Reducing Racial/Ethnic Disparities in HIV Outcomes By Optimizing Culturally Salient Cost-Effective Interventions Using the Multiphase Optimization Strategy (MOST)

Background and Purpose. African American/Black and Latino/Hispanic (AABLH) individuals comprise the majority of the 1.1 million persons living with HIV (PLWH) in the U.S., but experience greater challenges than their White peers staying well-engaged in HIV care and taking HIV medication with sustained high adherence. This, in turn, leads to greater morbidity, lower quality of life, and earlier mortality among AABLH PLWH compared to Whites. Factors driving these serious disparities include individual- (e.g., medical distrust, substance use), social- (e.g., complex stigma), and structural-level influences (e.g., poor access to high-quality care, poverty). Compound barriers such as these call for multi-component interventions, but innovative approaches are needed to make interventions efficient, cost-effective, and scalable. We are using the engineering-inspired multiphase optimization strategy (MOST) framework to first test the effects of individual intervention components and their interactions, and then optimize a cost-effective culturally salient intervention to improve engagement in HIV care and increase sustained medication use for AABLH PLWH. This presentation will provide an overview of barriers AABLH PLWH experience to care/medication, the MOST framework, and preliminary results on intervention components’ acceptability, feasibility, and evidence of efficacy.

 Methods. Participants (N=353 of 512 recruited to date) are adult AABLH PLWH with poor engagement in HIV care and detectable HIV viral load (indicating insufficient medication use). Five promising culturally salient intervention components are being tested using an efficient fractional factorial design. Components are grounded in self-determination theory, motivational interviewing, and social-cognitive counseling approaches, designed to address theoretical mediators, and delivered by trained social workers. They are: individual counseling sessions, pre-adherence skill/habit building, peer mentoring, focused support groups, and patient navigation. Participants engage in structured assessments, laboratory tests, intervention components, and qualitative interviews over 12 months.

Results. Participants were mostly male (72%), African American/Black (70%), from low-SES backgrounds, 47 years old on average (SD=11 years), and had lived with HIV for 19.7 years on average (SD=9.1 years). Average log₁₀ HIV viral load (VL) at enrollment was 4.07 pp/mL (SD=1.09 pp/mL). Stopping and starting antiretroviral therapy was common (mean=11.2 times [SD=19.6 times]). Results from qualitative analyses highlighted that participating in distinct, diverse components delivered by different interventionists (to prevent contamination) was feasible, acceptable, engaging, and motivating. Consistent with hypotheses, participants found specific aspects of the components useful. Preliminary quantitative analysis found a significant reduction in HIV VL across all components at the first follow-up period (t(99) = 6.17, p < .001; mean reduction in VL = 0.91 log₁₀ VL). In the next phase of the study, the most cost-effective combination of components will be identified, which will comprise the “optimized” multi-component intervention.

Conclusions and Implications. Innovative, efficient, and culturally salient intervention approaches are needed to reduce racial/ethnic disparities in HIV. The MOST framework is acceptable and feasible for this population, and the culturally salient intervention components are promising.