Tailored Motivational Interviewing Implementation-Effectiveness Trial in Multidisciplinary Adolescent HIV Care Settings

The NIH Office of AIDS Research called for implementation science (IS) to address the
behavioral research-practice gap.Motivational Interviewing (MI) is the only behavioral
intervention to date shown to be effective to improve self-management for youth living with
HIV (YLH). MI was also the only intervention to demonstrate success across the youth HIV care
cascade. MI interventions can target multiple behaviors and be delivered by multiple
provider-types as is common in adolescent HIV care settings. Finally, MI is already embedded
in the clinical guidelines for HIV care and HIV risk reduction. Implementation Science is the
scientific study of methods to promote the uptake of research findings and evidence-based
practice (EBPs) to improve the quality of behavior change approaches in health care settings.
A primary challenge of scaling up EBP's is the balance of flexibility (adaptation to context)
and fidelity (provider adherence and competence). The Dynamic Adaptation Process (DAP) guides
tailoring of MI implementation at the exploration, preparation, implementation, and
sustainment phases (EPIS) of scale up. The goal of this proposal is to test a multi-faceted
Tailored Motivational Interviewing, Implementation intervention (TMI), based on the DAP to
scale up an EBP in multidisciplinary adolescent HIV care settings while balancing flexibility
and fidelity.

The pilot work for TMI included tailoring of initial workshop training based on innovative
methods in communication science, developing efficient fidelity measurement, and pilot
testing the revised intervention. The initial TMI workshop was adapted based on findings from
sequential analysis of provider interactions with youth living with HIV (YLH) by emphasizing
provider communication strategies most associated with patient motivational statements
("change talk"), de-emphasizing MI strategies that were unrelated to change talk, and
suppressing those that were associated with a motivational statements ("counter-change
talk"). Additional tailoring based on the DAP requires that qualitative and quantitative data
are collected during the exploration phase. In the preparation phase, these data are reviewed
by an implementation team comprised of local stakeholders and experts in MI implementation
who recommend necessary adaptations for the service context while balancing the need for
fidelity (adherence to minimum implementation requirements and achieving provider competency
thresholds). In the implementation phase, ongoing fidelity monitoring determines the need for
ongoing coaching, thus amount of coaching is tailored to the individual provider. Finally,
the sustainment phase addresses the maintenance of innovation beyond 1 year utilizing
strategies such as developing communities of practice (CoPs) and promoting internal
facilitation of TMI.

In a hybrid implementation-effectiveness (Type 3) trial, the effect of TMI will be tested on
fidelity EBP, and secondarily on HIV cascade-related outcomes, using a dynamic wait-listed
design (DWLD) 18 with 165 providers nested within 10 Adolescent Medicine Trials Network for
HIV/AIDS Interventions (ATN4) sites. With this design, the 10 clinics will be randomly
assigned in 5 clusters to receive TMI. For each randomization, 2 clinics receive TMI and the
others remain in the wait-list condition. This will continue until the 5th cluster has been
randomized to TMI. After one year of TMI's external facilitation based on the DAP, a second
randomization will compare internal facilitator monitoring and coaching plus the
encouragement of CoPs to CoPs alone. Fidelity will be assessed on a quarterly basis through
the 24 months of intervention and an additional 6 months of follow-up. The proposal uses the
EPIS model, to guide the investigation of the interacting elements that influence successful
implementation. The qualitative method will be nested within the quantitative study to
provide a deeper understanding of the implementation context and understand why or why not MI
is integrated with fidelity across the 150 providers. Providers and key stakeholders will
complete qualitative interviews and brief assessments based on EPIS at baseline, after one
year of TMI (first randomization), and after 1 year of follow-up (second randomization).

Inclusion Criteria:

- All youth HIV providers (prevention and care) at our target clinics will be eligible
to participate.

Exclusion Criteria:

- Non-providers of youth HIV prevention and care