Enhancing the Organizational Social Context to Improve Viral Suppression and Retention in HIV Care: A Randomized Controlled Trial

Abstract/ Project Summary: Despite the widespread availability of effective antiretroviral therapy (ART), the HIV epidemic remains a persistent public health crisis in the United States. A significant proportion of individuals living with HIV are not consistently retained in care and do not achieve sustained viral suppression (VS), limiting both individual health outcomes and efforts to reduce community transmission. Longitudinal engagement in HIV care is needed for sustained VS and decreased community transmission of HIV. Although the outpatient setting is a vitally important aspect of care provision for PLWH, there are limited data on the impact of intra-organizational factors on HIV outcomes. The organizational social context (OSC) includes organizational culture (organizational norms and values that drive quality of care), organizational climate (perception of the culture and how it impacts personal well-being), and workers’ attitudes. Using a randomized controlled trial, we will implement ARC (Accessibility, Responsiveness, Continuity) to improve organizational behavior and HIV outcomes for PLWH. ARC is an evidence-based intervention that uses three strategies (ARC principles, ARC component tools, and ARC mental models) to create OSCs that support the implementation of interventions to improve patient outcomes. Clinics will be randomized to ARC (n = 2) or standard of care (SOC; n= 2). Those assigned to ARC will address factors occurring at the organizational level affecting care, including referral and treatment patterns for PLWH. A pre-implementation period will be followed by ARC and ARC-associated implementation strategies for 36 months and then a 12-month post-implementation period where we will continue to measure HIV outcomes in both arms. We will compare HIV outcomes, namely VS and retention in care, and intermediate outcomes, such as linkage to mental health treatment and staff turn-over in clinics assigned to ARC and OSC. We will also evaluate whether individual (self-efficacy, patient satisfaction, and provider trust) and organizational factors (OSC and cohesion of OSC measures) mediate the relationship between ARC, intermediate, and HIV outcomes. In preparation for the RCT, we will evaluate baseline OSC measures across 12 HIV clinics in Philadelphia and determine aspects of the OSC associated with VS and retention in care in a multi-level model adjusting for neighborhood and patient-level factors and clustering of patients nested in clinics and neighborhoods. We will then test the effectiveness of ARC in improving a primary outcome of VS and secondary outcome of retention in care at the end of the implementation period. We will examine the acceptability, sustainability, and cost of implementing ARC in outpatient HIV care. This research will advance understanding of the impact of organizational level factors on HIV treatment outcomes and health services research and the implementation of a disseminable evidence-based practice aimed at improving clinic culture and climate.