Technical Assistance for Improved Implementation of a Couple-Based HIV Prevention Program: Implications for Implementation of EBPs

Objective: Couple-based HIV counseling and testing (CHCT), behavioral HIV prevention and medication adherence are increasingly used  in the U.S. as evidence-based practices (EBPs) that reduce risk for new infections. Successful implementation of EBPs requires technical assistance (TA) for practitioners who disseminate and implement them. This study examines data from post-training TA sessions to identify key barriers to the implementation of Connect, an evidence-based HIV prevention intervention for couples, featured in the Centers for Disease Control (CDC) Dissemination of Effective Behavioral Interventions (DEBI) program.

Methods:The sample included 253 practitioners from 80 HIV services agencies across New York State. Eligible agencies had non-profit status and provided HIV prevention to at-risk populations, including heterosexual couples. Agencies were randomized to receive a four-day training in delivery of a web-assisted (n=40) or manualized (n=40) version of the program for up to 6 staff.  We collected qualitative data regarding technical assistance needs at two and four months post-training via conference calls. We used a semi-structured protocol to document progress reported by agency staff along a continuum of implementation tasks from recruitment through to implementation and evaluation. These TA calls were audiotaped.  Two independent coders conducted a template analysis of a sample of audiotaped transcriptions to identify most commonly occurring themes, including barriers.  We achieved 100% agreement on codes reported. We used this template to examine the frequency of responses on all TA sessions.   Emergent codes were added after coders conferred and reached agreement.  This process continued until all data were reviewed.

Results:  Most agencies (92%, n=74) and providers (67%, n=169) participated in TA sessions. Data suggested the following most frequent barriers to implementation: 1) practitioner inability to integrate the program as a new or existing service (problems face regarding recruitment of couples and reimbursement, for example); 2) practitioner and agency lack of resources to adapt the program (for Spanish language, same-sex and transgendered couples); 3) lack of staffing and supervision to support implementation; and 4) misunderstanding regarding to whom the program may be targeted (HIV positive, negative or sero-discordant couples). Findings suggest that researchers and policy makers must improve the conditions under which agencies are required to integrate new services.

Conclusions:  Findings suggest a number of key barriers to implementation, some unique to couple-based programming and others consistent with existing literature on EBP implementation. To overcome these barriers, training and TA for implementation of evidence based programs targeting couples should integrate the following components: 1) engage in discussions with administrators regarding how best to integrate EBPs into existing programs, including how to reimburse for couple-based services, how to recruit dyads, and how to supervise practitioners new to couples work; 2) skills building on adaptation of the program for agency context and for new target populations; 3)  skills building practice in recruitment strategies (clarify suitable target populations for the program). Ongoing TA calls may influence and strengthen the implementation process by sustaining support and building capacity to address new challenges as they arise.