Integrating Harm Reduction, Critical Race Theory, and Self-Determination Theory to Advance Interventions for Black and Latinx Persons Living with HIV Not Well-Engaged in HIV Care Nor Virally Suppressed

Background and Purpose: Black and Latinx (BL) persons living with HIV (PLWH) experience serious structural, social, and individual-level challenges to engagement along the HIV care continuum, including structural racism, leading to health inequity. The complex factors driving these inequities call for innovative approaches. We tested five social/behavioral intervention components for BL-PLWH poorly engaged along the HIV care continuum that integrate harm reduction (HR), critical race theory (CRT), and self-determination theory (SDT). HR was applied broadly to physical/mental health challenges, including substance use. CRT was used to center the experiences/perspectives of BL-PLWH regarding structural barriers. SDT tapped into participants’ intrinsic motivation and autonomy, consistent with HR. This mixed methods study describes the HR-CRT-SDT conceptual approach, participants’ perspectives on acceptable/useful study features, and preliminary evidence of intervention efficacy.

Methods: Participants were part of a larger study using multiphase optimization strategy to optimize an HIV care continuum intervention. All staff were trained in HR-CRT-SDT, which informed each aspect of study procedures (e.g., recruitment, the consent process, scheduling assessments), as well as the specific content of the five discrete intervention components (counseling sessions, pre-adherence skills/habits, peer mentoring, support groups, patient navigation). Participants were BL-PLWH with poor engagement along the HIV care continuum and non-suppressed HIV viral load (VL; N=512). HIV VL was tested at enrollment and throughout the 12-month study period. A subset of participants was randomly selected for in-depth interviews (N=48). A team of co-coders used a systematic content analysis approach that was theory-driven, deductive, and inductive.

Results: Participants were mostly men (72%), Black (70%), from low-socioeconomic status backgrounds. At enrollment, participants were, on average, 47 years old (SD=11 years) and had lived with HIV for an average of 19.7 years (SD=9.1 years). HIV log₁₀ VL at enrollment was high (4.07 pp/mL [SD=1.09 pp/mL]), and serious barriers to engagement were prevalent (substance use, homelessness, incarceration, unemployment). Preliminary analyses found a significant reduction in HIV VL across components at first follow-up (t(99)=6.17, p< .001; mean reduction=0.91 log₁₀ VL). Results indicated the HR-CRT-SDT approach produced a number of effective non-specific study features, primary among them a non-judgmental, positive emotional environment that fostered study engagement. Other useful non-specific features included financial incentives, active outreach, individual attention, staff flexibility and expertise. Effective specific aspects of intervention components identified were consistent with HR-CRT-SDT (e.g., prompting goal formation, self-reflection, and decision-making autonomy). Structural barriers persisted but could be partially circumvented in conjunction with proper supports. These non-specific and specific features were seen as largely absent in most service settings.

Conclusions and Implications: HR-CRT-SDT complement each other and, in combination, can be a potent model guiding the design of both non-specific aspects of clinical and research settings, as well as specific intervention components that produce an environment supportive of autonomy and reflective of participants’ larger social/structural contexts, including structural racism. This, in turn, has great potential to support individuals’ behavior change goals, including ART uptake/adherence. Future research will include further exploration of the HR-SDT-CRT model, and possible applications to other domains where inequities exist.