Trauma informed care

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PROJECT SUMMARY The high prevalence and associated negative impact of trauma on the mental and physical health of people living with HIV and their engagement in HIV care (i.e., retention, viral suppression) underscore the need for systematically addressing trauma within primary HIV care. Trauma-informed care (TIC) is an evidence-based treatment framework that involves understanding, recognizing, and responding to the effects of trauma. Evidence from other settings demonstrates that TIC improves patient outcomes, increases staff morale, and is cost- effective. In recent years, WHO, HRSA, and NIH have called for trauma-informed HIV systems, yet limited research exists on the strategies needed to facilitate TIC implementation in HIV care settings. In a pre- implementation study to assess TIC provision and factors influencing adoption and implementation of TIC in Ryan White-funded HIV Clinics (RWCs) at the epicenter of the US HIV epidemic (DHHS Region IV), we found that most providers/staff felt that TIC was appropriate for RWCs and had some trauma screening and referral protocols in place, but training on trauma and methods for working with trauma survivors and lack of staff support for managing the emotional toll of working with trauma survivors were salient factors limiting TIC adoption. Importantly, TIC training and use of an implementation advisor (herein called implementation facilitation) were identified as potential strategies for facilitating TIC implementation in RWCs, including implementation of staff support. Guided by the Interactive Systems Framework, our Emory team with expertise in TIC will work in collaboration with The Emory Centers for Public Health Training and Technical Assistance (Emory Centers) and RWCs to develop and pilot test two implementation strategies (TIC training and facilitation (of TI-staff support practices, e.g. debriefings, selfcare, etc.)) on provider- and clinic-level implementation and patient effectiveness outcomes. The aims include: 1) to develop trauma-informed HIV care trainings and an implementation facilitation process to tailor staff support practices to clinic-specific needs, with iterative feedback via theater testing methodology with RWC staff/providers/administrators to inform content, dose, intensity and delivery to optimize effectiveness for RWCs; 2) to refine the two implementation strategies developed in Aim 1 using a modified Delphi method to build consensus on content and delivery with RWC stakeholders across the DHHS Region IV to optimize use across a diversity of RWCs; and 3) to pilot and perform a mixed-methods evaluation of the preliminary effectiveness of the refined implementation strategies on provider- and clinic-level implementation outcomes at two high-volume RWCs in Metro Atlanta. The results of this study will inform a future Hybrid Type 2 effectiveness-implementation trial examining the impact of centralized delivery of TIC training and facilitation on TIC implementation and patient HIV effectiveness outcomes and enable an evidence-driven response to the high-level calls for integration of TIC into HIV primary care services.