Behavioral and social interventions to promote optimal HIV prevention and care continua outcomes in the United States

Abstract

Purpose of Review:

This review reports on trends in behavioral and social intervention research in the United States published over the past year (2020–2021) investigating HIV prevention and care outcomes, organized by the level of intervention focus – individual, dyadic, and organizational.

Recent findings:

Researchers have continued to develop and evaluate behavioral and social interventions to reduce HIV acquisition risk and disease progression. With few exceptions, social and behavioral interventions have primarily focused on individuals as the unit of behavior change. Interventions operating at the individual-, dyadic-, and organizational-level have made strides to reduce HIV transmission risk and disease progressing by addressing mental health, substance use, stigma, peer and romantic relationships, and, to some extent, structural vulnerabilities.

Summary:

Social and behavioral interventions continue to be critical in addressing HIV inequities in the United States. An important gap in the literature is the need for multi-level interventions designed and implemented within existing community-based organizations and local healthcare settings. We call on researchers to continue to attend to the structural, environmental, and economic vulnerabilities that shape HIV inequities in the development of multi-level approaches necessary to realize the full potential of existing and emerging HIV prevention and care strategies.

INTRODUCTION

Multi-disciplinary advances in HIV research over the past four decades have produced a range of evidence-based interventions to prevent HIV transmission and ensure that people living with HIV live longer, healthier lives [1, 2]. Scientific discoveries including pre-exposure prophylaxis (PrEP) [3] and “treatment as prevention” (TasP) have been particularly transformative[4]. Consequently, substantial investments have been made to further develop and evaluate interventions to increase PrEP uptake among those at heightened risk for acquiring HIV and antiretroviral therapy (ART) adherence among people living with HIV [5]. Sophisticated conceptual frameworks regarding the HIV prevention and care continua have also emerged that describe each step in promoting HIV bio-behavioral prevention and treatment services via regular HIV testing and linkages to and retention in HIV prevention and care, i.e., PrEP among individuals not living with HIV and ART and viral suppression among people living with HIV [6–10].

Despite this scientific progress, troubling inequities remain across both the HIV prevention and care continua in the United States [11], resulting in continued and disproportionate burdens of HIV risk, infection, illness, and mortality in historically marginalized populations [12–15]. Persistent challenges to uptake and use of biomedical technologies in the United States as outlined in the Ending the HIV Epidemic initiative [11] include: interlocking systems of oppression and stigma [15, 16]; the co-occurrence of intersecting health problems (e.g., mental health, substance use, violence) [17]; and structural vulnerabilities that contribute to HIV inequities [18, 19].

Behavioral and social interventions are essential to strengthen the basic building blocks of human experience necessary to adequately deploy HIV prevention strategies, including biomedical technologies [20]. Behavioral and social interventions are guided by approaches that center people within their social contexts with the understanding that biomedical technologies and other strategies focusing on HIV outcomes are not sufficient in and of themselves to curb the HIV epidemic [21]. Accordingly, behavioral and social interventions seek to address people’s immediate realities and barriers to engaging in HIV prevention and care such as mental health, violence, and substance use. For many people, these barriers take precedence over HIV prevention or treatment goals.

In this paper, we provide a review of behavioral and social intervention research in the United States over the past year (September 1, 2020 to September 23, 2021) investigating HIV prevention and care outcomes, organized by the level of intervention focus – individual, dyadic, and organizational level. At each level, we consider trends in intervention science, provide illustrative examples of intervention approaches, identify missed opportunities, and propose implementation considerations.

Individual-Level Interventions

Individual-level interventions have been the focus of behavioral and social HIV science since the early days of the epidemic [22], and their ubiquity persists. These interventions prioritize cognitive, affective, and behavioral processes contributing to uptake and engagement in risk reduction, prevention, or treatment. Often, they are guided by social-psychological theories of health behavior (e.g., the information-motivation-behavioral skills model) [23] that use principles of motivational interviewing, psychoeducation counseling, and cognitive-behavioral therapy. Notably, individual-level interventions have been criticized for their emphasis on individual agency and limited recognition of the interpersonal and social constraints on behavioral autonomy [24].

A dominant theme observed in the current state of individual-level interventions is the use of mobile or online technology to promote home-testing for HIV and other sexually transmitted infections (STIs) [25, 26], reduce sexual risk behavior and substance use [27–31], and support engagement in HIV care [32]. For example, Biello et al. demonstrated the feasibility, acceptability, and short-term effects of an app-based approach for young sexual minority men to request and self-administer home testing kits for HIV and other STIs [25]. Santa Maria et al. tested an app-based approach that delivers personalized just-in-time HIV prevention messages to unstably-housed young adults, showing promising short-term reductions in sexual risk and substance use [31].

An important feature of technology-delivered interventions is their potential for improving engagement of marginalized populations in HIV prevention support. Advantages of technology-delivered interventions include their ability to reach individuals in underserved or remote locations as well as engage individuals concerned with privacy and confidentiality that arise when seeking in-person services. However, technology-delivered interventions require consideration of device access, service and usage costs, usability, and the rapidly evolving nature of the internet and mobile apps that can render these platforms outdated or obsolete [33].

Individual-level interventions also focused on the integration of mental health and stigma topics alongside content on HIV prevention or care [32, 34–37]. Many interventions over the past year focused on priority populations such as sexual minority cisgender men, transgender women of color, and youth, who may experience multiple forms of stigma and co-occurring mental health concerns. For example, Saberi et al. developed an intervention using video counseling and mobile texting for young people living with HIV – the majority of whom were Latino or Black gay men – and found promising short-term effects on ART adherence, HIV knowledge, depression, anxiety, and stigma [32]. Brawner et al. demonstrated the short-term health improvement effects of an intervention that integrated emotional regulation and mental health coping with HIV prevention strategies for Black heterosexual youth [34], and Wells et al. showed that an expressive writing intervention had short-term effects on reducing sexual risk among young adults [37].

Only one intervention identified in this review focused on the structural vulnerabilities individuals might face (e.g., employment concerns, housing). The EMERGE program (Engaging Microenterprise for Resource Generation and Health Empowerment) was developed for Black young adults experiencing housing instability and economic precarity [38].* The intervention included weekly in-person meetings covering entrepreneurship, micro-business planning, and financial literacy and included mentorship with local entrepreneurs, a small start-up grant to support their business plan, and weekly informational messaging on HIV risk reduction and job announcements. Preliminary findings showed short-term effects with participants in the intervention condition reporting higher levels of employment and reductions in condomless sex compared to those in the control condition [39].

The current generation of individual-level interventions extends decades of prior work by incorporating mobile technology, content on mental health and stigma, recognizing the groups disproportionately burdened by HIV (e.g., youth of color, sexual minority men and transgender women of color). Further research should establish intervention effects on behavioral, psychological, and biomedical outcomes in the long-term and evaluate the implementation of programs in complex environments and less-resourced delivery settings. Additional emphasis on how structural determinants of health, including intersectional systems of oppression, shape individual-level behavioral processes is especially needed.

Dyadic-Level Interventions

For several decades, scholars have noted the limited scope of individual-level HIV prevention and care interventions and called for research that focuses on the relational contexts that contribute to HIV transmission risk and promote optimal HIV care continua outcomes [40, 41]. The field has seen the development and evaluation of couples-based interventions focused on HIV prevention and treatment [42], with two published within the past year [43, 44]. Additionally, a third study evaluated a dyadic-level intervention with friendship pairs to increase HIV testing among young Black sexual minority men and transgender women [45].

These interventions expand upon Couples HIV Testing and Counseling (CHTC), in which participants receive pre-test counseling, HIV testing, and post-test counseling together, and prevention messages are tailored to the dyads’ serostatus [46]. All three interventions used motivational interviewing principles while leveraging the dyadic interaction as a platform for negotiating HIV prevention [43], providing support around ART adherence for serodifferent same-sex male couples [47], and reducing risk factors such as drug use for young sexual minority men and their same-sex partners in which one partner was not living with HIV [43]. For example, Frye et al. developed the TRUST intervention for young Black sexual minority men and transgender women and their friends who were both not living with HIV. Friendship pairs engaged in a peer-delivered interactive session focused on HIV self-testing, identifying and communicating peer support needed for consistent testing and planning for risk reduction, and developing a personalized plan to support themselves and their friend in their prevention goals [45].* The novel focus on friendships instead of romantic partnerships may be more relevant to the developmental stage of younger populations [45].

Although these recent dyadic interventions show promise, it is not clear whether they will have an impact on improving HIV prevention and care continua outcomes among priority populations in real-world settings. The two couples-based interventions sampled predominantly white, sexual minority men who reported high levels of education and employment; thus their generalizability to communities most disproportionately impacted by the epidemic is unknown [48–50]. Notably, only one of the dyadic interventions demonstrated longer-term effects on self-reported ART adherence at 12- and 18 month follow up [44], whereas the others demonstrated short-term effects on HIV prevention outcomes [43, 45]. Despite efforts to provide technical assistance in implementing CHTC in community settings [51], use remains low [52] and service organizations can lack the time, resources, and cultural competency necessary to implement these programs [53]. Dyadic interventions rely on established communication skills and trust within pairs and may be not be suited for individuals who do not have the communication skills, self-efficacy, or supportive relationships necessary to engage with the intervention as intended [52]. However, focusing on friendships as in the TRUST intervention may make dyadic-level interventions more viable for younger populations and for those whose partners are reluctant to engage in couples interventions [52, 54].

Organizational-Level Interventions

Organizational-level interventions have the potential to address the often interrelated behavioral, social, and structural barriers to engaging in HIV prevention and care of priority populations that experience stigma and societal violence embedded in interlocking and cyclic systems of racism, heterosexism, sexism, cisgenderism, and classism [55, 56]. These barriers include but are not limited to geographic inaccessibility, lack of emotional and instrumental social support, lack of culturally relevant and de-stigmatizing care, and pressing needs for housing, mental health or substance use treatment, and economic support [57–60]. Although there has been increasing attention to the role of social determinants of HIV, including funding initiatives focused on addressing social determinants and HIV prevention, care, and treatment outcomes [61], there have been none focused on changing structures and/or environments and only a few studies have focused on developing and evaluating interventions within existing organizational settings.

Four studies published within this past year evaluated interventions premised on co-locating services to enhance uptake and use of HIV prevention and treatment technologies [62–65]. Lipps et al. integrated infectious disease specialists within emergency departments to increase HIV and STI testing and treatment and to provide additional training, resources, and timely support to medical providers. Post-test evaluation results demonstrated short-term increases in testing for syphilis and HIV and highlighted the importance of providing linkage to care services to ensure patients receive treatment [62].

Peer navigation has the potential to bridge these gaps in testing and treatment by increasing timely linkage to care. Lillis et al. demonstrated short-term increases in PrEP appointments in a sexual health clinic when a peer navigator was available for a warm handoff compared to those who received a referral from a provider or an email from peer navigators [63]. Sevelius et al. developed and implemented a gender-affirming PrEP program for transgender adults at two healthcare centers, demonstrating the potential of co-locating peer navigation and gender affirming care in existing healthcare settings [64].* Finally, Shade et al. used data from five state-level demonstration programs to show that peer navigation services are associated with long-term effects of increasing viral suppression and were shown to be cost efficient [65].

There remain important challenges to evaluating and implementing peer navigation programs. Most notably, there is no clear and common conceptual understanding of peer navigation. Across interventions, peer navigators have different roles, training, organizational support, and connections to the communities they serve. Additionally, peer navigators may be unable to provide consistent, uniform support to clients as scheduling constraints and ability to adequately address clients other needs (e.g., substance use, violence) may vary [63, 64].

Peer navigation models and co-locating services are critical for ensuring clients receive the support needed to fully engage and maximize the benefits of biomedical technologies. Organizational interventions must be implemented with an evidence-based foundation while also ensuring they are consistent with the culture, mission, and value systems of their settings. Additional attention to the organizational factors that sustain these interventions is an important area for future research, which includes consideration of costs, staffing, supervision, organizational commitment, and relationships with community partners. Selecting or adapting appropriate organization-level theories of change may aid this process. Disseminating findings from these types of evaluations can begin to build an evidence base to support more widespread implementation of effective HIV prevention and care interventions. Given recent calls to attend to social determinants of HIV [61], more efforts are needed to develop and evaluate organization-level interventions. Researchers and funders should consider prioritizing organizational-level interventions, which often requires more time and resources than individual-level intervention studies evaluated within controlled research settings.

Conclusions

In this review of research publications during the past year, we observe a body of evidence corroborating the fundamental importance of behavioral and social approaches to advancing the end of the HIV epidemic in the United States. While we acknowledge the critical need for biomedical technologies (e.g., PrEP, ART) to biologically protect against HIV infection or disease progression, studies identified in this review highlight the essential role of behavioral and social interventions to optimize the uptake and use of any biomedical HIV strategy. Importantly, behavioral and social interventions identified in this review in and of themselves can reduce HIV acquisition risk and disease progression by addressing mental health and stigma and leveraging romantic and peer relationships.

There are, however, key considerations for the design of behavioral and social interventions going forward. Many prevention studies prioritize PrEP as a gold standard; however, PrEP is not the only viable and important HIV prevention strategy for many key populations. In many contexts, other prevention strategies have equal or more relevance such as consistent condom use, monogamy, and sexual decision making based on partners’ serostatus and viral load [66]. We recommend the design of studies that include composite indicators of HIV risk, which recognize the multiple options that can reduce HIV transmission and improve disease progression [67].

Another consideration for the field is the role of extra-individual processes that constrain personal agency and undermine choice. The majority of interventions exclusively emphasized individual-level factors despite their conceptual focus on marginalized key populations whose HIV risk and treatment outcomes are determined by complex social factors. With few exceptions (e.g., EMERGE, TRUST, peer navigation), social and behavioral interventions have not focused on critical economic or interpersonal challenges to engagement in HIV prevention and treatment technologies. Thus, there is an urgent need to intervene upon social determinants of HIV infection and disease progression. Doing so will require new conceptual frameworks that reimagine intervention targets, mechanisms, and outcomes of change beyond the individual unit [61].

An overarching challenge, and a priority for the field, is the sustained implementation of effective interventions. Interventions designed and tested in controlled settings do not easily translate to real-world services delivery [68]. Implementation sites may not have the resources to deliver complex programs, which are often designed for highly educated clinicians or require infrastructure (e.g., mobile/internet platforms) unavailable outside of well-funded institutions. Delivery of HIV programs often rely on non-profit and non-governmental organizations; these organizations are typically under-funded, and frontline staff may experience economic and occupational precarity [69]. Greater investment in the HIV service delivery sector and appropriate remuneration and acknowledgement of frontline staff is a necessary precursor to sustainable implementation of evidence-based programs. In addition, research on implementation optimization often follows after interventions are designed and tested. We advise researchers to consider developing and testing interventions guided by specific awareness of the implementation realities of delivery settings. For example, front-line staff should be more closely involved in intervention development and evaluation before and during the research process.

This review has important limitations. We reviewed the literature of interventions published during the past year (September 1, 2020 to September 23, 2021), which notably coincided with the COVID-19 pandemic. Thus, relevant and timely studies might have been omitted due to the timing of our search and/or because of publication delays. Other limitations to this review include exclusively focusing on the United States and excluding promising pilot studies and published protocols.

The studies included in this review provide evidence for the utility of social and behavioral interventions to address disparities across both the HIV prevention and care continuum. Despite awareness of the upstream factors that shape HIV inequities [18, 19], the majority of interventions continue to focus on the individual as the unit of behavior change. Increasing our focus on the structural, environmental, and economic vulnerabilities that shape HIV inequities will require novel multi-level approaches developed in partnership with community settings in order to realize the full potential of existing and emerging biomedical HIV technologies [61].

Key points:

1. Social and behavioral interventions continue to make strides in addressing mental health, substance use, stigma, peer and romantic relationships, and structural vulnerabilities to reduce HIV transmission risk and disease progression.

2. Recent studies have focused primarily on the individual as the unit of change.

3. Multi-level approaches are necessary to realize the full potential of existing and emerging biomedical HIV technologies in order to attend to the structural, environmental, and economic vulnerabilities that shape HIV inequities.