Examining Multilevel System Dynamics Affecting HIV Community Viral Load

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ABSTRACT Policy makers and healthcare providers increasingly seek broad, multi-sectoral responses to manage, mitigate, and eventually eliminate the HIV epidemic. Such community health outcomes depend on a coordinated and highly effective local HIV test-and-treat (T&T) service system to find, treat and maintain viral suppression in all people with HIV (PWH). System improvements require stakeholder coalitions from across the care continuum with capacity to identify service gaps and develop and carry out strategic plans to improve service integration and delivery. However, such plans may suffer from stakeholders' incomplete `mental models' of system complexity and system dynamics (SD) that affect population health outcomes. A SD simulation model that has been developed and validated through participatory model building offers conceptual, methodological and analytical tools to achieve these goals. SD simulation modeling allows community coalitions to learn about system complexity and identify mechanisms likely to affect system improvements. They can hypothesize single, multiple, or sequenced interventions and other actions expected to achieve desired community-level and public health outcomes, then test those virtually through model simulation before expending effort and resources to implement them. However better understanding is needed of the process by which stakeholder coalitions can use SD simulation models, whether simulation can help them design strategic plans they have confidence will improve community-level health outcomes, and how this process enhances coalition capacities to move their plans forward. Our 3-year study (R01-MH103176) used mixed methods and participatory SD modeling to build a SD model of the HIV T&T care continuum in Hartford, CT. With additional funding (R21- MH110335) we triangulated expert knowledge, local primary and secondary data, and scientific evidence to calibrate the SD model for simulation. User interface tools of the SD simulation model allow recalibration/ tailoring and enable SD-modeling-naïve coalitions to use simulation for strategic planning. This 2-year renewal of our current R01 will address the following new specific aims that are outside the scope of the current studies. Using mixed qualitative and quantitative research methods, document and measure: Aim 1: the strategic planning process of a new stakeholder coalition when using a validated SD simulation model of the HIV T&T system to develop strategies expected to reduce community-level HIV; Aim 2: comparative strategic plans designed and selected by the coalition before and after training in, and throughout iterative use of, the SD simulation model of the HIV T&T system; and Aim 3: changes in coalition capacities, including member, relational, and organizational capacities, expected to improve their ability to implement proposed plans to achieve long-term system improvements. Findings from this renewal study will be used to produce a Toolkit that will make possible replication of the SD simulation modeling approach by coalitions in other communities to facilitate rigorous multisite testing in a subsequent implementation study.