior member of the team. Barriers and facilitators were extracted and analyzed according to the Consolidated Framework for Implementation Research (CFIR). Frequency of determinants across studies was mapped according to CFIR, valence, study design, delivery setting, unit of analysis, population of interest, region of the U.S., and year.

RESULTS

We identified 1,739 implementation and innovation determinants from 186 articles. Most determinants were for HIV testing rather than linkage-to-care. Most determinants were identified in the inner setting and individuals domains of CFIR, with the fewest identified in the process and innovations domains. Determinants of providers were only slightly more frequently identified than determinants of recipients. However, determinants of organizations and systems were rarely identified.

CONCLUSION

This review provides a synthesis of innovation and implementation determinants of HIV testing and linkage-to-care using the most-cited implementation science (IS) framework, CFIR. This synthesis enables the larger field of HIV science to utilize IS in efforts to end the HIV epidemic and positions IS to consider the application of IS frameworks to fields like HIV.

Establishing evidence criteria for implementation strategies in the US: a Delphi study for HIV services

BACKGROUND

There are no criteria specifically for evaluating the quality of implementation research and recommending implementation strategies likely to have impact to practitioners. We describe the development and application of the Best Practices Tool, a set of criteria to evaluate the evidence supporting HIV-specific implementation strategies.

METHODS

We developed the Best Practices Tool from 2022-2023 in three phases. (1) We developed a draft tool and criteria based on a literature review and key informant interviews. We purposively selected and recruited by email interview participants representing a mix of expertise in HIV service delivery, quality improvement, and implementation science. (2) The tool was then informed and revised through two e-Delphi rounds using a survey delivered online through Qualtrics. The first and second round Delphi surveys consisted of 71 and 52 open and close-ended questions, respectively, asking participants to evaluate, confirm, and make suggestions on different aspects of the rubric. After each survey round, data were analyzed and synthesized as appropriate; and the tool and criteria were revised. (3) We then applied the tool to a set of research studies assessing implementation strategies designed to promote the adoption and uptake of evidence-based HIV interventions to assess reliable application of the tool and criteria.

RESULTS

Our initial literature review yielded existing tools for evaluating intervention-level evidence. For a strategy-level tool, additions emerged from interviews, for example, a need to consider the context and specification of strategies. Revisions were made after both Delphi rounds resulting in the confirmation of five evaluation domains - research design, implementation outcomes, limitations and rigor, strategy specification, and equity - and four evidence levels - best, promising, more evidence needed, and harmful. For most domains, criteria were specified at each evidence level. After an initial pilot round to develop an application process and provide training, we achieved 98% reliability when applying the criteria to 18 implementation strategies.

CONCLUSIONS

We developed a tool to evaluate the evidence supporting implementation strategies for HIV services. Although specific to HIV in the US, this tool is adaptable for evaluating strategies in other health areas.

A systematic review of experimentally tested implementation strategies across health and human service settings: evidence from 2010-2022

BACKGROUND

Studies of implementation strategies range in rigor, design, and evaluated outcomes, presenting interpretation challenges for practitioners and researchers. This systematic review aimed to describe the body of research evidence testing implementation strategies across diverse settings and domains, using the Expert Recommendations for Implementing Change (ERIC) taxonomy to classify strategies and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework to classify outcomes.

METHODS

We conducted a systematic review of studies examining implementation strategies from 2010-2022 and registered with PROSPERO (CRD42021235592). We searched databases using terms "implementation strategy", "intervention", "bundle", "support", and their variants. We also solicited study recommendations from implementation science experts and mined existing systematic reviews. We included studies that quantitatively assessed the impact of at least one implementation strategy to improve health or health care using an outcome that could be mapped to the five evaluation dimensions of RE-AIM. Only studies meeting prespecified methodologic standards were included. We described the characteristics of studies and frequency of implementation strategy use across study arms. We also examined common strategy pairings and cooccurrence with significant outcomes.

FINDINGS

Our search resulted in 16,605 studies; 129 met inclusion criteria. Studies tested an average of 6.73 strategies (0-20 range). The most assessed outcomes were Effectiveness (n=82; 64%) and Implementation (n=73; 56%). The implementation strategies most frequently occurring in the experimental arm were Distribute Educational Materials (n=99), Conduct Educational Meetings (n=96), Audit and Provide Feedback (n=76), and External Facilitation (n=59). These strategies were often used in combination. Nineteen implementation strategies were frequently tested and associated with significantly improved outcomes. However, many strategies were not tested sufficiently to draw conclusions.

CONCLUSION

This review of 129 methodologically rigorous studies built upon prior implementation science data syntheses to identify implementation strategies that had been experimentally tested and summarized their impact on outcomes across diverse outcomes and clinical settings. We present recommendations for improving future similar efforts.

"Your Package Could Not Be Delivered": The State of Digital HIV Intervention Implementation in the US

PURPOSE OF REVIEW

Despite continuous innovations and federal investment to create digital interventions addressing the HIV prevention and care continua, these interventions have not reached people in the U.S. at scale. This article reviews what is known about U.S. implementation of digital HIV interventions and presents a strategy to cross the research-to-practice chasm for these types of interventions.

RECENT FINDINGS

We conducted a narrative review of U.S.-based original research on implementation of digital HIV interventions and identified few studies reporting on implementation determinants, strategies, processes, or outcomes, particularly outside the context of effectiveness trials. To supplement the literature, in 2023, we surveyed 47 investigators representing 64 unique interventions about their experiences with implementation after their research trials. Respondents placed high importance on intervention implementation, but major barriers included lack of funding and clear implementation models, technology costs, and difficulty identifying partners equipped to deliver digital interventions. They felt that responsibility for implementation should be shared between intervention developers, deliverers (e.g., clinics), and a government entity. If an implementation center were to exist, most respondents wanted to be available for guidance or technical assistance but largely wanted less involvement. Numerous evidence-based, effective digital interventions exist to address HIV prevention and care. However, they remain "on the shelf" absent a concrete and sustainable model for real-world dissemination and implementation. Based on our findings, we call for the creation of national implementation centers, analogous to those in other health systems, to facilitate digital HIV intervention delivery and accelerate progress toward ending the U.S. epidemic.

Navigating grey areas in HIV and mental health implementation science

INTRODUCTION

Implementation science (IS) offers methods to systematically achieve the Ending the HIV Epidemic goals in the United States, as well as the global UNAIDS targets. Federal funders such as the National Institutes of Mental Health (NIMH) have invested in implementation research to achieve these goals, including supporting the AIDS Research Centres (ARCs), which focus on high-impact science in HIV and mental health (MH). To facilitate capacity building for the HIV/MH research workforce in IS, "grey areas," or areas of IS that are confusing, particularly for new investigators, should be addressed in the context of HIV/MH research.

DISCUSSION

A group of IS experts affiliated with NIMH-funded ARCs convened to identify common and challenging grey areas. The group generated a preliminary list of 19 grey areas in HIV/MH-related IS. From the list, the authors developed a survey which was distributed to all ARCs to prioritize grey areas to address in this paper. ARC members across the United States (N = 60) identified priority grey areas requiring clarification. This commentary discusses topics with 40% or more endorsement. The top grey areas that ARC members identified were: (1) Differentiating implementation strategies from interventions; (2) Determining when an intervention has sufficient evidence for adaptation; (3) Integrating recipient perspectives into HIV/MH implementation research; (4) Evaluating whether an implementation strategy is evidence-based; (5) Identifying rigorous approaches for evaluating the impact of implementation strategies in the absence of a control group or randomization; and (6) Addressing innovation in HIV/MH IS grants. The commentary addresses each grey area by drawing from the existing literature (when available), providing expert guidance on addressing each in the context of HIV/MH research, and providing domestic and global HIV and HIV/MH case examples that address these grey areas.

CONCLUSIONS

HIV/MH IS is key to achieving domestic and international goals for ending HIV transmission and mitigating its impact. Guidance offered in this paper can help to overcome challenges to rigorous and high-impact HIV/MH implementation research.

Establishing Evidence Criteria for Implementation Strategies: A Delphi Study for HIV Services

Background

There are no criteria specifically for evaluating the quality of implementation research and recommend implementation strategies likely to have impact to practitioners. We describe the development and application of the Best Practices Rubric, a set of criteria to evaluate the evidence supporting implementation strategies, in the context of HIV.

Methods

We developed the Best Practices Rubric from 2022-2023 in three phases. (1) We purposively selected and recruited by email participants representing a mix of expertise in HIV service delivery, quality improvement, and implementation science. We developed a draft rubric and criteria based on a literature review and key informant interviews. (2) The rubric was then informed and revised through two e-Delphi rounds using a survey delivered online through Qualtrics. The first and second round Delphi surveys consisted of 71 and 52 open and close-ended questions, respectively, asking participants to evaluate, confirm, and make suggestions on different aspects of the rubric. After each survey round, data were analyzed and synthesized as appropriate, and the rubric and criteria were revised. (3) We then applied the rubric to a set of research studies assessing 18 implementation strategies designed to promote the adoption and uptake of pre-exposure prophylaxis, an HIV prevention medication, to assess reliable application of the rubric and criteria.

Results

Our initial literature review yielded existing rubrics and criteria for evaluating intervention-level evidence. For a strategy-level rubric, additions emerged from interviews, for example, a need to consider the context and specification of strategies. Revisions were made after both Delphi rounds resulting in the confirmation of five evaluation domains - research design, implementation outcomes, limitations and rigor, strategy specification, and equity - and four evidence levels - best practice, promising practice, more evidence needed, and harmful practices. For most domains, criteria were specified at each evidence level. After an initial pilot round to develop an application process and provide training, we achieved 98% reliability when applying the criteria to 18 implementation strategies.

Conclusions

We developed a rubric to evaluate the evidence supporting implementation strategies for HIV services. Although the rubric is specific to HIV, this tool is adaptable for evaluating strategies in other health areas.

A Systematic Review of Implementation Research on Determinants and Strategies of Effective HIV Interventions for Men Who Have Sex with Men in the United States

Men who have sex with men (MSM) are disproportionately affected by HIV, accounting for two-thirds of HIV cases in the United States despite representing ∼5% of the adult population. Delivery and use of existing and highly effective HIV prevention and treatment strategies remain suboptimal among MSM. To summarize the state of the science, we systematically review implementation determinants and strategies of HIV-related health interventions using implementation science frameworks. Research on implementation barriers has focused predominantly on characteristics of individual recipients (e.g., ethnicity, age, drug use) and less so on deliverers (e.g., nurses, physicians), with little focus on system-level factors. Similarly, most strategies target recipients to influence their uptake and adherence, rather than improving and supporting implementation systems. HIV implementation research is burgeoning; future research is needed to broaden the examination of barriers at the provider and system levels, as well as expand knowledge on how to match strategies to barriers-particularly to address stigma. Collaboration and coordination among federal, state, and local public health agencies; community-based organizations; health care providers; and scientists are important for successful implementation of HIV-related health innovations.

PrEP Use and HIV Incidence Among Youth At-Risk for HIV Infection in Los Angeles and New Orleans: Findings From ATN 149

INTRODUCTION

Expanding HIV pre-exposure prophylaxis (PrEP) use is key to goals for lowering new HIV infections in the U.S. by 90% between 2022 and 2030. Unfortunately, youth aged 16-24 have the lowest PrEP use of any age group and the highest HIV incidence rates.

METHODS

To examine the relationship between HIV seroconversion and PrEP uptake, adherence, and continuity, we used survival analysis and multivariable logistic regression on data of 895 youth at-risk for HIV infection enrolled in Adolescent Trials Network for HIV Medicine protocol 149 in Los Angeles and New Orleans, assessed at 4-month intervals over 24 months.

RESULTS

The sample was diverse in race/ethnicity (40% Black, 28% Latine, 20% White). Most participants (79%) were cis-gender gay/bisexual male but also included 7% transgender female and 14% trans masculine and nonbinary youth. Self-reported weekly PrEP adherence was high (98%). Twenty-seven participants acquired HIV during the study. HIV incidence among PrEP users (3.12 per 100 person year [PY]) was higher than those who never used PrEP (2.53/100 PY). The seroconversion incidence was highest among PrEP users with discontinuous use (3.36/100 PY). If oral PrEP users were adherent using 2-monthly long-acting injectables, our estimate suggests 2.06 infections per 100 PY could be averted.

CONCLUSIONS

Discontinuous use of PrEP may increase risk of HIV acquisition among youth at higher risk for HIV infection and indications for PrEP. Thus, to realize the promise of PrEP in reducing new HIV infections, reducing clinical burdens for PrEP continuation are warranted.

Keep It Up! 3.0: Study protocol for a type III hybrid implementation-effectiveness cluster-randomized trial

BACKGROUND

Despite evidence that eHealth approaches can be effective in reducing HIV risk, their implementation requirements for public health scale up are not well established, and effective strategies to bring these programs into practice are still unknown. Keep It Up! (KIU!) is an online program proven to reduce HIV risk among young men who have sex with men (YMSM) and ideal candidate to develop and evaluate novel strategies for implementing eHealth HIV prevention programs. KIU! 3.0 is a Type III Hybrid Effectiveness-Implementation cluster randomized trial designed to 1) compare two strategies for implementing KIU!: community-based organizations (CBO) versus centralized direct-to-consumer (DTC) recruitment; 2) examine the effect of strategies and determinants on variability in implementation success; and 3) develop materials for sustainment of KIU! after the trial concludes. In this article, we describe the approaches used to achieve these aims.

METHODS

Using county-level population estimates of YMSM, 66 counties were selected and randomized 2:1 to the CBO and DTC approaches. The RE-AIM model was used to drive outcome measurements, which were collected from CBO staff, YMSM, and technology providers. Mixed-methods research mapped onto the domains of the Consolidated Framework for Implementation Research will examine determinants and their relationship with implementation outcomes.

DISCUSSION

In comparing our implementation recruitment models, we are examining two strategies which have shown effectiveness in delivering health technology interventions in the past, yet little is known about their comparative advantages and disadvantages in implementation. The results of the trial will further the understanding of eHealth prevention intervention implementation.

Examining HIV Organizational Structures and their Influence on Engagement with Young Black Gay, Bisexual, and other Men who have Sex with Men in Atlanta, Georgia

Young Black gay, bisexual, and other men who have sex with men (YB-GBMSM) are disproportionately impacted by HIV. Structural influences on these disparities, including characteristics of the various organizations that serve YB-GBMSM living with HIV, remain understudied. We drew on Weick's model of organizing to conduct and analyze qualitative interviews with 28 HIV service providers representing healthcare and community-based organizations in Atlanta, Georgia. Enactment of HIV service provision was described as following simplified and standardized responses-defined as "rules", and/or more dynamic exchanges to formulate responses -otherwise known as "communication behavior cycles" (CBCs). Rules, including patient quotas and limited hours of operation, were viewed as rigid, out-of-touch, and inhibiting engagement with YB-GBMSM. CBCs, such as patient feedback loops and rejection of traditional hierarchies, fostered creative insights to combating the epidemic and increased levels of cultural awareness and community buy-in. Organizations should strive to enact CBCs, to foster culturally congruent approaches to service delivery for YB-GBMSM.

Tracking dynamic changes in implementation strategies over time within a hybrid type 2 trial of an electronic patient-reported oncology symptom and needs monitoring program

Background

Longitudinal tracking of implementation strategies is critical in accurately reporting when and why they are used, for promoting rigor and reproducibility in implementation research, and could facilitate generalizable knowledge if similar methods are used across research projects. This article focuses on tracking dynamic changes in the use of implementation strategies over time within a hybrid type 2 effectiveness-implementation trial of an evidence-based electronic patient-reported oncology symptom assessment for cancer patient-reported outcomes in a single large healthcare system.

Methods

The Longitudinal Implementation Strategies Tracking System (LISTS), a timeline follow-back procedure for documenting strategy use and modifications, was applied to the multiyear study. The research team used observation, study records, and reports from implementers to complete LISTS in an electronic data entry system. Types of modifications and reasons were categorized. Determinants associated with each strategy were collected as a justification for strategy use and a potential explanation for strategy modifications.

Results

Thirty-four discrete implementation strategies were used and at least one strategy was used from each of the nine strategy categories from the Expert Recommendations for Implementing Change (ERIC) taxonomy. Most of the strategies were introduced, used, and continued or discontinued according to a prospective implementation plan. Relatedly, a small number of strategies were introduced, the majority unplanned, because of the changing healthcare landscape, or to address an emergent barrier. Despite changing implementation context, there were relatively few modifications to the way strategies were enacted, such as a change in the actor, action, or dose. Few differences were noted between the trial's three regional units under investigation.

Conclusion

This study occurred within the ambulatory oncology clinics of a large, academic medical center and was supported by the Quality team of the health system to ensure greater uptake, uniformity, and implementation within established practice change processes. The centralized nature of the implementation likely contributed to the relatively low proportion of modified strategies and the high degree of uniformity across regions. These results demonstrate the potential of LISTS in gathering the level of data needed to understand the impact of the many implementation strategies used to support adoption and delivery of a multilevel innovation.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT04014751, identifier: NCT04014751.