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The Ryan White CARE Act provides federal dollars supporting low income people living with HIV/AIDS (PLWH). Regional Ryan White Planning Councils (RWPC) are responsible for setting priorities and deciding CARE Act fund allocations, using local data to identify greatest need. However, RWPC are challenged with interpreting complex epidemiological, service utilization, and community needs data to inform priority setting and resource allocations. We piloted system dynamics (SD) learning, using a validated HIV care continuum SD simulation model calibrated to one northeastern U.S. Ryan White funding area. The pilot applied systems thinking to understand the complex HIV care continuum and to simulate and compare outcomes of various resource allocation decisions. Three scripted workshops provided opportunities to learn the SD modeling process and simulation tool, simulate various resource allocations, and compare population health outcomes. Mixed methods evaluation documented the SD modeling process, member responses to the modeling sessions, and attitudes regarding benefits and limitations of SD modeling for RWPC decision-making. Despite high member turnover and complexity of the SD model, members could understand the simulation model and propose strategies to seek greatest improvements in HIV care retention, viral suppression, and reduced infections. Findings suggests the value of SD modeling to assist RWPC decisions., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Introduction: The use of digital technology in HIV-related interventions and implementation strategies is increasing. Whether the use of technology is to directly improve patient outcomes (ie, part of the intervention) or as part of the strategy to implement interventions has important implications. In this article, we present 5 case studies of projects that feature the use of technology in HIV-related implementation research to identify and describe challenges specific to technology-based implementation research about study design, outcome measurement, implementing in an evolving technology landscape, and equity., Methods: For each case study, we identified the technological components, classified the components as intervention or implementation strategy, and identified implications for measuring performance and ensuring equity. The Exploration, Preparation, Implementation, and Sustainment framework was used to identify the research stage of each project., Results: Technology is being leveraged across a diverse array of implementation strategies to promote Ending the HIV Epidemic in the United States. The case studies were primarily in the exploration and preparation phases of implementation, yet technology played a different role in each project- developing educational materials, mass media to recruit participants or distribute evidence-based campaigns, providing training, guiding tailoring, and implementing novel methods to democratize intervention development., Discussion: Technology can play multiple roles in HIV-related implementation research projects, including serving as the intervention, being leveraged within implementation strategies, or both. We identified multiple considerations across projects that should be taken into account when measuring success and planning for equitable and sustained impact., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives. To create causal loop diagrams that characterize intersectional stigma experiences among Black, gay, bisexual, same gender-loving, and other men who have sex with men and to identify intervention targets to reduce stigma and increase testing and prevention access. Methods. Between January and July 2020, we conducted focus groups and in-depth interviews with 80 expert informants in New York City, which were transcribed, coded, and analyzed. These qualitative insights were developed iteratively, visualized, and validated in a causal loop diagram (CLD) using Vensim software. Results. The CLD revealed 3 key feedback loops-medical mistrust and HIV transmission, serosorting and marginalization of Black and gay individuals, and family support and internalized homophobia-that contribute to intersectional HIV and related stigmas, homophobia, and systemic racism. On the basis of these results, we designed 2 novel intervention components to integrate into an existing community-level anti-HIV stigma and homophobia intervention. Conclusions. HIV stigma, systemic racism, and homophobia work via feedback loops to reduce access to and uptake of HIV testing, prevention, and treatment. Public Health Implications. The CLD method yielded unique insights into reciprocal feedback structures that, if broken, could interrupt stigmatization and discrimination cycles that impede testing and prevention uptake. ( Am J Public Health . 2022;112(S4):S444-S451. https://doi.org/10.2105/AJPH.2022.306725).

The continuing HIV pandemic calls for broad, multi-sectoral responses that foster community control of local prevention and care services, with the goal of leveraging high quality treatment as a means of reducing HIV incidence. Service system improvements require stakeholder input from across the care continuum to identify gaps and to inform strategic plans that improve HIV service integration and delivery. System dynamics modeling offers a participatory research approach through which stakeholders learn about system complexity and about ways to achieve sustainable system-level improvements. Via an intensive group model building process with a task force of community stakeholders with diverse roles and responsibilities for HIV service implementation, delivery and surveillance, we designed and validated a multi-module system dynamics model of the HIV care continuum, in relation to local prevention and care service capacities. Multiple sources of data were used to calibrate the model for a three-county catchment area of central Connecticut. We feature a core module of the model for the purpose of illustrating its utility in understanding the dynamics of treatment as prevention at the community level. We also describe the methods used to validate the model and support its underlying assumptions to improve confidence in its use by stakeholders for systems understanding and decision making. The model's generalizability and implications of using it for future community-driven strategic planning and implementation efforts are discussed., Competing Interests: The authors have declared that no competing interests exist.

Competing Interests: The authors report no real or perceived vested interests that relate to this article that could be construed as a conflict of interest.

Women in the US continue to be affected by HIV through heterosexual contact. Sexual risk behaviors among women have been associated with a syndemic, or a mutually reinforcing set of conditions, including childhood sexual abuse (CSA), depression, substance use, violence, and financial hardship. Baseline data from a cohort of women with and at-risk for HIV (N = 620; 52% HIV+) were analyzed with Poisson regression to assess evidence for additive, independent and interactive effects among syndemic conditions in relation to reported sexual risk behaviors (e.g., unprotected and transactional sex) over the past 6 months, controlling for age and HIV status. The number of syndemic conditions was incrementally associated with more types of sexual risk behaviors. For example, women with all five syndemic conditions reported 72% more types of risk behaviors over 6 months, as compared to women without any syndemic conditions. Compared to women with no syndemic conditions, women with three syndemic conditions reported 34% more and women with one syndemic condition reported 13% more types of risk behaviors. Endorsing substance use in the past 6 months, reporting CSA, and experiencing violence as an adult were independently associated with 49%, 12%, and 8% more types of risk behaviors, respectively compared to women without these conditions. Endorsing both substance use and violence was associated with 27% more types of risk behaviors. These associations were not moderated by HIV status. Understanding specific relationships and interactions are needed to more effectively prioritize limited resources in addressing the psychosocial syndemic associated with sexual risk behavior among women with and at-risk for HIV. Our results identify interrelated psychosocial factors that could be targeted by intervention studies aiming to reduce high-risk sex in this population.

Irregular participation in HIV medical care hinders HIV RNA suppression and impacts health among people living with HIV. Cluster analysis of clinical data from 1,748 patients attending a large academic medical center yielded three HIV service usage patterns, namely: 'engaged in care', 'sporadic care', and 'frequent use'. Patients 'engaged in care' exhibited most consistent retention (on average, >88 % of each patient's observation years had ≥2 visits 90 days apart), annualized visit use (2.9 mean visits/year) and viral suppression (>73 % HIV RNA tests <400 c/mL). Patients in 'sporadic care' demonstrated lower retention (46-52 %), visit use (1.7 visits/year) and viral suppression (56 % <400 c/mL). Patients with 'frequent use' (5.2 visits/year) had more inpatient and emergency visits. Female, out-of-state residence, low attendance during the first observation year and detectable first-observed HIV RNA were early predictors of subsequent service usage. Patients 'engaged in care' were more likely to have HIV RNA <400 than those receiving sporadic care. Results confirm earlier findings that under-utilization of services predicts poorer viral suppression and health outcomes and support recommendations for 2-3 visits/year.

System dynamics (SD) modeling belongs to the rapidly evolving, interdisciplinary field of system science research. This field adds value to more traditional health research by contributing to the design and testing of complex integrated models of change, to examine health system performance and patient outcomes. Using selected milestones in HIV care management to frame our simulation research, we created a SD model to examine three patient subgroups of women of color (WOC) represented in our multi-site cohort, classified by their health care seeking status at baseline. Asked to reflect on their circumstance 6 months prior to enrollment in the MSE cohort, 53% noted they were receiving some care (In Care, n = 341), 31% that they had been seeking care (Seeking Care, n = 201), and 16% that they were undecided about seeking care (i.e., answered that they may or may not look for care) for treatment of their HIV (May or May Not Seek Care, n = 103). Our SD model compared simulated patterns of patient retention over 24 months in relation to: (1) access to antiretroviral therapy (ART), (2) adherence to ART, and (3) viral suppression. Assessed patterns yielded insights about system capacities and constraints in the context of the SPNS initiative under evaluation.

This paper presents a case study of a participatory process that was used to understand the needs of persons living with HIV/AIDS in a US state. The case illustrates that participation in a community-based research project is a dynamic phenomenon that must be negotiated among an evolving web of roles and relationships. Using a continuum to model the multiple modes of community participation, we follow the changing nature of participation over the course of a single project. Our analysis illustrates the different levels of participation given by the continuum as well as the dynamic nature of participation. A shared understanding of participation evolves as the roles and relationships of those involved are negotiated and renegotiated. However, lack of reflection over power differentials can lead to disempowering outcomes even after achieving a seemingly participatory process. The case reveals that failing to resolve divergent assumptions about power and purpose can lead to fissures that are difficult to overcome.