Advancing HIV Justice in the U.S. South through Equity-Centered Implementation Exploration: Examining the Compass Initiative Listen in Session Methodologies, Outcomes and Applications

Background

HIV in the U.S. South has been shaped by structural racism, anti-Blackness, and intersectional oppression.These harmful structures continue to drive HIV transmission as well as inequities in access to care and health outcomes. To advance health equity, HIV initiatives in the U.S. South must account for this sociopolitical context throughout implementation. Attention to equity is particularly consequential during the exploration phase, when critical decisions are being made regarding project narrative, resource distribution and stakeholder engagement. Despite this, there is little academic literature identifying best practices in equity-centered exploration. In response, we present a case study of the exploration phase for a large-scale, multi-state initiative to combat HIV in the U.S. South through funding, organizational capacity building, and leadership training. Using the Public Health Critical Race Praxis framework (Ford & Airhihenbuwa, 2010) and emerging work in equity-centered implementation science (Stanton et al., 2022), we examine our strategies to address power and inequity during exploration, as well as their impact on our resulting data and, ultimately, initiative implementation.

Methods

Multiple sources of reflective data were leveraged for this study, including LIS Team internal notes and planning documents, diverse qualitative and quantitative data collected through LIS activities, programmatic structures resulting from LIS findings, and initiative evaluation outcomes. Best practices were identified through regular reflexive discussions with the LIS team, guided by our theoretical frameworks. These insights were then layered onto existing thematic analysis of LIS data used for formative evaluation, as well as quantitative outcome evaluation data, for a comprehensive view of LIS methods, outcomes and applications.

Results

We identified four best practices that facilitated the integration of racial justice and health equity in both LIS results and process: 1) the LIS Team developed transparent decision-making methods for LIS site selection and protocol development to center marginalized voices and prioritize communities disproportionately impacted by HIV; 2) the LIS Team drew on diverse sources of data, accessing a range of epistemic positionalities; 3) people living with HIV, were involved at all stages; and 4) we developed community accountability structures to act on LIS data and track its integration into program implementation. These practices led to data rich with insights into the machinations of structural racism impacting HIV in the South and directly informed initiative implementation. Evaluation data indicates equity-promoting outcomes of initiative implementation, such as high rates of grants awarded to organizations led by populations disproportionately impacted by HIV, material support of grassroots and advocacy oriented organizations and investment in equity-centered approaches to HIV care such as harm reduction and trauma informed care.

Discussion

Implementation science can be effectively leveraged to promote health equity. However, this will not be achieved without conscientious integration of theories which directly address power and the racialized construction of society. Further, attention to equity in initial phases must be tracked throughout implementation and, ultimately, through outcomes. Our case study instantiates this process, its challenges, opportunities and implications for social work.