Assessing Client Factors Associated with Detectable HIV Viral Loads; and Models of Care the Ryan White HIV/AIDS Program

RWHAP Viral Suppression Study – Provider Interview Guide

OMB Number: 0906-XXXX

Expiration Date: XX-XX-20XX

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0906-XXXX.  Public reporting burden for this collection of information is estimated to average 120 minutes per interview. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 4N39, Rockville, Maryland, 20857.

Attachment A: Ryan White HIV/AIDS Program Viral Suppression Outcomes – Provider Interview Guide

INTRODUCTION

Thank you for taking the time today to talk with us. The overarching goal of this project is to identify the characteristics of RWHAP clients with detectable viral loads and explore the barriers to reaching viral suppression. Identifying individuals’ specific barriers to reaching viral suppression will enable the development of better targeted interventions for achieving and maintaining viral suppression. This project will expand the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau’s (HAB) in-depth understanding of the characteristics of RWHAP clients who do not achieve and/or maintain viral suppression, as well as the circumstances that create barriers to successful management of their HIV.

This interview includes questions focusing on HAB’s objectives for this evaluation, specifically an assessment of the factors that affect an individuals’ ability to reach and /or maintain viral suppression. For the purposes of this interview, we define viral suppression as an HIV viral load count of less than 200 copies/mL (at last visit). Our interview will include questions on the community context and background of this clinic, how the clinic is organized, the services provided, and your perceptions of the barriers or facilitators that clients may experience in attaining and/or maintaining viral suppression. We expect that the interview will take no more than 2 hours.

Date(s) of Interview
Facility Name and Location
Participants (full name & credentials)	Title and Role

1. Background and Clinic Context

To begin, we would like to gain a clearer understanding of the larger context in which your clinic/facility operates.

1. Thinking about the neighborhood/community where your clinic is located, please describe the socio-economic and cultural characteristics of the community.

2. How does this influence services, program and operations at your clinic/facility?

3. Please discuss the availability of medical and support services (including Ryan White HIV/AIDS Program and non-Ryan White HIV/AIDS Program funded services) for people living with HIV within your community?

4. Now please think about the population of clients that your clinic primarily serves. Please describe socio-economic, cultural characteristics (race, ethnicity, age, gender, etc.) and/or transmission risk groups (MSM, IDUs, etc.) of these individuals.

5. Which statement best describes your clinic?

   1. We are a primary care clinic that has not integrated HIV care.

   2. We are a primary care clinic that has integrated HIV care.

   3. We are a specialist clinic (HIV, STDs, infectious diseases) that has not integrated primary care.

   4. We are a specialist clinic (HIV, STDs, infectious diseases) that has integrated primary care.

   5. We are a general outpatient clinic

      1. Which services apply (primary care, HIV care, infectious diseases, substance abuse services, mental health services, other)?

6. Is your clinic officially recognized or certified as a Client Centered Medical Home (PCMH)?

7. Please describe the types of collaboration or integration of HIV services and primary care offered at your clinic.

Probe: Collaboration types range from minimal collaboration to fully integrated care teams.

8. In the past year, approximately how many HIV positive clients has your facility/clinic served?

9. In general, what proportion of these clients were virally suppressed at last visit?

2. Clients and Viral Suppression

In this section, we would like to discuss client-specific factors that may affect a client’s ability to achieve and/or maintain viral suppression. Please answer these questions based upon your professional experience providing services at your clinic. Please note that we are interested in clients who were diagnosed with HIV at least three (3) months ago. Again, for the purposes of this interview we define viral suppression as an HIV viral load count of less than 200 copies/mL (at last visit).

10. Excluding clients with viral resistance, what are some key differences that you have consistently observed between clients who are able to achieve and/or maintain viral suppression compared to those who are unable to do so?)?

Probe: Discuss any demographic (age, gender), socio-economic factors (housing, income), medical/health (mental illness, substance abuse), interpersonal (social support, violence), or transmission risk group (MSM, PWID, IDUs, etc.) characteristic differences that you have noticed during your time as a provider at this clinic.

11. Please describe common client-specific barriers or challenges to accessing and/or maintaining engagement with HIV medical care.

Probes:

• How do factors such as education level, job status, housing, income level, language, and health literacy affect client engagement with HIV medical care?

• How does time since diagnosis factor into these barriers?

• How do other co-morbidities factor into these barriers? Which co-morbidities?

• How are these barriers or challenges different from those experienced by clients with regularly suppressed viral loads?

12. Please describe common client-specific barriers or challenges to achieving/maintaining adherence to treatment.

12a. How do factors such as education level, job status, housing, income level, language, and health literacy affect adherence to treatment?

12b. How does time since diagnosis factor into these barriers?

12c .How do other co-morbidities factor into these barriers? Which co-morbidities?

12d .How about do things like pill burden/size, length of time on ARVs, complications of medication, etc. factor into these barriers?

12e .How are these barriers or challenges different from those experienced by clients with regularly suppressed viral loads?

13. Please describe the most common barriers or challenges clients experience when accessing HIV-specific medications.

14. How do the types and frequency of HIV medical services accessed through RWHAP differ between clients who are virally suppressed and those who are not?

Probes:

• Please describe differences in the types of services used by the two groups

• What differences have you observed in the general frequency of accessing HIV medical services?

15. Please describe the most common barriers or challenges to accessing HIV medical services.

16. How do the types and frequency of HIV support services accessed through RHWAP differ between clients who are virally suppressed and those who are not?

Probes:

• Please describe differences in the types of services used by the two groups

• What differences have you observed in the general frequency of accessing HIV support services?

17. Please describe the most common barriers or challenges to accessing support services (case management, financial and/or housing assistance, transportation, food etc.).

18. Do the patterns and frequency of HIV medical or support services differ by client characteristics (i.e. demographics, risk group)?

3. Engagement in Care

In this section, we will ask about your experiences engaging clients in HIV care.

19. Please describe the steps or approach you or your facility takes to engage and/or retain a client in HIV care and treatment.

19a. What types of assistance do you typically provide to clients beginning HIV care to improve the likelihood they will return for continuing care?

19b. What types of tools or resources do you use to assess your clients’ readiness for initiating or continuing HIV care or treatment?

19c. What steps or approach do you take if a client refuses HIV care or treatment?

19d. What types of assistance do you provide to established clients to help them return for follow-up appointments (e.g., appointment reminders by mail, phone, or other, or follow-up for missed appointments)?

19e. What types of assistance do you provide to re-engage clients who have dropped out of care?

19f. What types of tools or resources do you use to assess your clients’ need for a referral to other health-related services (e.g. mental health, substance abuse, dental care, case management)?

19g. In your opinion, are these tools and resources adequate? What could be improved?

20. What are some of the barriers that you experience as a provider when attempting to help clients engage and/or remain in HIV care?

21. What are some of the barriers that you experience when attempting to re-engage clients in care?

22. What are some of the barriers that you experience when attempting to refer clients to other services?

23. Please describe any aspects of your organization’s service model used for engaging HIV-positive clients that you consider to be innovative. This could include novel approaches to accessing care and/or HIV medication, new methods for tracking retention in care or flagging viral loads and/or high risk clients, etc.

24. How do non-HIV health conditions (i.e. hypertension, diabetes, hepatitis, etc.) affect client’s ability to maintain suppressed viral load?

4. Social Determinants

In this section, we will ask you some questions pertaining to social determinants of health and how those affect your clients.

25. How does internalized stigma and/or stigma in the community/environment affect client viral suppression?

Probes:

• Describe any differences between clients who are suppressed and those who have a detectable viral load.

• Which of these are most commonly experienced among clients with a detectable viral load?

26. How do stressful or traumatic life events affect client access to HIV medical care, maintaining treatment adherence, and/or viral suppression?

Probes:

• Describe any differences between clients who are suppressed and those who have a detectable viral load.

• Which stressful or traumatic life events are most commonly experienced among clients with a detectable viral load?

5. Closing

27. In your opinion, what are the 3 most important factors related to clients successfully achieving and/or maintaining viral suppression?

28. Are there any additional thoughts you would like to share before we conclude?

Thank you very much for your time today. We are at the end of our interview.

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