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Comprehensive Process Mapping and Qualitative Interviews to Inform Implementation of Rapid Linkage to HIV Care Programs in a Mid-Sized Urban Setting in the Southern United States

Pettit, April C. MD, MPHa; Pichon, Latrice C. PhD, MPHb; Ahonkhai, Aima A. MD, MPHa; Robinson, Cedric BSc; Randolph, Bruce MD, MPHc; Gaur, Aditya MDd; Stubbs, Andrea MPAd; Summers, Nathan A. MD, MSce; Truss, Kimberly MPHf; Brantley, Meredith PhD, MPHf; Devasia, Rose MD, MPHf; Teti, Michelle MPH, DrPHg; Gimbel, Sarah PhD, MPHh; Dombrowski, Julia C. MD, MPHi

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: July 1, 2022 - Volume 90 - Issue S1 - p S56-S64
doi: 10.1097/QAI.0000000000002986
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Abstract

  • Evidence-based innovation: Rapid initiation of HIV antiretroviral therapy (ART).
  • Innovation recipients: People newly diagnosed with HIV.
  • Setting: The municipal health department sexually transmitted infections clinic and a nearby, high volume Ryan White-funded HIV clinic in Memphis/Shelby County Tennessee, a Phase I Ending the HIV Epidemic jurisdiction in the US South.
  • Implementation gap: Rate-limiting steps and barriers in the process from HIV testing to ART prescription.
  • Primary research goal: Adapt innovation to be locally relevant and contextually appropriate.

INTRODUCTION

The Centers for Disease Control and Prevention (CDC) estimated that 38,000 people were newly diagnosed with HIV in the United States in 2018.1 The US Ending the HIV Epidemic (EHE): A Plan for America set goals for a 75% reduction in new HIV infections by 2025 and 90% by 2030. This initiative focuses on geographic “hot spots” that account for >50% of new diagnoses. A critical component of the US EHE plan is rapid and effective antiretroviral therapy (ART) to achieve sustained viral suppression2; this is important for both individual and community health because it extends the lives of people living with HIV (PLWH) and prevents HIV transmission.3 As such, the US HIV treatment guidelines recommend initiation of HIV treatment on or as close to the date of HIV diagnosis as possible.4

Memphis/Shelby County, Tennessee, is a US EHE “hot spot,” ranking fourth in 2018 among all Metropolitan Statistical Areas (MSAs) for new HIV diagnoses.1 Among those newly diagnosed in Memphis, 85% are Black compared with 42% nationally. In 2018, only 47% of those newly diagnosed with HIV in Memphis/Shelby County were linked to HIV care within 30 days5 compared with 80% nationally.6

Experience from large, urban settings shows that rapid ART initiation within days of HIV diagnosis is feasible and leads to improved HIV outcomes,7–9 but data from smaller urban settings including southern mid-sized cities such as Memphis, Tennessee, are limited. In 2018, a rapid ART program for youth younger than 21 years old was launched at the St. Jude Children's Research Hospital HIV Clinic in Memphis. Perceived barriers to rapid ART in this population include difficulties with adjustment to diagnosis and disclosure to family, mental health comorbidities, and readiness to start and maintain medication adherence.10 However, these rapid ART models are fit to their specific patient population and setting, requiring adaptation for implementation in new populations or settings. We gathered preimplementation data on the determinants of rapid ART initiation in Memphis for adults 21 years and older to inform the future design and implementation of a locally relevant and contextually appropriate rapid ART model.

METHODS

Methodologic Overview

Systems engineering, qualitative, and implementation science grounded methodologies were used in this analysis.11 Process mapping is one important systems engineering technique in which physical maps are drawn by health care workers of the paths their patients take during clinical care.12 This approach helps identify rate-limiting steps and brings stakeholders to consensus on the system-level processes their patients navigate. Using process mapping and in-depth interviewing methods, we collected preimplementation data on the determinants of rapid ART initiation in Memphis/Shelby County. Results from process mapping and in-depth interviews (IDIs) were evaluated using a Consolidated Framework for Implementation Science Research (CFIR)-guided lens to systematically assess barriers and facilitators to rapid ART initiation. We prioritized 2–3 constructs within each of the 5 CFIR domains: Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Process. Selection of CFIR constructs was guided by available literature and existing knowledge of current Memphis/Shelby County ART initiation processes among study team members.

Community Stakeholder Engagement

Local community stakeholders were actively involved in process mapping and qualitative interview activities. These stakeholders included the Memphis Connect to Protect (C2P) HIV community coalition coordinated by St. Jude Children's Research Hospital Department of Infectious Diseases. In this way, we used a community-engaged approach for conceptualization of the project, facilitation of data acquisition and policy information, collection of feedback, and dissemination of results.

Process Mapping

The 2 organizations of focus were selected based on a priori knowledge of their role in providing high-volume HIV testing and care services in Shelby County, their proximity in location (to facilitate rapid ART start), and involvement in the Memphis EHE planning activities. The municipal health department's Sexually Transmitted Infections Clinic (hereafter referred to as “the STI Clinic”) is the single largest HIV diagnosing site in Memphis and serves a priority population who are mostly uninsured, predominantly underrepresented minorities, and thus disproportionately affected by poor HIV outcomes. The nearby HIV care clinic (hereafter referred to as “the HIV Clinic”) is funded by the federal Ryan White HIV/AIDS Program (RWHAP), managed by the Health Resources and Services Administration (HRSA) to provide a comprehensive system of HIV primary medical care, essential support services, and medications for low-income PLWH. This clinic serves over 2000 people living with HIV and 80% are Black, which is comparable with the proportion Black of those newly diagnosed with HIV throughout Memphis. The Vanderbilt Institutional Review Board (#191633) determined that the process mapping component did not qualify as human subjects research per 45 CFR §46.102(d).

The study team worked with leaders at the sexually transmitted infection (STI) and HIV Clinics to identify staff interviewees at each step along the HIV testing to treatment cascade using site organizational charts. Research team members conducted process mapping interviews from November 2019 to January 2020. We conducted one site visit at the STI Clinic and a second site visit at the HIV Clinic on dates during which staff from each area of the clinic were on-site and there was an average patient census. Both site visits began with administrative leadership meetings to discuss the goals of the project and the day's agenda. Interviews were conducted sequentially, from the patient perspective, to map the care-seeking process, starting with the front desk staff who greet patients at arrival. All interviews were conducted in person, and whenever possible, in the actual location of the staff member's work without the presence of a supervisor.

We created a semistructured interview script, guided by an iterative questioning format covering the sequential patient care steps and prioritizing relevant CFIR domains/constructs. We collected related data forms, such as patient registration forms, test result cards, and patient informational handouts to understand how they informed navigation through the care process. We asked each staff member during individual interviews to estimate the time required to complete each step and process delays, including facility-specific policy requirements. After each visit, the research team reviewed interview notes and drafted a process map that was discussed at a consensus meeting attended by the research team, local stakeholders, and leadership from both the STI and HIV Clinics. Process maps were finalized using Microsoft Visio software.

Qualitative In-Depth Interviews

Key informants (KIs) were recruited using convenience sampling through a personal email invitation. IDIs were conducted from October 2019 to May 2020 to elucidate current care systems and inform system-level improvements in rapid ART initiation. Using a semistructured discussion guide developed by the community–academic partnership and guided by prioritized CFIR constructs/domains, individual interviews were conducted with KIs representing Memphis-based linkage coordinators, medical/support service providers, CDC HIV Prevention Program-funded HIV testers, and newly diagnosed/linked clients not affiliated with either the HIV or STI Clinics. The University of Memphis Institutional Review Board (PRO-FY2020-62) determined that the IDI process did not qualify as human subjects research per 45 CFR §46.102(d).

Interviews were digitally recorded, transcribed verbatim, and verified by a research team member (L.P.). Two research team members (L.P. and M.T.) independently read each transcript, developed a codebook, used thematic analytic approaches, and met monthly to reconcile coding discrepancies. Terms such as “barriers,” “problems,” and “challenges” were used to assign descriptive code labels, and each coder matched excerpts from the text to codes.

RESULTS

Process Mapping: HIV Testing at the STI Clinic

At the STI Clinic, research team members interviewed 15 staff (Table 1), and the consensus process map is shown in Figure 1. Patients who present to the STI Clinic for HIV testing complete an HIV risk assessment that identified individuals as high risk if they reported any of the following: sex with a gay or bisexual man, someone living with HIV, a man who has served time in prison, and someone who uses injection drugs; personal history of injection drug use or incarceration; and exchange of sex for money or drugs. Patients who meet the clinic's high-risk criteria have a blood-based rapid HIV antibody test performed in the clinic-based laboratory, with results in 20 minutes (OraQuick Advance). Those who do not meet high-risk criteria and those with positive rapid tests have blood drawn for a HIV antigen/antibody test, performed by the TDH State Laboratory (Nashville, TN), which provides results within 7 days (Geenius). Patients with positive tests receive their results in-person.

TABLE 1. - Characteristics of STI Clinic Staff Interviewed
Job Title Duties Number Interviewed
Health Officer Oversees health department HIV/STI prevention activities 1
Manager, Office of Epidemiology and Infectious Diseases Oversees the STI Clinic operations and HIV/STI disease intervention processes 1
Chief of Epidemiology Oversees collection and reporting of public health HIV/STI data 1
Front Desk Staff Register patients in STI Clinics 2
Medical Records Staff Create clinic charts, enter laboratory results into medical records, and receive calls from patients 1
Medical Assistant Collects specimens for HIV/STI testing 1
Clinical Nurse Assesses patients with STI-related symptoms 1
Disease Intervention Specialists Deliver HIV results to patients, conduct partner service interviews, and connect patients with new HIV diagnoses to social worker 2
Social Worker Medical case management, support service referrals, and assistance scheduling initial HIV Clinic appointment 1
HIV/STI Epidemiology Surveillance Staff Conduct administrative investigation and data entry for all HIV test results in Shelby County 3
RWHAP Part A Director Oversees RWHAP-funded services in the STI Clinic and community contracts for HIV support services 1
Total 15

F1
FIGURE 1

If a patient with a newly positive rapid HIV result is younger or aged 21 years, the health department's disease intervention specialist (DIS) conducts a same-day partner service interview and contacts a linkage coordinator at St. Jude Children's Research Hospital. If the patient is older than 21 years, the DIS conducts a partner service interview and provides HIV education. On the same day, an on-site social worker provides information on care options, conducts a needs assessment for payment assistance and support services, and begins documentation for RWHAP eligibility. The patient is advised to return in 7 days for receipt of their confirmatory HIV test results, meet with a social worker to receive their RWHAP eligibility card (if documents are complete), and schedule an HIV medical care appointment (Fig. 1). Attempts to reach patients who do not return to clinic for HIV test results are conducted until contact is made.

Process Mapping: Establishing Care at the HIV Clinic

In Tennessee, RWHAP funds require documentation of diagnosed HIV infection by a CDC-recommended laboratory algorithm,13 residence in Tennessee , and a modified adjusted gross monthly household income ≤400% of the current federal poverty level. Proof of residence includes photo identification, 2 documents addressed to the patient such as utility bills, or an attestation. Income documentation requires either pay stubs or an attestation. Collecting RWHAP eligibility documents often necessitate significant time and assistance from DIS staff.

At the HIV clinic, research team members met with 17 staff (Table 2), and the consensus process map is shown in Figure 1. New patient appointments are generally available 4–6 weeks from the time of STI Clinic notification. Once scheduled, a peer navigator completes a personal phone call reminder before the first appointment. At the first HIV Clinic visit, the patient meets with case management staff and HIV health care provider staff. The timing of ART initiation is provider-dependent, with some providing same-day ART initiation and others waiting until a 2–4-week follow-up visit (Fig. 1).

TABLE 2. - Characteristics of HIV Clinic Staff Interviewed
Job Title Duties Number Interviewed
Program Manager Oversees HIV Clinic operations 1
Medical Director Oversees HIV Clinic medical services 1
Case Management and Early Intervention Services Manager Oversees case management and early intervention services staff 1
Front Desk Staff Register patients in HIV Clinic 2
Medical Assistant/Nursing Staff Assigns patient to examination room, assess vital signs, and administer vaccinations 2
Laboratory Specimen collection and processing 1
HIV Care Providers Provide HIV care and treatment services 2
On-site Pharmacy Process and dispense ART prescriptions 1
Data Manager Data entry and reporting to HRSA 2
Case Management Medical case management and support service referrals 1
Peer Coordinator Direct health system navigation, health advocacy, education, and linkage to relevant health resources 1
Early Intervention Services Counseling, referral to services, linkage to care, and HIV education and health literacy training 2
Total 17

Process Mapping: Rate-Limiting Steps in HIV Testing and Linkage

In the joint meeting between STI and HIV Clinic staff facilitated by the study team, several rapid ART determinants were identified. At the STI Clinic, the wait time for laboratory-based confirmation of HIV test results was identified as a barrier to expediting ART initiation. At the HIV Clinic, the need for additional HIV care provider availability/clinic space and variability among providers in the knowledge and acceptability of rapid ART initiation were identified as rapid ART initiation barriers. Staff from both sites identified RWHAP eligibility documentation requirements, lack of expansion of Medicaid in Tennessee, and lack of resources to address social determinants of health (housing instability, food insecurity, and lack of transportation) as additional barriers to accelerating ART initiation.

Qualitative In-Depth Interviews

We interviewed 23 KIs; 30% were living with HIV, 78% were cisgender female, 78% were heterosexual, 91% were Black, and 50% were members of the Memphis C2P HIV community coalition. Five themes emerged to describe KIs' perspectives on rapid ART initiation. IDIs corroborated process mapping interviews in several notable ways. Each theme is described below and representative quotes can be found in Table 3.

TABLE 3. - Description of Key Themes as Barriers to Rapid Linkage and ART Initiation
Themes Example Quotes
Stigma, fear of unknown, and medical mistrust “It's the initial shock, and it's sometimes anger, sometimes it's not wanting to be bothered, they want to deal with it on their own in the best way they can, they try to put it to the back of their mind like it never happened. A lot of it is they don't want their family to know, just being harder on themselves, because of the stigma that's attached to HIV, and that sometimes prevents people from coming in.”
“The medical case manager said that the young man had a terrible attitude. I asked him, ‘Well what happened?’ He was saying he had an attitude because when they did the blood from his arm, they snatched it out, and it hurt. I'm like be patient centered not fake it.”
Provider knowledge, attitudes, and beliefs “I've learned that doctors don't do well with nondoctors. It's like if you can get medical providers to get on board, it's going to be other medical providers convincing them to do that.”
“Only thing I would be concerned is if a certain medication doesn't work for a certain particular person's virus.”
“In the studies and guidance on the rapid start, they recognize when someone's really not ready to start. You do have to be aware of that. Of course, we're concerned about resistance. With the Biktarvy, we don't really see a whole lot of integrase inhibitor resistance. The M184 is the common resistance pattern you see, but that could go away over time. It doesn't necessarily mean they're going to be permanently resistant to that. We're not as terrified of resistance as we used to be. That would be people's excuse for not doing it, is bringing resistance from non-adherence. That's not even as scary as it used to be.”
Provider capacity “At first I thought, we're going to be bombarded with patients. My fear was that you start them on this medication on the first day, we didn't have a genetic result. That was my concern until this new class of medicines the integrase inhibitors came out. Once I realized it was a new medicine, I was more apt to agree with starting them on the first day. Initially, I was very apprehensive about it because I didn't know if they had any resistance to any of the medicines that were out already.”
“I was a little apprehensive about it [rapid ART].”
“It would just take the agency being willing to try something different. Some providers, some agencies feel they don't have appointment times and space.”
“We just need more options for people. In Memphis, we need more access points for Ryan White patients so that they can be seen sooner.”
“I just think it depends on what type of clinic setting you have. If your provider is only seeing this type of client that day, that's fine. If you're integrated with everything else, to me, it takes time to switch gears.”
Patient insurance coverage “There's no cookie cutter approach to getting a patient on medication because I can see 5 different patients in a day and I would have to go through 5 different steps to give that person what they possibly needed. We're not even talking about if they have Medicare, they have the part B plan. There's a stipulation for everything.”
Social determinants “People have transportation barriers. Patients are poor. They don't have resources, so they can't come to their doctors. Some of them feel like ‘Look, I'm going to miss work. I can't miss work. I just started this new job’. It's so many other things that are really challenges. The problems that I feel are bigger problems are problems that our patients have to deal with, meaning poverty. If we could change some of that, some of these other challenges, like even delayed entry to care, some of these other things would not be as big of an issue.”

Stigma, Fear of Unknown, and Medical Mistrust

Clients newly diagnosed with HIV expressed fears of not being accepted by loved ones and sex partners. KIs discussed client concern of HIV status disclosure without their permission. A new HIV diagnosis can be overwhelming for clients, and some described poor treatment during initial health care visits. According to KIs, clients experience emotional responses of shock, depression, and anger that may prevent rapid ART initiation.

Provider Knowledge, Attitudes, and Beliefs

Several HIV care providers expressed apprehension regarding rapid ART initiation with concerns about medication resistance and effectiveness.

“Initially, I was very apprehensive about it because I didn't know if they had any resistance to any of the medicines that were out already.”

Provider Capacity

KIs expressed concerns of the impact of rapid ART initiation on individual providers and understaffed clinics. Community-based organizations offering HIV testing lack the capacity to employ on-site providers to prescribe ART.

“Concern would be how [Rapid ART] affects the clinic's flow. If you have patients that you're seeing regularly and someone comes in and they test positive, then you have to stop and do extra steps. If you're the only provider there, that could be a bit much. There should be somewhere people can go for service.”

Patient Insurance Coverage

Assessing and documenting RWHAP eligibility is another challenge for rapid ART initiation.

“You got to bring these papers in, you got to do this…. It's a lot of challenges out there with the system.”

Proof of residency is the main challenge for transient clients, and proof of income is a barrier for those unemployed or informally employed. One KI mentioned case managers are asked to attest for the client but are unable given the short window of time knowing the client and insufficient rapport built. Another KI lamented the stipulations of private insurance and the use of specialty pharmacies for medications.

“Oftentimes, I would almost prefer people to be uninsured because it's easier. For example, Cigna and Blue Cross Blue Shield require a patient to go to a specialty pharmacy. On top of that, they will require a prior authorization. Which is like adding more steps. It can be a process, unnecessarily, just because that's what the insurance requires.”

Psychosocial Determinants

KIs discussed client denial of their new HIV diagnosis and beliefs about treatment readiness as barriers to rapid ART initiation. KIs discussed factors such as poverty, transportation, and employment status as determinants superseding delayed medical treatment.

Table 4 provides the barriers and facilitators of rapid ART initiation identified in both the process mapping and IDIs using the CFIR.

TABLE 4. - Important CFIR Domains and Constructs Identified in Process Mapping and Qualitative In-Depth Interviews
Domains Constructs Preimplementation Determinants Identified
Intervention characteristics Evidence strength and quality
Relative advantage
Perceptions regarding published evidence strength/quality and relative advantage differ by HIV providers
Inner setting Implementation climate
Goals and feedback
Readiness for implementation
Leadership engagement
Available resources
Need to consider the impact of COVID-19 pandemic
Leadership of HIV testing and treatment facilities is engaged in planning and preimplementation
Staff of HIV testing and treatment facilities have concerns over availability of staff, space needs, and workflow disruption
Staff from both HIV testing and treatment facilities have requested establishment of goals and feedback on progress toward goals
Outer setting Patient needs/resources
Cosmopolitanism
Peer pressure
External policies/incentives
Patients desire rapid ART initiation; experience stigma, fear of unknown, and medical mistrust; and need resources to address social determinants of health
Staff of HIV testing and treatment facilities feel communication between the 2 should be improved
Successful rapid ART initiation model exists in Memphis between health department and St. Jude for adolescents and young adults
Local Memphis and national EHE initiatives prioritize rapid ART initiation models
Characteristics of individuals Intervention knowledge/beliefs
Other personal attributes
Motivation
Knowledge and beliefs regarding rapid ART initiation and associations with loss to follow-up and adherence/ART resistance differed by providers
Motivation of HIV care providers to be flexible with scheduling newly diagnosed individuals is variable
Process Planning
Engaging
Opinion leaders
Champions
External change agents
Reflecting and evaluating
Planning for rapid ART initiation has been ongoing for almost 2 yr with support from Tennessee Center for AIDS Research EHE supplement funding
Opinion leaders and champions within both administrative and clinical leadership are present at both HIV testing and care facilities
Tennessee Center for AIDS Research serves as an external change agent
Reflection and evaluating requested

DISCUSSION

Our preimplementation process mapping and qualitative IDI approach identified several areas where procedures and policy changes could have the greatest impact on improving systems flow and patient-level HIV clinical outcomes. By working directly with the front-line staff and clinic leaders, funders of HIV testing, and care and support services and facilitating consensus conversations with key decision makers, we were able to stimulate rapid ART program planning in Memphis, Tennessee.

The current process of a rapid HIV test performed in the STI Clinic followed by a laboratory-based HIV test processed off-site contributed to long delays in HIV status confirmation allowing for loss to follow-up. Confirming a positive test with a second rapid test of a different type13 could substantially decrease the time to HIV status confirmation, eliminate loss to follow-up at the confirmation phase, and facilitate rapid ART initiation. The Tennessee Department of Health has supported rapid––rapid HIV testing in other clinical settings across the state by providing testing kits, updating local HIV testing protocols, and providing rapid–rapid HIV testing training; leveraging of these resources by local public health in Memphis will be critical to rapid ART implementation. This shift in the HIV testing algorithm could also have potential implications for the St. Jude rapid ART program as youth with false-positive HIV screening tests collected at the STI Clinic would not need to visit St. Jude for HIV test confirmation.

The RWHAP is crucial for uninsured and underinsured PLWH. However, RWHAP eligibility documentation requirements were identified as barriers to rapid ART initiation. It can take days to weeks for PLWH to acquire documentation for RWHAP eligibility confirmation. Although presumptive eligibility without confirmatory documentation is allowed for 60 days for RWHAP Part A (PLWH residing in the Memphis Transitional Grant Area, administered by Memphis/Shelby County Health Department), it was not allowed for Ryan White Part B (PLWH residing outside the Memphis Transitional Grant Area, administered by Tennessee Department of Health) at the time of this study. Routinely using presumptive RWHAP eligibility processes could substantially streamline processes for rapid ART initiation.

Insufficient provider availability and clinic space were identified as barriers to rapid ART initiation. Several studies have shown gaps between the current workforce with HIV expertise and demand for HIV services.14,15 This gap is alarmingly wide in the US South, the epicenter of the US HIV epidemic.16 Armstrong et al proposed a two-pronged strategy to address the HIV workforce shortage. First strategy is establishment of a broad base of clinicians serving a small number of patients. Second strategy is recruitment and training of HIV experts working as high-volume providers in high-burden areas such as Memphis, Tennessee.17 Task-sharing and differentiated care models that prioritize patients with higher medical needs and those newly diagnosed with HIV are other potential means to address the qualified provider shortage.18–20

In addition to the provider shortage, knowledge, attitudes, and beliefs about rapid ART initiation varied by provider. Funded by HRSA, there exists a national system of AIDS Education Training Centers (AETCs) consisted of leading HIV experts who provide locally based, tailored education to integrate high-quality comprehensive care for PLWH. Several studies have demonstrated success of AETCs in expanding and increasing quality care provided to PLWH.21,22 As an example, the Southeast AETC, coordinated by the Vanderbilt Comprehensive Care Clinic (Nashville, TN), conducted a 4-year practice transformation initiative, in which participating clinics worked toward self-selected organizational goals to increase their HIV care capacity and quality.23 Improvement, expansion, and provider uptake of initiatives focused on rapid ART initiation may help address provider variability.

Lack of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) in Tennessee was identified as a barrier to rapid ART initiation. The ACA allowed for elimination of exclusion based on pre-existing conditions, reformation of private insurance with institution of qualified health plans (QHPs),24 and expansion of Medicaid eligibility in 2014. However, many states in the US South opted out of Medicaid expansion despite serving a disproportionately large population of uninsured PLWH. Although the HRSA HIV/AIDS Bureau now allows for AIDS Drug Assistance Program funds to be used for copayments, deductibles, and premiums associated with enrollment in QHPs,25 there is also regional variability in QHP access. The proportion of PLWH who were insured increased after ACA implementation, although a significant proportion of PLWH remained uninsured.26,27 However, it is unclear whether there have been significant changes in important HIV continuum of care outcomes, including viral suppression.27–29 This may be because Medicaid and QHPs do not provide “wrap-around” services like the RWHAP including case management and mental health care.

Social determinants of health including housing instability, food insecurity, transportation, and psychological factors, including stigma, fear of the unknown, and medical mistrust, are well-known to have crucial impacts on HIV health outcomes. For rapid ART programs to succeed, health systems need to design programs that address social determinants of health and attend to psychosocial factors. Integration of screening and referral or provision of services for psychosocial determinants with HIV care and treatment is critical. There is also evidence that community health worker interventions can improve psychosocial outcomes for PLWH. A community health worker is defined by the American Public Health Association as a front-line public health worker who is a trusted member of the community or has an unusually close understanding of the community served.30 Community advocates have an important role in pushing structural and policy change to address social determinants of health and change factors such as HIV criminalization laws that foster stigma.

Both facilities identified a need for increased cosmopolitanism or interorganizational networking.31 Collaboration between the STI and HIV Clinics, supported by their leadership and facilitated by this study, was critical to the success of our preimplementation work. HIV community organizing groups such as the Memphis C2P HIV community coalition are crucial for facilitating ongoing, sustained cross-agency collaboration to make rapid ART initiation a reality in Memphis.

There were limitations to this work. These results are generalizable only to individuals who reach the health care system and do not address those with undiagnosed HIV infection. This work was conducted at 2 clinics in Memphis, Shelby County, although we expect the results will be generalizable across this EHE jurisdiction, Tennessee, and regions of the US South with similar demographic characteristics and health care challenges. Even if the results themselves are not generalizable, our methods could be used to generate local results in settings across the country. In addition, KIs were not affiliated with, and therefore not in a position to implement rapid ART, either the HIV or STI Clinic. This limited their ability to describe rapid ART determinants in these specific settings, although they were well-positioned to describe city-level and county-level determinants.

CONCLUSIONS

Our preimplementation work including process mapping and qualitative IDIs identified several areas where procedures and policy changes may have the greatest impact on improving systems flow and patient-level clinical outcomes. We plan to use these results to generate potential implementation strategies that will be refined and evaluated in future research. Ultimately, this work will inform the design and implementation of a multifaceted, rapid ART initiation package locally relevant to the Memphis community and scaling out rapid ART across Tennessee.

ACKNOWLEDGMENTS

The authors acknowledge the Connect to Protect (C2P) Memphis HIV community coalition for their feedback and input on this work. C. Robinson is deceased author.

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Keywords:

HIV; linkage to care; ART; process mapping; in-depth interviews; EHE

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