Implementation Research to Enhance Equity- Focused HIV Prevention in New York City

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7.1. PROJECT SUMMARY/ABSTRACT -- CORE Project One of the fundamental challenges to effective implementation of HIV prevention interventions is the engagement of clients who are eligible for and would benefit most from them. This Core Project is focused on this critical implementation problem: the need to develop and test novel implementation strategies that increase engagement, uptake, and sustainment of proven HIV prevention interventions, including rapid testing, PrEP/PEP, and iART. Based on a review of the research literature and data collected directly from community members in their EHE high priority jurisdictions, the New York City Health Department (NYC HD) has identified three core determinants of this HIV prevention implementation problem: (1) clients’ anticipated and experienced stigma and discrimination limit acceptability and uptake; (2) providers’ implicit and explicit bias limit offers and dissemination; and (3) systemic emphasis on siloed services and risk-based eligibility limits access and availability. In response to this problem, the NYC HD has chosen an implementation strategy called the GOALS Approach to Sexual Health, which is designed to: a) universalize and normalize HIV prevention conversations and interventions; and b) disseminate a client-centered, gender-affirming, non-discriminating, anti-stigmatizing and trauma-informed approach to sexual history and HIV prevention conversations. This Core Project uses a two-phase cluster-randomized, stepped-wedge implementation trial to evaluate adoption of the implementation strategy in 20 agencies funded by the NYC HD. Based on an implementation science model, we will examine outcomes at three levels: a) implementation outcomes (e.g., rates of HIV testing, PrEP uptake, immediate linkage of newly diagnosed patients to care); b) service outcomes (e.g., equitable distribution of HIV prevention interventions to highest priority populations); and c) patient outcomes (e.g., impact on city-wide HIV incidence, engagement in care, and viral suppression). Secondary analysis will also be conducted on hypothesized mechanisms (i.e., mediators) as defined in the program’s logic model, including dimensions of provider competence and patients’ experience. Model fidelity data will be collected on enactment of the GOALS Approach implementation strategy by the NYC HD, and its ability to successfully implement the strategy at each of the individual agencies. Finally, qualitative data will be collected to assess barriers and facilitators to implementation at both the health department and agency levels to inform future adaptation and dissemination of the implementation strategy. 7.2. PROJECT SUMMARY/ABSTRACT -- COLLABORATIVE Project One of the most persistent challenges in health care provision is quality. It is often easy to determine which or how many services are being provided to clients by a given agency or program, but it is far more difficult to determine how well these services are being delivered, or what aspects of service delivery have the greatest impact on outcomes. This Collaborative Project is based on the scientific premise that quality can be defined, measured, and supported by a re-envisioning of health department contract practices, and that an implementation science approach can evaluate this innovative strategy and identify its strengths and weaknesses for broader dissemination. In this Collaborative Project, we address the persistent problem of quality through: a) an implementation strategy that defines quality in HIV prevention services and operationalizes a logic model through which higher quality services will address known barriers and inequities at the community-, system-, and client-levels; b) a data collection and quality improvement and management (QIM) strategy that focuses on quality and quality metrics as incentive-based deliverables in HIV prevention contracts; c) a training and technical support system that works with agencies to identify challenges to quality service provision and supports them to identify and enact approaches to address those challenges; and d) a collaborative research design that measures initiation, adoption, and sustainment of each component of this implementation strategy, and applies a programmatic logic model to examine the impact of each component on hypothesized determinants, mechanisms, and outcomes. The New York City Health Department (NYC HD) has selected a Quality-Based Financing (QBF) model to fund its HIV prevention contracts (in contrast to a traditional fee-for-service model) as an implementation strategy to decrease inequities in access, utilization, and outcomes for HIV prevention services, and to equitably decrease the HIV incidence among NYC’s highest priority populations. This Collaborative Project has four main objectives: (1) conduct an interrupted time series (ITS) analysis to evaluate the impact of implementing the QBF model; (2) qualitatively explore factors that potentially explain differences in successful implementation of QBF across different agencies; (3) Identify factors significantly associated with differential effectiveness of the QBF model using longitudinal multiple regression analysis; and (4) Measure model fidelity and monitor QBF implementation at the level of the health department and funded agencies.