Breaking Barriers: Innovating HIV Elimination with Social Network Strategies and Routine Substance Use Screening

ABSTRACT This proposal focuses on identifying viremic and/or people with substance use disorder (SUD), to engage for early intervention, as these often-overlapping populations are key drivers of the remaining HIV epidemic in the U.S. An estimated 80% of new HIV transmissions result from persons with diagnosed infection who are not receiving regular care (43%) or do not know they have HIV infection (37%).1 HIV incidence in the U.S. remains the highest among sexual and gender minorities of color (SGMC).2 Substance use is common among SGM,3,4 and impacts HIV transmission. Viral suppression is 20% lower among people with SUD,25 yet screening for SUD is not integrated in most federally qualified health centers (FQHC)s.26,27 In Chicago, viral suppression among SGMC is ~60%.28 Interventions to identify and treat SUD among SGMC can significantly reduce population level HIV incidence,29 but strategies to ensure universal identification of SUD must be improved. Proposed Solution. We propose a two-prong Hybrid Type I trial34 at a large FQHC network that primarily serves SGM in Chicago, IL. The first-prong is implementing routine screening for SUD (using the NIDA Quick Screen 1.038); and the second is a social network intervention (SNI) to identify individuals who are viremic, have SUD, or both and link them to harm reduction and HIV continuum of care services. Although social network methods have been successful at finding people unaware of their serostatus, and have demonstrated effectiveness in finding viremic SGMC through simulation studies,36 they have not been adapted as an intervention for finding PLWH who are viremic or people with SUD to support HIV elimination.35,37 The present study will test the system-wide implementation of a SUD screener and SNI for finding SGMC who are viremic and/or have SUD. To study implementation, we will conduct a rigorous mixed-methods evaluation across all study years guided by EPIS (Exploration, Preparation, Implementation, Sustainment)38 as the determinants framework and the Proctor Implementation Outcomes Framework (IOF)39 as the evaluation framework. The specific aims are: Aim 1: Evaluate the effectiveness of the SUD Screening and SNI implemented at a large FQHC. Aim 1a: Estimate the increased rate of SUD detection with the SUD screener vs. EMR documentation. Aim 1b: Evaluate whether the SNI is effective at identifying people who are viremic and/or have SUD compared a functional control (new or re-engaged FQHC patients seen during the same period). Aim 2: Develop a multifaceted implementation strategy package to support the adoption and sustainment of SUD screening + SNI in organizations serving SGMC. Aim 3: Evaluate the potential population-level reduction in (i) new HIV infections, (ii) individuals out-of-care, and (iii) individuals virally unsuppressed over 10-years if SU screening and SNI are implemented across Chicago.