Table 1 Description of the intervention components explored in the present study

All components

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▪ Guided by the IIT-ICM and uses the motivational interviewing approach, in addition to evidence-based approaches and behavior change techniques specific to that component

▪ Constructed to address or circumvent the primary multi-level barriers that AABL PLWH experience to HIV care continuum engagement and to be both culturally and structurally salient

▪ Takes the stance that HIV medication is PLWH’s best chance for a long and healthy life and optimal quality of life at the population level, but does not presume HIV medication is “right” for any individual participant at this time; elicits and respects personal decisions about HIV care and medication

▪ Considers substance use as a barrier

▪ Guided by manuals comprised of interactive exercises; manuals are flexible, individualized (i.e., elicits and attends to barriers related to race/ethnicity, social class, sex, time living with HIV, and sexual/gender minority status)

▪ Led by a clinically trained master’s level interventionist with expertise in commitment to structural and cultural competency and motivational interviewing

▪ Interventionists do not make individual medical recommendations but instead refer participants back to their health care providers; staff members’ level of medical knowledge is comparable to a health educator

Core session

HIV health education

▪ All participants receive the core session

▪ Goals: Foster engagement, build trust and relationships between the project and participant, increase or reinforce fundamental knowledge of recommended HIV care engagement and HIV medication use

▪ Modality: 1 health education session held in-person with participants individually, < 60 min

▪ Approach/Behavior change technique: Health education

▪ Content: Standard treatment education on the current U.S. Department of Health and Human Services recommendations for frequency of HIV care appointments, timing of HIV medication initiation, and importance of high levels of adherence

▪ Examples of cultural/structural salience: Implicitly recognizes that not all AABL PLWH attend HIV care appointments and take HIV medication due to complex multi-level barriers (structural salience, trust building, de-stigmatizing, individualized care); presumes participants are experts on their own health but that health education may be welcome (strengths-based, dignity enhancing)

A. Motivational Interviewing Sessions

Health beliefs

(e.g., outcome expectancies, self-efficacy); and

emotions

(e.g., medical distrust, fear of HIV medication)

▪ Goals: Guide participants in uncovering and articulating ambivalence about and exploring and resolving challenges to behavior change to thereby foster movement toward personal health goals (HIV-related or otherwise)

▪ Modality: 4 in-person sessions held with participants individually, approximately 60 min each

▪ Approach/Behavior change techniques: Uses specific motivational interviewing techniques such as articulating emotions and values, identifying discrepancy, setting personal goals and barriers to achieving goals, problem-solving barriers, planning

▪ Content: Each session includes 1–2 culturally and structurally salient video narrative segment(s) to highlight key issues (e.g., distrust, fear, counter-narratives, poverty, stigma) and foster discussion about these topics

▪ Session 1 addresses barriers to HIV care; Sessions 2 and 3 target barriers to HIV medication (S2: evoking barriers, fostering readiness; S3: decisions, plans); Session 4 addresses medication adherence barriers and their solutions in depth and finalizing care/HIV medication plans

▪ Examples of cultural/structural salience: Explicit focus on specific barriers to care/medication that are prevalent among AABL PLWH such as medical distrust, fear, counter-narratives (trust building, culturally salient, structurally salient), incorporates participants’ own views on how to best manage HIV and medication without judgment (non-judgment, individualized care, autonomy support)

B. Pre-Adherence Skill Building

Behavioral skill to manage HIV medication adherence (habits)

▪ Goals: Prepare the physical and social “adherence environment,” put long-term HIV medication supports in place, and build adherence skills including using pill boxes, visual aids and reminders, and building adherence habits

▪ Modality: Six-week intervention period with meetings between the interventionist and participant at the beginning and end of the intervention period, approximately 60 min each, and brief weekly check-in phone calls. Thus, conducted with participants individually in-person (session 1 and 6) and by phone (sessions 2–5)

▪ Approach/Behavior change techniques: Identify barriers to and facilitators of HIV medication adherence in the physical and social environments, action planning, learn and practice habit formation (behavioral practice), and feedback

▪ Content: Guided by the US Health Resources and Services Administration (HRSA) guidelines for preparing PLWH for treatment success

▪ Those who do not wish to take medication at this time can apply the concepts to other health behaviors

▪ First session assesses readiness for medication, identifies individual barriers to adherence prior to initiating medication (e.g., lack of supports, active substance use), links adherence to daily activities to build habits (e.g., taking medication at the same time as another regular activity), puts educational and visual aids and reminders in place (e.g., pill boxes, alarms), identifies long-term supports/supporters who can reinforce successes, and plan to minimize lapses if doses are missed

▪ Participants then have the opportunity to practice and build adherence habits. The interventionist will check in with the participant weekly to discuss and provide feedback. Barriers of/facilitators to adherence, if any, will be explored

▪ Final session to review progress made and future plans

▪ Examples of cultural/structural salience: Reflects the major practical and psychosocial barriers AABL PLWH experience to viral suppression such as lack of privacy in home setting, stigma, fear (structurally salient)

C. Peer Mentorship

Peer modeling and peer norms (primary), social support and stigma (secondary)

▪ Goals: Provide credible “successful” role models and challenge negative peer norms about HIV care engagement and HIV medication use, provide social support and reduce stigma

▪ Modality: Four-month intervention period with individual meetings held approximately weekly in-person or by phone (including two-way text messaging communication). The initial meeting is held in-person

▪ Approach/Behavior change techniques: Modeling of behavior, social support (practical and emotional), feedback on behavior, social comparison with peer mentor

▪ Content: Based on the HRSA-funded Peer Education & Evaluation Resource (PEER) model

▪ Participants are linked with a “successful” peer mentor (i.e., a demographically similar PLWH who has consistently engaged in HIV care and is taking HIV medication with high levels of adherence)

▪ The role of the peer mentor is to: model healthy HIV behavior; provide practical tips for managing HIV care/medication based on their personal experience; and provide social support. The peer’s experience managing HIV and willingness to share personal experiences reduces stigma and challenges social norms that AABL PLWH are typically poorly engaged along the HIV care continuum

▪ Examples of cultural/structural salience: Peer is also AABL and living with HIV and an expert in the barriers this population experiences to engagement along the HIV care continuum, as well as solutions to barriers (strengths-based, trust building, de-stigmatizing)

D. Focused Support Groups

Social support and stigma regarding care/ HIV medication status

▪ Goals: Provide emotional and instrumental social support for health goals and other concerns, reduce stigma

▪ Modality: 6 in person groups, ~ 90 min, every 2–3 weeks, over 4 months

▪ Approach/Behavior change techniques: Social comparison, demonstration of the behavior, and social support, and encourage shifts in perspective in a group process context

▪ Content: Group members choose a primary topic to discuss

▪ Topics include barriers to and decisions regarding care/HIV medication, reasons for not taking HIV medication, distrust and fear of HIV medication, race/ethnicity and social class and HIV medication, substance use and HIV medication, coping with HIV medication, managing pressure to take HIV medication in HIV care, mental health, stigma, managing communication with health care providers, and adherence to HIV medication

▪ Examples of cultural/structural salience: Groups addressed major barriers AABL PLWH experience to engagement along the HIV care continuum that are not commonly discussed in other settings such as medical distrust, fear of HIV medications, counter-narratives, substance use issues (de-stigmatizing, culturally salient, structurally salient)

E. Navigation

Ameliorating structural barriers to care and HIV medication

▪ Participants receive either the short (three month) or long (six month) duration of this component

▪ Goals: Identify needs and barriers to meeting needs and address or circumvent structural barriers to HIV care and ancillary services in the context of poverty

▪ Modality: Weekly sessions held with participants individually, initial meeting in person (< 90 min) and then weekly meetings in-person or via phone. Menu-based and highly focused

▪ Approach/Behavior change techniques: Needs assessment to assist PLWH in identifying barriers to health services for HIV and other needs (e.g., for substance use and mental health, housing, insurance), problem-solving and navigation to circumvent or resolve barriers

▪ Content: Based on the HRSA HIV System Navigation model. Navigation is an efficacious, flexible, individualized, strengths-based approach

▪ Comprised of an initial face-to-face meeting (30–60 min.) for review of participant’s readiness for and barriers to care/HIV medication, including substance use and mental health, and creation of a Change Plan/Action Plan

▪ A minimum of weekly phone (including text messages), email, and in-person meetings during the navigation period, depending on need

▪ The menu of activities includes screening and “Fast Track” referrals for housing, substance use, mental health, and other concerns; problem-solving barriers to appointments; and accompaniment to health care appointments

▪ Examples of cultural/structural salience: Designed to address the primary structural barriers that AABL PLWH experience to HIV care, HIV medication, and ancillary services such as for substance use, mental health (individualized care, structurally salient)