Community expert insights on anticipated implementation challenges for an evidence-based adherence intervention for Black clients

Abstract

Black people in the US are highly affected by HIV and other health disparities. Rise, a culturally congruent Motivational Interviewing-based adherence intervention for Black adults with HIV, is included in the CDC’s Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention (NCT03331978, clinicaltrials.gov, 10-30-2017). Rise was developed and tested in a community-based organization in Los Angeles County, California. We aimed to understand how interventions such as Rise could be modified to be status-neutral (for people with and without HIV) for national dissemination in community-based settings. We conducted focus groups with 40 community experts in two US Ending the HIV Epidemic Initiative jurisdictions (Los Angeles County; Birmingham and Montgomery, Alabama) and an online discussion with 14 community experts in Los Angeles County. Consistent with the Health Equity Implementation Framework, participants identified multiple levels of barriers to national community-based implementation related to the: External Environment (HIV stigma, restrictive policies, access to resources, and poor public infrastructure, especially in communities in the rural US South); Inner Setting (low community-based organization trustworthiness and understaffing); and Rise Program (need for cultural tailoring at the community and organizational level, inadequate resources to address social determinants of health, and insufficient incentives). To effectively reduce health disparities, evidence-based interventions designed in higher-resource communities may need substantial tailoring for lower-resource and rural communities prior to implementation. Key words: Black/African American; community-based participatory research; health disparities; implementation science; Motivational Interviewing.

Introduction

Black people in the US show disparities across multiple health indicators and conditions, including HIV [1]. Black Americans with HIV (PWH) are less likely to be virally suppressed than people of other races and ethnicities, and Black sexual minority men (SMM) accounted for 35% of new HIV diagnoses in 2022 in the US [2]. Older Black SMM with HIV are estimated to have a 6.8 year lower life expectancy than their White counterparts, in part because of health-related comorbidities and inequities [3]. HIV disparities for Black SMM are even starker in the US South [4, 5].

Structural inequities, including social, political, and economic marginalization, intersectional stigma and discrimination, and responses to experienced inequities such as internalized stigma and medical mistrust, contribute to health disparities [5, 6]. Intersectionality theory [7–9] suggests that stigma’s effects may be amplified among Black SMM, who are at the nexus of marginalized social identities from which they face stigma (minoritized race and sexual minority identity, and potentially, living with HIV) [10]. Anticipated, internalized, and enacted (i.e., discrimination) stigma are barriers to effective HIV prevention and care for Black individuals [11–14].

Despite the persistence of HIV disparities, only one evidence-based intervention (EBI) in the US Center for Disease Control and Prevention’s (CDC’s) Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention [15] was culturally tailored for all Black adults with HIV in the US. Rise, a community-based adherence counseling intervention, is customized to Black adults’ shared identities, beliefs, history, and experiences, including addressing responses to historical and ongoing inequities [16–18]. Rise peer counselors, positioned in community-based organizations, use a client-centered, non-judgmental, empathetic style (Motivational Interviewing) while acknowledging discrimination and medical mistrust. Rise counselors assess unmet needs through referrals and use warm hand-offs to local social services to address social determinants of health that may impede adherence.

Rise was developed and tested through mixed methods research, community engagement, and two randomized controlled trials in a large HIV service organization connected to a Federally Qualified Health Center (FQHC) in Los Angeles County, California [16–20]. Rise showed large antiretroviral therapy adherence effects, reduced HIV stigmatizing beliefs and medical mistrust, and cost-effectiveness. However, Rise’s applicability to other communities with high HIV disparities, including in the US South, is unknown. Rise was tested as an intervention narrowly focused on HIV treatment adherence, which may not meet needs of aging PWH with comorbid physical conditions [21–23]. To address health inequities and reduce HIV stigma, holistic, flexible HIV status-neutral interventions are needed that focus on general health and well-being, including adherence to HIV treatment or pre-exposure prophylaxis (PrEP) for HIV prevention [24], as well as for other chronic conditions. We aimed to determine how to adapt evidence-based interventions tested in one setting for successful implementation in other settings—specifically, how to modify Rise to be status-neutral and more flexible for use across settings for future dissemination.

Methods

Setting

To explore perceived place-related differences in Rise implementation, we conducted focus groups with community expert focus groups in two high-priority jurisdictions identified in the US Ending the HIV Epidemic (EHE) Initiative [25]: Los Angeles County, California, and the state of Alabama (specifically in Birmingham and Montgomery). Los Angeles County is the most populous county in the US (> 10 million) [26]. In 2022 in Los Angeles County, 1,600 people (including 312 Black people) were diagnosed with HIV, 80.2% of all those newly diagnosed (72.0% of newly diagnosed Black PWH) received care within one month, and 65.0% of all PWH (59.0% of Black PWH) were virally suppressed [27]. The population of Alabama is about 5 million [26]. In 2022, 701 people (including 448 Black people) were diagnosed with HIV, 78.7% of all those newly diagnosed (76.1% of newly diagnosed Black PWH) received care within one month, and 59.1% of all PWH (58.0% of Black PWH) were virally suppressed [27]. Social determinants of health indicators showed relatively higher levels of poverty (8.6% vs.7.4%) and uninsured individuals (8.8% vs. 8.2%) in Alabama versus Los Angeles County [26]. Furthermore, California’s laws provide protections across sexual and gender minority identities, whereas Alabama generally has a punitive legal context for such groups [28, 29]. Birmingham (in Jefferson County) is the largest metropolitan area in Alabama and has stronger healthcare infrastructure than Montgomery (in Montgomery County). Jefferson County, with a population of approximately 665,409, has an uninsured rate of 10.3% and a poverty rate of 16.9%; Montgomery County, with a population of 226,941, has a higher uninsured rate of 11.2% and a poverty rate of 19.4% [26].

Participants

Eligibility criteria included (1) aged 18 or older and (2) community expert in HIV services (social services providers and expert clients, e.g., social workers, case managers, peer counselors, community activists) in Los Angeles County California, or Montgomery or Birmingham, Alabama. The team offered participation to all members of three HIV-focused community advisory boards (CABs) in Los Angeles County. Potential participants in Alabama were identified by leaders at two HIV service organizations and screened for eligibility by the team. All community organizations and advisory boards were engaged in the project starting at the proposal stage.

Procedures

Four one-hour audio-recorded focus groups were conducted with 40 community experts (20 in Los Angeles County, and 20 in Birmingham and Montgomery). LMB (a PhD social psychologist; she/her/hers), SJL (a BA-level study coordinator; he/him/his), and MM (a PhD sociologist; he/him/his) facilitated the Los Angeles County focus groups; LMB and SM (ScD public health researcher; she/her/hers) facilitated the Alabama focus groups. LMB and SJL held an additional online CAB discussion with 14 community partners in Los Angeles County; although the online discussion was not recorded, the team captured the text content of the online chat and took notes to capture the main discussion points. The sample size was consistent with qualitative sample size recommendations for attaining thematic saturation within and across meaningful subgroups (in this case, the two EHE jurisdictions) [30]. Focus groups were conducted from August 2023 to January 2024.

Facilitators used brainwriting premortem, a focus group method that originated in marketing and was adapted for implementation science, to identify potential implementation barriers for a revised Rise program [31, 32]. This approach is used to encourage participants to generate plausible reasons for a program’s failure, allowing those who have experience with similar programs or who are concerned about implementation barriers to speak up in a safe space that minimizes social desirability bias. Facilitators first presented a detailed description of a status-neutral Rise program and answered any questions. Participants then were asked to imagine that a status-neutral Rise program had already been implemented for a year in their organization or community, and that, hypothetically, Rise had not been effective. They were asked to brainstorm why Rise was ineffective, writing down (on paper) “as many ideas that pop into your head.” When participants finished writing, they were directed to share their ideas with the group by passing their paper to others until everyone had read all ideas that were advanced. Participants were told that they could write on others’ papers if seeing others’ ideas prompted additional ideas. After all participants reviewed and had the opportunity to comment on others’ ideas, the facilitators led an audio-recorded discussion about key ideas that emerged. (In the online CAB discussion, participants wrote their ideas in the online chat, after which they briefly explained their ideas during a group discussion that was not audio-recorded.) Participants provided verbal informed consent and received a $100 gift card incentive.

Qualitative analysis

Hand-written hard copies and online chat content in response to the brainwriting premortem instructions, and audio-recorded focus group discussions were transcribed verbatim. In a directed content analysis [33], the study team analyzed these data by categorizing determinants of Rise’s hypothetical ineffectiveness at multiple implementation levels based on the Health Equity Implementation Framework [34], including the external environment (i.e., policies, resources, and geography), inner setting (i.e., organization implementing Rise), and innovation (i.e., Rise program components, clients, and counselors). The framework was selected because it centers clients, with attention to social and historical marginalization and societal and health determinants of equity.

Two team members (LMB and SM) independently reviewed all notes and transcripts and collaborated on a rapid qualitative analysis to draft a summary of preliminary themes. This summary was presented for feedback to all co-authors and members of the CABs and community-based organizations in Los Angeles County and Alabama who participated in the focus group discussions. LMB, SM, ABa (MPH researcher in AL; she/they), and ABe (Masters of Science Management Information Systems in AL; she/they) then developed a codebook based on the preliminary themes and review of all data that incorporated levels of the Health Equity Implementation Framework. LMB and SM supervised coding by ABa and ABe, reviewing all codes. All 331 passages from the written brainwriting premortem exercise were double-coded by ABa and ABe and used to test for interrater reliability, which was satisfactory (Cohen’s Kappa = 0.67). Both coders then coded the focus group transcripts independently and met with each other and LMB and SM to resolve any discrepancies. Microsoft Excel spreadsheets and NVivo qualitative management software were used to manage the data.

Results

Participants

Of the 40 focus group participants, 20 were from Los Angeles County and 20 from Alabama (representing Jefferson, Montgomery, Autauga, and Fayette Counties). Half were cisgender women, 45% cisgender men, and 5% transgender women. Most (80%) were Black or African American, 10% Latino/a/e/x, 8% White, and 2% multiple races or ethnicities. Focus group participants’ average age was 44.9 (SD = 14.4). Half were expert clients and half were social service providers (e.g., program managers, PrEP navigators, prevention specialists, outreach coordinators).

Qualitative themes

Consistent with the Health Equity Implementation Framework, participants across focus groups described determinants of Rise’s hypothetical ineffectiveness at multiple implementation levels related to the external environment, inner setting, and Rise program. Table 1  shows representative quotes.

Table 1.

Qualitative themes about rise implementation at multiple levels of the health equity implementation framework (HEIF)

Subtheme	Quote (Montgomery or Jefferson County, AL)	Quote (Los Angeles County, CA)
HEIF Domain: External Environment
State and local policies, including limited funding for social services and non-Medicaid expansion in Alabama (and the US South) vs. California	“You all might have a surplus of resources [IN CA], but we don’t. We have a desert of resources here…Along with the lack of resources, like our laws…They’re primitive.” (Montgomery County) “It’s a privilege to have healthcare for a lot of parts here.” (Jefferson County)	“In Greater Atlanta, there were more chances for referrals to many community-based organizations compared to rural Georgia. We tried… to meet clients where they were at rural practices and establish connections for community organizations, but also made an effort to follow up with the clients/advocates…”
Feasibility of status neutral program that requires access to social services for people who are HIV-negative	“Structurally, there’s a real issue … when it comes to status-neutral care because there is a lot that we can provide for our clients living with HIV. There’s very little we can do for our PrEP clients.” (Montgomery County)	“Evaluation of Medicaid-expansion vs non-expansion for low-income participants will be vital to [status-neutral] generalization.”
Low access to essential services	“Even when they know what we need, they don’t always have the resources to actually help us. It’s frustrating when you’re told they can’t do anything because they’re stretched too thin.” (Montgomery County)	“I think it would be important to look to smaller community orgs that also work with priority populations that have challenges with getting the same funding/grants/resources etc… in other words, just as there is a gap in Alabama services there are disparities within LA proper as well.”
Adequacy of public infrastructure (communication, transportation)	“Alabama’s not putting those resources out to get people to those appointments, making sure their phones are staying on.” (Montgomery County) “When you think about transportation, our bus systems don’t run 24 hours. Some of us don’t have buses. We don’t have public transportation. In certain areas here, we don’t have transportation because they cut them out. (Montgomery County)	“The setting is very important… a community setting that’s easy to get to.”
Intersection of communication infrastructure with client resources and preferences	“We use a lot of digital things, but we may not often consider that not only is there the lack of resources, but you have different generations who are engaging in healthcare, who will be able to utilize some of the things that we utilize all the time” (Jefferson County)	“If we’re doing it by phone, we need to make sure they’re in a space they can talk to us.” “Sometimes it seems so convenient to do Zoom, but yeah, people are pretty burnt out. … And there are some people who really don’t want to leave the house.”
Stigma	“A lot of people don’t come here or to our agency because our agency name… if I’m negative or I don’t have HIV, I may not want to come to a place that I know caters to people who are living with HIV” (Jefferson County) “The role of religion is huge here. Churches are often a place of refuge but they also are places where people are afraid of being judged for their sexual orientation or HIV status. It’s where we should find support, but it can also be a source of stigma.” (Montgomery County)	“Sometimes they don’t want to take home a card that has a bunch of men on it telling me they need to check this and that and all that stuff because they don’t know who’s going to see it at home.” “Even though there are stigmas that men face, I think women face a lot more of social weight when it comes to sexual diseases, specifically HIV, because it’s seen as you must have been a whore. It’s just like you must have been there to get this was no good. Because the perception of women in a lot of cases, when they’re being abused or whatever, it’s what she’s not doing. You’re upsetting him. You’re doing this.”
HEIF Domain: Inner Setting
Understaffing	“The staff are so overworked that they can’t give you the attention you need. You feel like just another number.” (Montgomery County)	“If folks doing the work are underpaid and overworked… in time, burnout happens even with the best intentions and training.”
Staff turnover and burnout	“Counselors have a lot on their plate, and if they don’t get the support they need, how can they support us?” (Montgomery County)	“Every time you get comfortable with someone, they leave, and then you’re back to square one with someone new who might not understand what you’re going through.” “Having someone that I could speak to [as a peer counselor] to help me process the way I was feeling about trying to help them was very necessary… just making sure that your peers have the support that they need to be able to do the important work.”
Trustworthiness/connection to community	“If there’s a lack of support, such as like having a gatekeeper or having a community engagement person, if you have a lack of that, you’re not going to gain as much support as you can from the community. You need that gatekeeper.” (Jefferson County)	“I don’t feel like [some agencies] understand the Black culture and what we go through. And I feel like we need Black [people] in the frontline …” “And I can tell you because we all dialogue with a lot of different groups out there. Not all organizations are really user-friendly. Some of them are like really formal and very strict and very condescending and it doesn’t work for real.”
HEIF Domain: Rise Program
Cultural tailoring/adaptation (program, materials)	“If the programs don’t speak to our culture or our reality, then they won’t work.” (Montgomery County) “You all [in L.A.] have transportation, food assistance, housing… you give us a curriculum or a program … to use with our consumers, and we can’t give that. And so then it’s a distrust with staff because you got this program that you’re telling me I can come here and get all this stuff from, but we can’t give it to you…” (Montgomery County)	“Research studies are a very skewed population, right? You look at the population, you look at who you’re going to disseminate this information to. When it then becomes an evidence-based intervention, I think there’s a cultural component that a lot of people don’t inform themselves about community. And that’s regardless of what it is, because it may be a Black organization, a White organization. I think we take for granted sometimes what the community looks like in its current iteration.”
Appropriate marketing	“When marketing from California to Alabama, it needs to be different. It needs to reflect the culture… Your marketing needs to look like Black people in the South. (Montgomery County)	I’ve seen a lot of flyers that have these abbreviations… I don’t speak hieroglyphs. So if there is a way to make sure that the materials that are disseminated in the community fit the language of the community that you are trying to reach. The wording on the flyer should be universal enough for my mother to understand it.”
Intervention counselor (cultural competency, training, etc.)	“I put cultural competency with the team because I think it’s important that we meet people where they are and not just expect them to conform to our norms.” (Jefferson County) “If I don’t see anybody that kind of resembles me, why am I here?”(Jefferson County)	“The counselors, they may need more training, especially for the referrals because you talk about the referrals, and sometimes they don’t know where to refer or they refer you to a place that they cannot help you.” “People have different styles and connect with different types of people. So yeah, you can’t just have that one type or one person.”
Tailoring for women	“Even when I see PrEP, I see it at places where they think that gay men would be. I’m not seeing it where I would see Black women… I don’t see it … at doctor’s offices, like having it where it’s just normalized.” (Jefferson County)	“[Programs] will erase this picture of a man, slap a picture of a woman [on a flier], and then perpetuate this narrative that women are difficult to engage… without really examining some of the social, structural, and contextual factors that facilitate why women are not involved in this conversation.”
Incentives (gift cards, social activities, certificates)	“Hand in hand with a lack of interest, the lack of incentive… I’ve noticed, or at least in the work that we do, sometimes there’s no interest around healthcare in the area if there is no incentive at all.” (Jefferson County) “We have a few events tailored towards Black women, young Black women, but we feed them. I mean, we can’t give them the money for their time, but they do come for the food. It’s good food.” (Montgomery County)	“They gave us gift cards, but if you can’t use them without paying a fee, what’s the point? Cash would be better, but if not, at least give us cards we can use anywhere.” “If you could possibly throw in some social activities that would encourage community participation, yeah. That’s really extremely helpful… They can easily lose interest … even though it’s got an incentive. So you need something else that attracts them to the next meeting…” “I run an enhanced patient navigation program… we have a graduation at the end for people who completed it successfully. And that graduation means everything in the world to some of those participants. And we make a big deal of it. We have a meal. We give them a certificate. I put a tassel on it. And for some of them, it’s like the first graduation they’ve ever had from anything. And to be rewarding them or acknowledging the efforts that they made to take care of their health is like beyond them. And there’s tears and there’s just appreciation and gratitude and pride.”

More than one quote per county is presented for some themes in order to fully represent subthemes

External environment

Discussions about the external environment dominated the discussions, especially related to limited funding, resources, and infrastructure, as well as policies around healthcare (and HIV) funding. External environmental barriers were seen as acute, especially in the US South and rural areas.

State and local policies that limited health-related funding emerged as main external factors that could impede Rise implementation, as a primary Rise component is linkage to social services. Participants directly compared public services available in Alabama, and the US South as a whole, to those available in California. For example, at the time of this writing, Alabama was a non-Medicaid expansion state (under the Affordable Care Act), whereas California had expanded Medicaid (to adults with incomes ≥ 138% of the Federal Poverty Level). As a result, Alabama participants discussed the extreme need of their clients around social determinants of health (e.g., food insecurity, housing, poverty) and related syndemics (e.g., mental health).

Because of this inadequate funding, participants noted a persistent shortage of essential resources to meet clients’ needs, particularly in rural areas. Although resource shortfalls were felt most acutely in Alabama, participants in Los Angeles County also discussed insufficient resources, such as mental health services. On a related point, participants across jurisdictions noted that Ryan White HIV/AIDS Care Act funding covered social services for people with HIV, but did not provide much funding for auxiliary services or programs for people who are HIV-negative. Given low funding for social services in general, one participant in Los Angeles County noted the low likelihood of EBIs such as Rise to be funded and implemented.

Another infrastructure issue that arose, especially in rural Alabama, was deficient or nonexistent public transportation to reach community-based organizations for in-person sessions. Participants in rural communities also discussed poor communication networks, not only in terms of internet access, but in some places, weak cell phone coverage—combined with some clients not knowing how to use technology or not having the privacy to do so in crowded, shared, and/or unstable living conditions. Given that infrastructure issues varied by place, participants supported the flexibility of Rise for in-person, online, or phone sessions, to meet different participants’ needs.

High levels of community stigma concerning HIV status, sexual minority identity, and gender emerged across focus groups as another environment determinant of Rise’s hypothetical ineffectiveness. Participants said that stigma could deter people from accessing Rise, as well as taking home information about the program, such as an informational flyer. Although faith and social support were seen as sources of resilience in the face of structural challenges such as stigma, especially in Alabama, it was also acknowledged that stigma may originate and be propagated in faith-based organizations and social networks.

Inner setting

Key themes emerged around the inner setting related to inadequacies in organizational staffing and trustworthiness of the organization in Black communities. Participants said that community-based organizations are frequently understaffed, which hampers staff members’ ability to conduct client-centered care and learn a new program such as Rise, and can lead to burnout. Such conditions led to high staff turnover, which contributes to negative client experiences. To counteract burnout, participants suggested that organizations provide support for counselors, to maintain their own mental health. In addition, participants felt that cultural tailoring of Rise was a strength that needs to be ensured at the organizational level. They noted that Rise implementation would be compromised if Rise were placed in organizations that are not fully engaged with and trusted by their surrounding community.

Rise program (Innovation)

Participants discussed a range of program-specific features that could affect implementation, including cultural tailoring, counselor factors, and incentives.

In terms of cultural tailoring, focus group participants said that, in their experience, generic programs often fail to resonate, and that Rise would need to be adapted for each setting (including the population of the locality and client base of the organization) in which it is implemented. Participants discussed the possibility of a cultural mismatch between where, how, and with whom Rise was tested, and where Rise will be disseminated. They said that Rise’s cultural tailoring would be facilitated by training Rise peer counselors to better understand the experiences of Black individuals in their catchment area. This sentiment was amplified by Alabama participants, who noted that Rise was fully developed and evaluated in California. Along similar lines, participants cautioned that program marketing materials needed to be clear and culturally sensitive, without medical jargon, to effectively recruit and retain clients from different subgroups of Black adults affected by HIV—especially women, who have different needs than other subgroups (e.g., sexual minority men) and for whom programs are seldom tailored.

Participants in one Los Angeles County focus group said that peer counselors would require solid training in order to make helpful referrals. They highlighted the need to train multiple Rise peer counselors in each organization, to avoid disruptions and also mentioned the need to build relationships through consistent follow-up from the same counselor.

Participants suggested incentivizing participation to increase client motivation. They said that clients may not prioritize joining an adherence program, given pressing needs related to social determinants of health. Although participants noted that cash would be preferred to motivate program attendance, they said that organizations could instead offer gift cards, transportation, food, small giveaways, and graduation certificates. Participants also suggested intrinsically motivating clients through social interaction, such as fun social group activities, beyond tangible incentives like money or food.

Disscussion

In this study, community experts in two high-priority EHE jurisdictions in the US described how Rise implementation may be stymied at multiple levels. Key factors emerging across jurisdictions included who conducts Rise, and in which organization and geographical region it is conducted. The most intractable barriers were related to the external environment: Policies where Rise is conducted drive access to funding and resources, a main theme discussed across all focus groups, with deficits especially acute in rural areas in the US South. Rise works in part because clients with unmet social service needs are provided with referrals by peer counselors; therefore, external resources must be available for such referrals. In contrast, few barriers were uncovered regarding the Motivational Interviewing peer counseling component compared to the social services component of Rise.

A critical external environment concern, mentioned across jurisdictions, was whether Rise, an EBI developed in a relatively well-resourced community-based organization that was connected to a FQHC, in a state with protective policies for people with HIV and sexual and gender minority individuals, would be applicable to under-resourced settings in Los Angeles County and the US South, especially in rural areas. Moreover, to be effectively implemented, status-neutral programs require access to additional funding streams and services beyond the Ryan White HIV/AIDS Program to address social determinants of health—funding streams and services that may be lacking in resource-poor states without Medicaid expansion. Being in a state with Medicaid expansion allows more funds to be funneled to social services for referrals. Participants suggested that peer counselors would need to identify the landscape of available local services for Rise clients, and make new connections to alternate services (e.g., through faith-based organizations), as part of their preparation for counseling sessions, to overcome this barrier.

The topics of trust and cultural congruence were interweaved through discussions about the inner setting and Rise program. Participants emphasized the need for representation and cultural competence within community-based organizations, in the Rise program, and on the Rise counseling team. However, community-based organizations are typically understaffed and under-funded. To address these concerns, Rise counselling and referral strategies could be integrated into existing counselors’ workflows that are consistent with Rise (e.g., that focus on adherence and linkage to services), rather than or in addition to their current daily responsibilities—alternately, dedicated funding could be secured for full-time peer counselors who could focus on implementing Rise.

Participants generally agreed that Rise should be flexible for use across modalities (in-person, online, phone). Programs delivered by phone or virtually can overcome multiple levels of transportation challenges for in-person delivery, such as poor regional infrastructure or traffic congestion, as well as low client mobility (e.g., lack of vehicle, disability). Moreover, phone delivery can address poor regional or organizational infrastructure, low client digital literacy, and lack of client internet access. However, participants cautioned that poor rural communication infrastructure could make Rise delivery infeasible by phone. Although research suggests that online and phone HIV treatment adherence counseling interventions can be effective for PWH [35], additional research is needed on feasibility that compares barriers and facilitators of different modalities among people in rural areas and from minoritized racial and ethnic groups.

Our conclusions are limited by the small number of focus groups in only two high-priority EHE jurisdictions. Other providers and expert clients in Los Angeles County and Alabama, as well as in other EHE jurisdictions, may suggest additional barriers to Rise implementation not identified here. Moreover, brainwriting premortem emphasizes deficits rather than strengths. Although discussions touched upon resiliencies in Black communities (e.g., religiosity, social support), participants did not provide in-depth discussion of these strengths. Similarly, positive attitudes about the acceptability of Rise were not systematically elicited through these methods. Our prior qualitative research [19] and ongoing community engagement work continues to suggest that Rise is highly acceptable, despite the identified potential challenges to implementation. Further research focused on addressing these barriers, drawing on strengths and resiliencies in Black communities, is needed.

To end the HIV epidemic in the US, there is an urgent need to implement effective, feasible interventions such as Rise to address inequities among Black adults regardless of HIV status and sexual and gender identity. Using these results, we will create a status-neutral Rise toolkit that addresses implementation barriers. Our research will provide a strong basis for expanded implementation of this EBI.

Author contributions

LMB led the study design, proposal and paper writing, data collection and analysis, and dissemination of results. SM, ABa, and ABe contributed to data analysis and primary writing of the manuscript. MM, SM, GW, KG, DPL, TS, and DT contributed to study design. SJL, MM, DT, NC, TS, and LLN contributed to data collection and dissemination of results. All authors reviewed and provided edits on the manuscript.

Funding

This work was funded by the National Institutes of Health National Institute of Allergy and Infectious Disease (Grant No. 3P30AI152501-02S1), with support from the National Institute of Mental Health (P30 MH58017).

Data availability

Not applicable.

Declarations

Ethics approval and consent to participate

The RAND Human Subjects Protection Committee determined that the project (#2023-N0271) was exempt from review under Category 2 (Educational Tests, Survey Procedures, Interview Procedures and Observation of Public Behavior) and approved the use of verbal informed consent. The procedures used in this study adhere to the tenets of the 1964 Declaration of Helsinki and its later amendments. The RAND Human Subjects Protection Committee determined that the project (#2023-N0271) was exempt from review under Category 2 (Educational Tests, Survey Procedures, Interview Procedures and Observation of Public Behavior) and approved of verbal consent procedures.

Consent for publication

Not applicable

Competing interests

The authors declare no competing interests.