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Supplement Article

Profile of the Portfolio of NIH-Funded HIV Implementation Research Projects to Inform Ending the HIV Epidemic Strategies

Queiroz, Artur PhDa; Mongrella, Melissa MHSa; Keiser, Brennan MSWa; Li, Dennis H. PhDa,b,c; Benbow, Nanette MASb,c; Mustanski, Brian PhDa,b,d

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: July 1, 2022 - Volume 90 - Issue S1 - p S23-S31
doi: 10.1097/QAI.0000000000002962

Abstract

BACKGROUND

In February 2019, the US government announced an ambitious goal to end the HIV epidemic in the United States by the year 2030. The Ending the HIV Epidemic in the US initiative (EHE)1 involves multiple federal agencies and is structured around 4 pillars: prevent, diagnose, treat, and respond to improve HIV programs, resources, and service delivery infrastructure. It assumes that health systems already have the necessary interventions to end the HIV epidemic but need to optimize their implementation to get them in the hands of the right people at the right time.

The Implementation Science Coordination Initiative (ISCI; HIVimpsci.northwestern.edu) provides scientific support and coordination for implementation research (IR) projects funded by the National Institutes of Health (NIH), primarily through its Centers for AIDS Research and AIDS Research Centers (CFAR/ARCs).2 Since 2019, NIH has funded 117 unique CFAR/ARC supplement projects, with 65 1-year planning projects in the first year. In the second year, 34 projects were funded, comprising new 1-year projects and 12 ongoing projects that received 2 years of additional funding. In the third year, 36 new 1-year projects were funded.

In years 2 and 3, NIH defined specific priority areas in the request for proposals, thereby shaping the overall makeup of each project cohort. In year 2, for example, 7 of the 34 projects focused on increasing pre-exposure prophylaxis (PrEP) uptake among cisgender heterosexual women, 6 leveraged data to inform key communication strategies for EHE, and 9 others were team-initiated IR projects. In year 3, 15 of the 36 new projects more were team-initiated IR and 21 sought out to address social and structural determinants using an intersectional framework. This trend of defining interest areas has continued into the fourth request for supplement proposals and plays a significant role in shaping the overall portfolio of IR supplement projects.

All IR projects involve partnerships between CFAR/ARC investigators and local health officials and/or community organizations in 1 of 57 EHE priority areas. Although these projects are based on complex scientific theory and methods, their real potential can only be achieved when derived from and implemented in “real-world” settings. These research–practice partnerships are essential because research alone can produce a “blind” and decontextualized notion of the needs of service delivery settings by prioritizing a pristine level of biomedical evidence much more than the social, economic, and policy context in which these interventions are applied.3,4

To meet the ISCI objectives of making the knowledge of these initiatives accessible and generalizable, in this article, we will describe these projects, characterizing them to understand how they respond to the objectives of the EHE, and provide a portrait of where HIV IS in the United States is heading. This description of projects can identify areas for shared learning, collaboration, and harmonization of different research areas while highlighting coverage and gaps in the growing US HIV IS portfolio.

METHODS

Participants

Data were obtained from the CFAR/ARC NIH supplement principal investigator or another representative of the project. Participation in data reporting was an expected component of funding, which increased participation and completeness on the part of projects. The institutional review board determined this data collection was not human subjects research.

Procedures

Baseline data were collected in September of each year that the projects were funded (ie, FY19, FY20, and FY21).2 Data collection used the REDCap platform (http://www.projectredcap.org), which allowed for multiple survey item types and error checking during data collection for sensible alpha-numeric content and ranges for numeric data. The integrated database for the baseline surveys had 180 questions (53 in FY19, 64 in FY20, and 63 in FY21).

Measures

The surveys included questions regarding the EHE pillar(s) addressed by the projects, IS framework used, geographic jurisdiction, type of organization of the implementation partner, and other projects characteristics. In the first year, most of the questions were free response (eg, “Describe the clinical or prevention intervention(s) that respondent is trying to implement in the supplement”). At the end of the first year, qualitative coding of themes allowed us to quantify and standardize measures for the survey, which informed multiple-choice questions in subsequent years (eg, “Choose the implementation frameworks being used”).

For the description of EHE projects in this article, we examined the following variables: funding year, pillars, county/state jurisdiction, type of organization of implementation partner, intervention used, target population(s), implementation stage, IS framework(s) used, and expected implementation outcomes. Most variables were multiple-choice questions.

The exploration, preparation, implementation, sustainment (EPIS) framework5 was used to guide the classification of project implementation stage, namely exploration (identifying practices to be implemented, assessing system, organization, provider, and client-level factors that explain service gaps and potential barriers/facilitators for a change), preparation (redesigning the system to enhance service availability and ensure consistent implementation of proposed changes), implementation (training, coaching, and active facilitation of evidence-based practices to be adopted), and sustainment (maintaining the use of the newly installed practices).

Analysis

Data were exported from REDCap to 2 Excel sheets, one with data for the first year and the other for the following years. This division was made because of differences in question format, where the first year was primarily qualitative data. Initially, open-ended variables with qualitative data were coded to match the question in the following years, allowing them to be combined in a single, integrated database.

The variables in the databases were characterized, transformed, and later recategorized to extend the analysis across the 3 years. We used univariate and bivariate analyses (by pillar) to describe the projects. The total number of funded projects included 147 independently funded supplements, 117 of which were funded for only 1 year and 30 of which received additional years of funding to expand on their initial 1-year project. For this analysis, the 2-year projects were considered independent (rather than combined with their initial 1-year grant) because some projects expanded their focus or moved in new directions with their 2-year awards and so it is most informative to treat them as distinct. Not all survey questions were asked every year, and others allowed more than 1 answer (such as the framework used or the partner institution); as such, the total number of responses per variable may vary. For this article, data are reported for 130 projects (out of 147 = 88%) that responded to the included variables, FY19 (n = 61), FY20 (n =33), and FY 21 (n = 36).

RESULTS

Geographic Location of the Projects

EHE phase 1 priority areas included 48 counties, Washington, DC, and San Juan, Puerto Rico, and 7 priority states, primarily Southern, rural ones, with high rates of HIV. For these EHE projects, California (n = 13, 11%), Alabama (n = 8, 7%), and Florida (n = 8, 7%) were the states with the highest number of projects. Although projects cover most of the priority areas established by the EHE, there were 21 areas without project coverage: 3 counties in Texas and Ohio, 2 in Florida and Maryland, and 1 in New York. The county jurisdictions in Michigan and Nevada and the state jurisdiction of Oklahoma also had no supplement project (Fig. 1).

F1
FIGURE 1.:
Geographical distribution of FY19-21 projects (N = 130, 3 projects did not report geographical data).

EHE Pillars and Interventions

The prevent pillar was the most addressed as the primary pillar among the projects (N = 59), whereas the respond pillar was the least addressed (N = 8). It is noteworthy to point that 97 projects addressed more than 1 pillar. Figure 2 illustrates this substantial overlap across pillars. Table 1 presents projects' intervention of focus. Consistent with many projects addressing the prevent pillar, PrEP was the intervention most used (24%), followed by linkage to care (13%), retention and re-engagement (11%), HIV testing (10%), and patient navigation for treatment (8%). Fewer projects addressed syringe services programs, supervised consumption services, condom distribution programs, partner services, nPEP, and cluster detection and response, which combined accounted for less than 9% of the selected interventions (Table 1).

F2
FIGURE 2.:
Pillars addressed by the projects (N = 130, 16 projects did not report data).
TABLE 1. - Interventions Reported by the Projects (N = 130)
Intervention n %
PrEP 49 24
Linkage to care 27 13
Retention and re-engagement 22 11
HIV testing 21 10
Patient/peer navigation 16 8
ART 16 8
Behavioral intervention 14 7
Social media marketing campaign 10 5
Improved surveillance data quality or collaboration 8 4
Cluster detection and response 5 2
nPEP 3 1
Condom distribution programs 2 1
Partner services 2 1
Syringe services programs 0 0
Supervised consumption services 0 0
Other 6 3
Not reported 37 28

Figure 3 presents the type of organizations that CFARs/ARCs partnered with for their studies. The most frequent partners were health departments (25%), community-based organizations (CBOs; 22%), and Federally Qualified Health Centers (FQHCs; 21%). Most of these partnerships were recently initiated (29%) or established in the past 2 years (28%), with some being long-standing partnerships of 5 years or more (21%).

F3
FIGURE 3.:
Type of organization of EHE project's implementation partners FY19-FY21. (N = 130, 16 projects did not report partners).

Figure 4 shows the priority populations that were the focus of projects, with larger percentage of projects focused on working with Black/African American communities (19%) or Latinx communities (13%) and with gay, bi+, and other men who have sex with men (MSM) (14%). Some populations, despite their high vulnerability, have less of a focus in the portfolio, especially transgender/nonbinary people (9%) and people who inject drugs (4%).

F4
FIGURE 4.:
Priority population focus of EHE projects (N = 130, 12 projects did not report partners.

IS Theories, Models, and Frameworks

The Consolidated Framework for IR (CFIR) framework6 was the most used to study implementation determinants (32%), followed by the RE-AIM7 framework (19%) and the proctor8 model (10%) for the conceptualization and measurement of outcomes. Just over one-third of projects (n = 44; 34%) used 2 or more frameworks (Table 2).

TABLE 2. - Frameworks Being Used by EHE Projects
Framework n %
Consolidated Framework for Implementation Research (CFIR) 59 32
RE-AIM framework 35 19
Proctor implementation outcomes 18 10
EPIS (exploration, preparation, implementation, sustainability) framework 15 8
Practical, robust implementation and sustainability model (PRISM) 5 3
Promoting action on research implementation in health services (PARiHS) framework 4 2
Andersen's behavioral model of health service utilization 4 2
Stages of implementation completion (SIC) 4 2
ADAPT-ITT model 4 2
Collective impact framework 1 1
Framework for reporting adaptations and modifications to evidence-based interventions (FRAME) 1 1
PRECEDE–PROCEED 1 1
CDC knowledge to action (K2A) framework 1 1
Other 20 11
I am not using any implementation framework 1 1
To be determined/I do not know 9 5
Not reported 16 12
N =130.

Figure 5 illustrates the implementation phase of the EHE projects by pillar as defined by the EPIS framework.5 In 2019, most projects were in the initial stages of IS, mainly exploration, and in later years, more projects report being in the preparation phase. Across all years, few projects focused on sustainability of an intervention. The 2 projects that focused on sustainment were in the prevent pillar (see Figure 5, Supplemental Digital Content 1, https://links.lww.com/QAI/B894).

Implementation Outcomes

In 2019, most projects listed implementation or reach as a measured implementation outcome, but acceptability and feasibility were the most frequently used outcomes across all 3 years. On the other hand, the least used were penetration, fidelity, cost, and maintenance (see Figure 6, Supplemental Digital Content 2, https://links.lww.com/QAI/B907).

Characteristics by Pillar

Projects that listed their primary pillar as diagnose, partnered primarily with FQHCs (21%), CBOs (17%), and substance use treatment facilities (21%). The main populations these projects focused on were MSM (13%), racial/ethnic minorities (Black/African American 26% and Latinx 16%), and immigrants (10%). The interventions of these projects follow the first steps of the HIV prevention and care cascades, where testing (31%) was the most frequent, followed by linkage to care (17%) and PrEP (14%). The most applied frameworks were RE-AIM (31%), EPIS (25%), and CFIR (19%) (Table 3).

TABLE 3. - Characteristics of Projects by Primary Pillar
Pillars
Diagnose Treat Prevent Response
Partners n % n % n % n %
 Health department 3 13 15 28 18 19 6 50
 Health department clinic 1 4 3 6 7 7 2 17
 Federally Qualified Health Center (FQHC)/community-based clinic 5 21 9 17 18 19 2 17
 Hospital system 1 4 6 11 6 6 0 0
 Community-based organization 4 17 11 21 28 29 1 8
 Elementary, middle, or high school 0 0 0 0 0 0 0 0
 College or university 1 4 1 2 7 7 0 0
 Faith or spiritual organization 1 4 0 0 1 1 0 0
 Jail/prison 0 0 0 0 0 0 0 0
 Private sector partner 0 0 1 2 2 2 0 0
 Local media 0 0 0 0 1 1 0 0
 Public program 0 0 1 2 2 2 0 0
 Substance use treatment facility 5 21 1 2 1 1 0 0
 Other 3 13 5 9 5 5 1 8
Intervention
 Condom distribution program 1 3 0 0 1 1 0 0
 PrEP 4 14 0 0 42 38 2 22
 nPEP 0 0 0 0 3 3 0 0
 Behavioral intervention 1 3 0 0 10 9 0 0
 Social media marketing campaign 1 3 0 0 7 6 0 0
 HIV Testing 9 31 0 0 11 10 1 11
 Patient/peer navigation 1 3 0 0 8 7 0 0
 Linkage to care 5 17 0 0 11 10 0 0
 Retention and re-engagement 2 7 0 0 7 6 0 0
 ART 2 7 10 63 3 3 1 11
 Data to care 1 3 3 19 3 3 1 11
 Cluster detection and response 0 0 0 0 1 1 4 44
 Partner services 1 3 0 0 1 1 0 0
 Syringe services programs 0 3 0 0 0 2 0 0
 Supervised consumption services 0 0 0 0 0 0 0 0
 Other 1 0 3 0 2 0 0 0
Framework
 RE-AIM framework 5 31 11 27 12 14 1 13
 Proctor implementation outcomes 0 0 8 20 15 18 2 25
 Consolidated Framework for Implementation Research (CFIR) 3 19 13 32 29 35 2 25
 Theoretical domains framework (TDF) 0 0 0 0 0 0 0 0
 Promoting action on research implementation in health services (PARiHS) framework 1 6 0 0 2 2 1 13
 Andersen's behavioral model of health service utilization 0 0 0 0 4 5 0 0
 EPIS (exploration, preparation, implementation, sustainability) framework 4 25 3 7 3 4 0 0
 Stages of implementation completion (SIC) 1 6 2 5 1 1 0 0
 PRECEDE–PROCEED 0 0 0 0 0 0 0 0
 Framework for reporting adaptations and modifications to evidence-based interventions (FRAME) 0 0 0 0 1 1 0 0
 ADAPT-ITT model 1 6 1 2 2 2 0 0
 CDC replicating effective programs framework 0 0 0 0 0 0 0 0
 CDC knowledge to action (K2A) framework 0 0 1 2 0 0 0 0
 Collective impact framework 0 0 0 0 0 0 0 0
 Other 1 6 2 5 12 14 1 13
 To be determined 0 0 0 0 2 2 1 13
 Not using any implementation research frameworks 0 0 0 0 1 1 0 0
Priority populations
 People who inject drugs 1 3 5 6 5 3 0 0
 Noninjection drug using populations 2 6 4 5 5 3 0 0
 Sex workers 0 0 2 3 4 2 0 0
 Adolescents/young adults 1 3 5 6 15 8 0 0
 Transgender/nonbinary populations 0 0 6 8 20 10 2 18
 Men who have sex with men 4 13 9 11 32 16 1 9
 Cisgender women 1 3 6 8 17 9 1 9
 Black/African American communities 8 26 11 14 40 20 0 0
 Latino/a/x or Hispanic communities 5 16 5 6 33 17 1 9
 American Indian/Alaska Native 1 3 1 1 2 1 0 0
 Immigrant populations 3 10 3 4 14 7 0 0
 General population 2 6 13 16 10 5 5 45
 Other 3 10 9 11 2 1 1 9
Outcomes
 Reach 11 22 21 14 21 13 3 15
 Effectiveness 5 10 16 11 13 8 3 15
 Feasibility 5 10 12 8 30 19 0 0
 Acceptability 9 18 21 14 36 22 5 25
 Appropriateness 5 10 13 9 17 10 2 10
 Adoption 5 10 15 10 19 12 2 10
 Fidelity 1 2 6 4 4 2 0 0
 Penetration 0 0 1 1 1 1 2 10
 Implementation 6 12 16 11 12 7 2 10
 Maintenance/sustainability/sustainment 1 2 15 10 5 3 1 5
 Cost 1 2 7 5 1 1 0 0
 Not applicable 2 4 1 1 3 2 0 0
 I do not know 0 0 1 1 0 0 0 0
N=130.

As for the treat pillar, there was a similar distribution regarding partnerships with CBOs (21%) and FQHCs (17%) but there was a larger percentage of partnerships with health departments (28%) and hospital systems (11%). In this pillar, projects sought to address timely access to care and treatment through antiretroviral therapy (63%) and data to care (19%) interventions with a focus on the following priority populations: MSM (11%), Black/African American communities (14%), and the general population of people living with HIV (16%). CFIR (32%) and RE-AIM (27%) were the most applied frameworks, and the primary outcomes for these projects were reach (14%) and acceptability (14%).

For the prevention pillar, partners included CBOs (29%), FQHCs (19%), and health departments (19%) to deliver PrEP (38%), sometimes in combination with HIV testing (10%) and linkage to care (10%), particularly for Black/African American communities (20%) and Latinx communities (17%), MSM (16%) and transgender populations (10%). The CFIR framework was the most used (35%), followed by the proctor model (18%) and RE-AIM (14%).

The response pillar also has a defined profile of its projects; regarding partners, half of them were in collaboration with the health departments (50%) around cluster detection and response (44%) and focusing on the general population (45%) and transgender/nonbinary people (18%). CFIR (25%) and the proctor model (25%) were the most applied frameworks, and acceptability (25%), reach (15%), and effectiveness (15%) were the most mentioned implementation outcomes.

DISCUSSION

This article describes the characteristics of IR projects funded by the NIH as supplements to CFARs and ARCs to support the EHE initiative. These supplements can help catalyze high-priority HIV IR in emerging areas. Therefore, the descriptions of these projects help forecast where US domestic HIV IS may be heading in the coming years because these projects mature and move to the next stage.

Most of the projects across the 3 years focused on the prevent pillar. Within this pillar, most studied the implementation of PrEP, in part, because PrEP was a focus topic of a supplement funding announcement in year 2. Other projects studied the implementation of HIV testing, aspects of linkage and retention in care to facilitate treatment as prevention, and behavioral interventions. It is worth noting a trend toward a decline in response-type projects after the first year, which could be related to changes in priorities and service delivery during the COVID-19 pandemic.9 It could also reflect the intrinsic complexity of the projects in this pillar; many of them focused on the detection of and response to rapidly growing HIV transmission,10 which can be challenging to address in a short-term project. Larger and multiyear projects may be needed to understand implementation of the respond pillar.

CFIR was the most used IS framework across projects which focuses on identifying barriers and facilitators to implementing the evidence-based intervention in question. CFIR is a metatheoretical framework and provides 39 constructs within 5 domains theoretically associated with effective implementation.11 This framework has already been used in other IR studies on HIV12,13 and allows the contextualization of data extracted from participants involved in the various stages of implementation.

The RE-AIM framework was one of the most used in the United States for defining implementation outcomes,14 and it was widely used among projects. It is a widely accepted framework that is used to assess the feasibility, quality, and public health impact of a health intervention. The framework includes 5 dimensions: reach to intended population; efficacy or effectiveness; adoption by target staff, settings, or institutions; implementation consistency and adaptations; and maintenance of the intervention over time. Its popularity likely stems from the ease of applying it to the distinct types of data (medical records, surveillance data, and qualitative data) collected in HIV service implementation efforts.15 The proctor framework was also highlighted among the projects, most likely for providing a taxonomy and outcomes (acceptability, adoption, appropriateness, cost, feasibility, penetration, sustainability, and fidelity) used in the structuring of many implementation actions and often together with the other CFIR and RE-AIM frameworks.16 In addition, ISCI began working with the projects in year 2 to pilot an implementation outcomes crosswalk, a battery of HIV IR outcome measures that draws heavily on RE-AIM and the proctor model for the conceptualization and operationalization of the included measures. It is likely that this also contributed to the uptake of both frameworks among the projects, especially in more recent years.

Consistent with the disproportionate impact of HIV on these communities, Black/African American communities were the most frequent population of focus (19%), followed by MSM and Latinx/Hispanic communities (14% and 13%, respectively). This pattern suggests that the projects seek to solve a known and systemic problem of the HIV epidemic: barriers to access in populations that need it most. Black and Latinx people have been systematically excluded from the care network,17 and few interventions to promote prevention have been developed and validated for young MSM.18 A smaller number of projects (9%) included transgender/nonbinary people, a population with substantial growth in NIH-funded research in recent years.

When analyzing the EPIS stage of implementation, we observe project advancement from exploration and preparation in FY20 (42% and 27%, respectively) to preparation and implementation in FY21 (47% and 22%, respectively). In a systematic review of the use of this framework, the authors point out how there is a tendency in IR projects to place greater attention on the exploration and preparation phases for implementation, whereas the sustainment phase is less consistent despite its importance.19 As the field progresses, it will be particularly important that more projects focus on implementation strategies that support the sustainment of interventions. For example, projects might consider the importance of deimplementing interventions that are no longer needed as an opportunity to improve the quality and effectiveness of HIV services20 or using existing tools for measuring sustainment.21

The funding opportunity announcement indicated that projects must collaborate with partners in 57 jurisdictions: local, county and state health departments, CBOs, and clinics funded by the CDC, HRSA, SAMHSA, or IHS. The existence of these partnership relationships in our data highlights how the guidance of funders such as the NIH can promote the integration between researchers and service delivery organizations, which is fundamental in IR. When asked about their next steps at the end of their project, 17 projects stated that they would try to apply for funding opportunities to expand or continue their activities. It is important to point out that 21 EHE jurisdictions across the United States have not yet benefited from an NIH-funded IR supplement project. This is likely, in large part, a result of the CFAR/ARC infrastructure and where these centers are geographically located. Still, these areas represent a ripe opportunity for future collaborations among CFAR/ARC investigators and local researchers and implementation partners. Capitalizing on a lesson learned by conducting research through the COVID-19 pandemic, HIV IR projects can be executed virtually, which would permit the portfolio to extend to some of the more rural contexts and midsized urban EHE jurisdictions readily.

CONCLUSIONS

Monitoring the projects resulting from NIH investments is critical to understanding the response to EHE, and achieving these results requires a systematic and continuous effort, with adequate investment data management and analysis. As part of this monitoring, it is possible to point out remaining gaps in the project portfolio, including geographical coverage, range of implementation outcomes being measured, and interventions still requiring further research. Although some of these gaps are closely related to the short-term study period and planning focus of these projects, they highlight future areas of expansion in HIV-related IR to achieve scale-up of evidence-based interventions needed to achieve EHE goals. The project portfolio shows substantial progress being made in the development of academic/practice partnerships necessary to conduct quality IR and in the shared use of IS models, frameworks, and outcomes needed to gain generalizable knowledge of common determinants and implementation strategies that can be applied in diverse settings and geographic areas. This landscape of projects also helps highlight where the HIV IS field is heading because the projects are designed to serve as springboards for larger IR initiatives.

ACKNOWLEDGMENTS

We acknowledge the support of all the staff of the Implementation Science Coordination Initiative, the collaboration with all the implementation science hubs and federal agency staff involved in the EHE initiatives, and for all the implementation research projects that we had the opportunity to work with.

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Keywords:

portfolio analysis; implementation science; Ending the HIV Epidemic

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