An implementation science study of violence screening practices among Ryan White-funded sites in the Southeastern United States

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ABSTRACT In the United States (US), 85% of people living with HIV (PLWH) are aware of their HIV status, but only 62% are linked to HIV care and less than half (48%) are retained in care and virally suppressed (49%). Violence has been increasingly recognized as a critical determinant of poor engagement along the HIV care continuum. For example, histories of intimate partner violence and child abuse are common among PLWH. Further, in the Southeast, the current epicenter of the national epidemic and a region plagued by persistent homophobia/transphobia, racism, social conservatism and poverty, PLWH are more likely to also experience hate crimes and other community violence. Thus, violence screening and intervention within HIV care is critical to ending the HIV epidemic in the South. But, given the multi-dimensionality of violence experience (i.e. intimate partner violence, child abuse, community violence including non-partner assault and hate crimes) and the resource and time constraints of Ryan White-funded HIV Clinics (RWCs) and Ryan White-funded AIDS Service Organizations (ASOs) who serve the bulk of PLWH, it is paramount to first determine which forms of violence are experienced most frequently and have greatest impact on HIV outcomes. This insight could help RW agencies prioritize violence screening and support services. Thus in, Aim 1, we comprehensively assess violence experience (interpersonal & community) and its association with RW program indicators of retention in care (% of patients with no medical visit in last 6 months of measurement year; % with medical visit every 6 months over 24-months) and viral suppression (% with HIV viral load <200 copies/ml) among 300 PLWH (men and women, cis and transgender) from RWCs and ASOs in Metro Atlanta. Next, in response to the dearth of evidence regarding preferences of PLWH for violence screening and to ensure violence screening does not inadvertently re-traumatize survivors, in Aim 2, we conduct semi-structured interviews among a purposive sample (n=75) of survey participants (men and women, cis and transgender PLWH, in and out of care) to determine acceptability and preferences for violence screening (e.g., what, where, how, who) and support services/treatment options that RWCs and ASOs could adopt. Lastly, in recognition of the need to integrate RW agency stakeholder preferences and address provider, staff, and agency-level barriers to screening and support service provision/referral for the process to be effective, in Aim 3, we conduct an explanatory sequential, mixed methods assessment consisting of a regionally-targeted survey (N=600) and key informant interviews (n=60) among administrators, staff and providers working in RWCs and ASOs in Atlanta and across the Southeast to assess inner and outer setting factors that may influence adoption and implementation of (a) violence screening, and (b) violence-relevant treatment/support. Findings will inform development of (1) key stakeholder-driven, evidence-based violence screening protocols and (2) a proof-of-concept violence support model that leverages existing local RWC and ASO infrastructure to address psychosocial consequences of violence among PLWH.