Frontline Perspectives from the Implementation of Evidenced-Informed Interventions to Improve Behavioral Health and HIV Outcomes Among Black Men Who Have Sex with Men in the United States

Abstract

The perspectives and contributions of frontline staff are critical to the success of integrated HIV and behavioral health services in the United States (US). In this analytic essay, we share five key priority areas from frontline staff at four diverse sites funded by the Health Resources and Services Administration to support the implementation of interventions to improve HIV and behavioral health outcomes among Black men who have sex with men (BMSM) living with HIV. The five main priorities focused on: (1) COVID-19 pandemic adaptations; (2) recruitment/enrollment; (3) retention; (4) frontline self-care; and (5) replication considerations. Projects had to be nimble and innovative in their delivery of services; leverage existing infrastructure; and they had to try multiple approaches to reach BMSM and modify/drop them as needed. Future implementers should expect to support frontline staff self-care given the added stress of working under COVID-19 pandemic conditions and in communities with limited and uncoordinated behavioral health services.

Introduction

Black men who have sex with men (BMSM) are disproportionately impacted by HIV in the United States (US).¹ Of all new HIV diagnoses in 2019, an estimated 26% were among BMSM. Recent scientific advances have shown that supporting people with HIV through the steps of the HIV care continuum, from linkage to the achievement and maintenance of viral suppression, not only has individual-level benefits but also community-level prevention benefits.^2
–4 However, BMSM are less likely to be linked to HIV care within 1 month of a new diagnosis, retained in HIV care, and virally suppressed compared with MSM of other racial/ethnic groups.⁵

Untreated behavioral health conditions contribute to poor engagement and retention in HIV care, antiretroviral therapy adherence, and viral suppression.⁶ Previous national estimates indicate high depressive symptoms (44–49%) and marijuana use (>50%) among BMSM living with HIV in the United States.⁷ Higher rates of depressive symptoms and younger age of first marijuana use have also been associated with higher rates of HIV treatment nonadherence.⁸ In addition, lifetime traumatic events (e.g., parental alcohol/drug use, domestic violence in the home have been shown to associate with HIV treatment nonadherence among BMSM.⁹

Limited engagement and retention in behavioral health utilization has been documented among BMSM living with HIV.¹⁰ A recent study among young BMSM living with HIV with access to colocated HIV and mental health services showed that among 158 young BMSM with identified mental health concerns, 79% were referred to mental health care, 56% set an appointment with a mental health provider, 41% attended an initial mental health care visit, and only 20% remained engaged in mental health care.¹⁰ Thus, integrated behavioral and HIV interventions are urgently needed and should be prioritized to improve behavioral health and HIV continuum of care outcomes among BMSM in the United States.¹¹

In December 2017, the Health Resources and Services Administration (HRSA) released a notice of funding opportunity entitled the “Implementation of Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes for Black Men Who Have Sex with Men (BMSM)” to support the implementation of evidence-informed interventions and/or models of care to engage, link, and retain BMSM in HIV medical care and supportive services by addressing their behavioral health needs.^12,13 Each site selected one of four models to adapt to address the needs of BMSM in their jurisdiction: a social marketing campaign,¹⁴ a case management program,¹⁵ recreation-based peer support,¹⁶ and a collaborative approach.¹⁷

Frontline staff [e.g., case managers, peer or health care navigators (HCNs), health educators, social workers, community health workers] are critical to the success of evidenced-based and/or informed HIV interventions.^18

–21 They serve a unique role given their cultural relevance, proximity, and frequency of contact with clients in the delivery of HIV interventions.^18

–21 However, their perspectives are oftentimes not included or considered in the development, implementation, and evaluation of such interventions. Their perspectives can be used to improve interventions, address identified barriers, and ultimately improve intended outcomes.²⁰ In this analytic essay, five frontline staff shared valuable insights in the implementation of evidenced-based and/or informed interventions focused on addressing the behavioral and HIV needs of BMSM living with HIV.

Methods

Five frontline staff from four of the HRSA-funded implementation sites (i.e., Durham, NC; Oakland, CA; New Orleans, LA; and Los Angeles, LA) participated in a reflection exercise led by an experienced facilitator to identify lessons learned in the delivery of evidenced-based and/or informed integrated interventions for BMSM living with HIV pre- and during the COVID-19 pandemic. IRB approval was not required for this exercise. The Durham, NC site implemented an adapted version of STYLE (Strength Through Youth Livin’ Empowered)¹⁴ using a peer HCN intervention, outreach, access to infectious disease specialists, and access to an online intervention developed for young BMSM, motivational interviewing, and behavioral health referrals. The Oakland, CA site implemented ERASE (Eradicating Racism and Striving for Excellence in HIV Care), an adapted intensive case management intervention.¹⁵

The New Orleans, LA site adapted a collaborative model¹⁷ and implemented the Plus Love intervention using a team- (i.e., peer case manager, triage social worker coordinator, behavioral health therapist) and technology-based approach (i.e., remote patient monitoring system). The Los Angeles, CA site implemented Building Brothers Up (2BU) using peer case managers and six peer case management intervention sessions in a community-based, rather than a clinical setting based on an adapted intensive case management intervention.¹⁵

Five key areas emerged as important considerations to highlight: (1) COVID-19 pandemic adaptations, to include reasons for adaptations and the impact of adaptations; (2) recruitment/enrollment successes, barriers, facilitators, and lessons learned; (3) retention successes, barriers, facilitators, and lessons learned; (4) the importance of self-care for frontline staff; and (5) replication considerations. The results are organized by these five main themes and are described in Table 1.

Table 1.

Summary of Key Findings by Site from Frontline Staff Involved in the Implementation of Interventions to Improve HIV and Behavioral Health Outcomes Among Black Men Who Have Sex with Men Living with HIV

Sites	Durham, North Carolina	Oakland, California	New Orleans, Louisiana	Los Angeles, California
Key priorities
Adaptions made	Strong and ongoing reliance on health care navigator to support the program	Increased home and community visits with clients during first wave of COVID-19 pandemic	Adaptation of a customized mHealth patient engagement system called CareSignal, which allowed participants to determine their level of engagementTriage social work coordinator hired in response to high behavioral health and social needs	Transitioned from in-person to virtual delivery to include videoconferencing, phone calls, text messages, and email format during first wave of COVID-19 pandemicSettled with hybrid model once COVID-19 restrictions lessened
Recruitment/enrollment	Pre-COVID recruitment consisted of QR code on a handbill and poster within participating clinicsInitial adaptions consisted of: (1) utilizing a health care navigator to personally recruit potential participants during clinic visits; and (2) social worker would contact health care navigator to be present during clinic visitAdaptation had to be modified to include a social worker contacting the health care navigator during or after a client visit or asking potential clients to contact the health care navigator themselvesBarriers—securing physician buy-in to support the study and some clinics stopped promoting the study.Facilitator—Participants stressed the importance of racial representation among staff	Conducted in-reach to recruit participants as they served more than 1700 adults living with HIVUtilized referral networks to support recruitment and enrollmentFacilitators—Importance of human touch/engagement	Paired recruitment and enrollmentUtilized internal patient system to find eligible clients, which was then cross-referenced with provider schedulesWarm hand-off coordinated after provider visit for screeningTwo recruiters later on-boarded to support recruitment and enrollment using social media appsAds also placed on social networking sites, and on buses and at bus stopsIncentivized referralsFacilitator—Participants stressed the importance of racial representation among staff	Community advisory board (CAB) in place before COVID-19 pandemicCAB recommended gatekeeper to support recruitment/enrollmentCommunity gatekeeper's engagement shifted from in-person to virtual outreach (e.g., phone and e-mail outreach)
Retention	Health care navigator stressed team approach to careHealth care navigator-built trust with clientsHealth care navigator emphasized that he was part of the communityLanguage adjustment—stressing that the study was a community project and their participation was critical to communityHealth care navigator communicated regularly with participants once enrolledGroup sessions	Virtual and community/home visits successful	CareSignal allowed for continuous engagementDual catastrophic events (i.e., COVID-19 and Hurricane Ida) intensified need for servicesCompensation tied to evaluation helped clients	Retention approach focused on addressing client holistic needsMemorandum of Understanding created with local agencies to support referrals to community services
Frontline self-care	Access to Personal Assistant Services to support self-careBoundary setting criticalWeekly team meetings	None reported	Mental health breaks and time-off encouragedAgency created and encouraged participation in online mental health relaxation sessionStaff could decide how to best engage with clients to address their own COVID-19-related anxiety	Bi-weekly meetings with therapist to support self-care
Replication considerations	Barrier—Limited and uncoordinated behavioral health servicesCultural competency among behavioral health specialists	Provision of core client services is criticalImplementation protocolsBarrier—Limited and uncoordinated behavioral health services	Location of team within federally qualified health center was a resourceCareSignal and remote patient monitoring provided higher level of connection to clientsBarrier—Limited and uncoordinated behavioral health services	Funds for research personnel, innovative technology, and travel resources for participantsBarrier—Limited and uncoordinated behavioral health services

Results

Overall adaptations made in response to the COVID-19 pandemic

Due to the COVID-19 pandemic, implementation sites had to implement organizational and/or program-level safety protocols to protect the health of participants and staff. They had to be nimble and innovative to deliver services that were centered on the needs of BMSM living with HIV. One approach was the movement from an in-person to a virtual or hybrid delivery model. Before the COVID-19 pandemic, 2BU in Los Angeles was completely delivered in-person at a nonclinical community-based research site. The program was successfully enrolling participants, delivering the intervention, and meeting enrollment goals. However, during the first wave of the COVID-19 pandemic, 2BU was on “pause” for a few months as per the Los Angeles COVID-19 “stay at home” orders. This impacted their ability to conduct in-person outreach and recruitment. The COVID-19 pandemic also impacted their clients' ability to access in-person services such as on-site study sessions.

Therefore, 2BU was adapted to be delivered virtually from in-person to a video conferencing, phone calls, text messaging, and email format. Early acceptability data indicated that participants actually preferred the in-person model to the virtual model, thus a hybrid model was developed to facilitate in-person and virtual models of care once COVID-19 restrictions lessened.

Another nimble approach was the increased reliance on community visits. ERASE in Oakland, CA continued to provide intensive case management services for enrolled participants throughout the COVID-19 pandemic. One adaption that was implemented during the first wave of the COVID-19 pandemic consisted of increased home and community visits with clients. They implemented this approach in response to the “stay-at-home” mandate and the rapidly changing organizational protocols that limited the number of staff members available in the clinic and the number of interactions that each staff member could have with clients.

A third approach involved the adaptation of a customized mHealth patient engagement system as in the case in New Orleans. The Plus Love team, housed at a federally qualified health center, used a remote patient-monitoring system called CareSignal.²² This system allowed clients to determine their level of engagement related to daily medication reminders, social determinants of health needs, and immediate and behavioral health needs identified from validated behavioral health assessments. As enrollment increased, the level of interaction and needs could not be fully met by only a case manager and therapist. The number of alerts that required staff response could average from 5 to 30 h a week depending on participant responses. This activity was in addition to already scheduled case management needs and behavioral health appointments. The calls that came in for an emergency alert did connect participants with a national crisis hot line, but the need for a more localized and rapid response led to the hiring of an additional team member (i.e., triage social work coordinator).

The New Orleans team added a triage social work coordinator to the Plus Love team in November 2020. The increase in emergency alerts of high Patient Health Questionnaire-9²³ and General Anxiety Disorder-7²⁴ scores as well as reports of suicidal ideations increased during the COVID-19 pandemic. Many participants were also experiencing housing, employment, and income insecurity. Participants in essential occupations were at high risk for COVID-19 exposure in the New Orleans area, which at the time was considered a COVID-19 hotspot. The triage social work coordinator position allowed for a more informed immediate reaction, including weekends and holidays, on alerts that would be considered a high priority. She was able to perform trauma-informed risk assessments to determine how to best help the participant in the moment and engage with other members of the team (i.e., peer case manager, behavioral health therapist) in the near future. She also met participants' immediate needs by giving community referrals for necessities, setting behavioral health appointments with team therapists, and informed the caseworker of nonimmediate needs.

This intervention allowed for a more comprehensive response when they engaged with a case manager and therapist. Team interaction and communication kept all parties informed of the needs of individual participants and how they were working with the participant to meet those needs. Participants reported that they felt their needs were being addressed and felt a higher level of commitment.

Finally, for the Durham, NC site, there was a strong and ongoing reliance on the HCN to support all aspects of the program and adaptions in response to COVID-19 as reported in the next four priorities.

Recruitment & enrollment

Implementation sites had to use a variety of approaches to reach BMSM living with HIV that leveraged and relied upon existing infrastructure [e.g., community advisory board (CAB), electronic medical system, staff]. For the Los Angeles site, having a community gatekeeper was critical to participant recruitment and enrollment. Before the COVID-19 pandemic, they had established a CAB to gather input and feedback in the development of their intervention. From the CAB, the team identified a key gatekeeper who had a successful history of in-person street outreach, recruitment, and enrollment, thereby leading them to contract with this individual as a community gatekeeper consultant. Their community gatekeeper was known by many clients because the gatekeeper had developed a reputation for working at multiple local service agencies. The Los Angeles team's nonclinical research site was the “last shop on the block” where many of their participants face homelessness, incarceration, and substance use, thereby having a community gatekeeper was critical to reaching BMSM.

Mandated “stay-at-home” orders made in-person street outreach challenging for the community gatekeeper to recruit participants during the COVID-19 pandemic. The Los Angeles site followed safety protocols by shifting from in-person to virtual outreach, thus the community gatekeeper would contact potential participants through calls, texts, and/or emails. This approach was not as successful as planned given the need for social distancing during the pandemic.

For the Oakland, CA site, recruitment and enrollment was steady because they were able to recruit a majority of ERASE clients from within their agency (currently over 1700 adult clients living with HIV, 45% of whom are African American, 70% of whom are men who have sex with men). The Oakland site also sustained and utilized their strong referral networks to ensure adequate recruitment and enrollment of BMSM. The only barrier was changing in-person recruitment to virtual and community visits. The most important lesson learned was the importance of human touch. The isolation, anxiety, and depression the clients experienced were expressed by many clients.

In Durham, NC, recruitment initially began with a QR code on a handbill and poster where interested potential participants would take a screener survey. The handbills were located at each participating clinic and provided to doctors and social workers for distribution to potential participants. Screener results were automatically sent to an HCN who would reach out to a potential participant. If the potential participant were eligible and interested, the HCN would either directly enroll the potential participant or set up a future time to enroll the potential participant. This approach was not as fruitful as expected, and two new options were implemented. One, the HCN would sit in the clinic and speak with potential participants after their visit with a provider. This face-to-face engagement allowed the HCN to meet the participant in person.

From there, the HCN would verbally screen the participant and start the enrollment process afterward. The second option was having a social worker contact the HCN to come to their clinic and visit a potential client on the day they were scheduled to come into the clinic. These new options were more successful and increased enrollment rates especially for newly diagnosed BMSM who had a lot of questions about their diagnosis.

The Durham, NC site's recruitment approach had to be modified once again during the COVID-19 pandemic and transformed into a social worker contacting the HCN or asking the potential participant to call the HCN. Sometimes the call was made in front of the social worker and sometimes it was later. The HCN would screen the potential participant and start enrollment if the participant was eligible. Throughout the entire study, the HCN had access to maestro care, an electronic medical record system, with their main clinic. Through this method, the HCN could look up potential participants and inquire about the patient to the doctor, social worker, or medical case manager. Once the HCN was given approval, the HCN could contact the participant through telephone. Sometimes the HCN would ask the doctor to have the patient contact the HCN if no working number was provided. This also proved to help with enrollment.

There were several barriers to recruitment and enrollment at the Durham, NC site. The first was securing physician buy-in to support the new study given their already busy schedules. Second, some of the participating clinics stopped advertising the study as they were unclear whether the study was still ongoing or turnover from clinical staff that were knowledgeable about the study. An important lesson learned from the enrollment process was that every participant said that had the HCN not been of the same race, they would not have enrolled into the study. Some participants also stressed the importance of representation, that is, seeing clinic staff that looked like and/or could understand living experiences of what they were going through.

In the case of New Orleans, recruitment and enrollment were paired together because that was the main method used in the Plus Love Program. The project coordinator would use Relevant, an internal patient system, to find eligible clients for the program. They would cross-reference this list with provider schedules in e-Clinical Works (eCW),²⁵ the electronic medical records system used at their location. The coordinator would call the participants 1 day before to remind them of their appointment and tell them of their eligibility for the Plus Love Program. The coordinator would then contact the provider to inform them of the eligible participant, and the two would coordinate a warm handoff after the appointment. The client would then be brought to the Prevention department where the coordinator would screen and explain the Plus Love Program. After the client understood and signed the consent form, they would start and complete the baseline survey. When completed, they would then be enrolled into the CareSignal²¹ text program.

The project coordinator would explain each aspect of the text system and decide with the participant when their texts would be scheduled. In addition to this method, the case manager and behavioral health therapist would contact the project coordinator after they met with their client for screening during appointments. The project coordinator sought to build trust between clients and the Plus Love Program by conducting warm handoffs between clients and team members. Similar to clients in Durham, many clients in New Orleans expressed relief when speaking with the project coordinator because they felt more comfortable speaking openly with another Black person.

The project coordinator relied on this method for recruitment for the first few months after the COVID-19 “stay-at-home” orders began. Eventually, the program added two recruiters to specifically help with recruitment and enrollment. As quarantine regulations and social distancing were imposed, the recruiters were trained in using Relevant²⁶ and eCW²⁵ to locate and identify eligible clients, but completed enrollment solely through phone calls.

After adding two additional staff to recruitment and enrollment, the Plus Love Program began using different methods of recruitment. During the Summer of 2020, recruiters placed ads on social media apps such as Grindr, Jack'd, etc. to contact and recruit potential participants. The New Orleans site received information about click through and engagement rate with the ads and found that the costs were exorbitant for actual number of calls that they received because of the ads. The high price of the online ads made the team consider other ways to reach the community in New Orleans that would be more cost effective.

According to the American Community Survey, New Orleans is one of the top 50 cities with the highest public transportation use.²⁷ The high use of buses and bus stops helped the team make the decision to place ads on five buses and two bus shelters in high traffic areas where potential participants may live. The local bus ads were significantly cost-efficient and increased the number of interest calls. The individuals in the ads were also from the agency and involved in community work. The team believed this familiarity of seeing people in an ad, whom a participant may know, and who looks like them, led to increased enrollment. The last recruitment effort added as a final push in October of 2020 was the implementation of incentivized referrals. Clients received gift card incentives for referring new clients to enroll in the program.

Retention successes, barriers, facilitators, and lessons learned

For the Oakland, CA site, retention was high. The virtual and community visits made it possible for EBAC to keep and in some cases increase retention numbers. The weekly (first 2 months) and then monthly (following 22 months) one-on-one visits was conducted in the community and in a client's home. This strengthened the bond between case management and clients. ERASE case managers continued to provide education about the treatment process, assisted with transportation, and appointment accompaniments if needed.

For the Los Angeles site, conducting research at a nonclinical community site has its challenges. To provide resources to participants through “warm hand-off” referrals, Memorandum of Understanding (MOU) were created with local agencies for participants to follow through with clinical care. Participant overall experiences, when making referrals, increased retention and ensured individual needs and barriers were being addressed. During the peak of the COVID-19 pandemic, many clinical, behavioral, social support, and testing services were on “pause” or had limited capacity and available services. The Los Angeles site leveraged their existing MOUs and reached out to their established partnerships to obtain up-to-date information on available services and resources due to mandated closures. Creating collaborative “warm hand-off” referrals ensured that participants were linked into much needed services and retained in care during the COVID-19 pandemic.

In the case of North Carolina, the HCN specifically informed potential participants that achieving their health goals was a team effort between them and the HCN. The second step was building trust between participants and the HCN by addressing head on that the HCN was not living with HIV but knew much about the virus to help with navigation, understand boundary limits, and have empathy without pity. The third was letting participants know that the HCN was part of the same community, and to look at him as a peer and not a provider. Even though this was stated, some participants still called the HCN a case worker. The last step was changing the language that the study was “a study.” The HCN called the study a project, reassuring the participants that the project could not get done without them and that the project was also focused on building network and community support systems. Many participants remained in the study because many were interested in building a support system.

Once enrolled, the HCN kept in constant contact with participants. The use of weekly groups helped the HCN know what was happening in the lives of the participants. Some participants had emergency needs that required immediate attention, and participants kept in touch for those reasons. After 6 months, the HCN scaled down those interactions and began to contact participants two to three times per month to check in and remind clients that he was there if they needed him. For some cases, the check in would become more frequent if the participant needed assistance with things like finding housing or other resources.

Groups were necessary for the Durham, NC site, as participants were able to talk about topics that interested them. Some talks were open discussions where participants could talk about current events. Some discussion topics were chosen by the group or by the HCN. The HCNs lead the group but provided space where participants were more open to be themselves and not worry about being monitored or made to talk about things that did not matter to them or pique their interest.

For the New Orleans site, the connection to CareSignal²¹ allowed for continuous engagement on a regular basis with participants, even if they were not seeking services with the case manager or with the therapist. One challenge with engagement was the ability for clients to keep phone service and the same phone number for service. To address this issue, team members confirmed the participant's phone number at every contact point. Because the Plus Love team was housed in a federally qualified health center, team members could also track address or phone changes with the medical providers in house. Some people, however, found the CareSignal²² contact to be overwhelming and asked to be disengaged. Out of 141 enrollees in CareSignal,²² only four participants asked for alerts to be paused during the program. In December 2021, 121 participants were engaged and using the system and only 16 participants were unengaged. Participants determined their level of engagement and what they used the system for, but engagement levels remained relatively high. Offering compensation to complete evaluation surveys also helped keep participants engaged in the program.

The New Orleans site also observed an increase in retention after Hurricane Ida caused a power disruption to the entire metropolitan area of New Orleans for a minimum of 3 days and up to weeks for some. The power disruption and damage caused widespread gas and food shortages, employment gaps, and general malaise for many participants. Once the team was able to reconvene, an effort was made to contact every enrolled member of Plus Love to do a wellness check and see how the staff might be able to help. This effort contributed to higher engagement with participants through a combination of case management services to address transportation and emergency food needs, behavioral health, and daily or weekly remote patient monitoring check-ins. The compensation tied to completing the evaluation components (e.g., survey) also helped the many participants who faced employment issues during the dual (i.e., Hurricane Ida, the COVID-19 pandemic) catastrophic events. These elements strengthened the participant/provider connection, and participants have accepted and embraced therapy as an added component of medical care.

Self-care for frontline staff

It became evident quite early on that frontline staff had to create a space for their own self-care. In Los Angeles, the 2BU peer case managers found biweekly meetings with a licensed PhD-level therapist to help with self-care and intervention facilitation. For instance, a peer case manager found it beneficial to discuss new problem-solving strategies and coping skills around clients' suicidal ideation to navigate crisis intervention. Having an opportunity to have one-on-one meetings with a licensed therapist helped to deal with on-going participant challenges that were identified during the program. The ability to address issues through a clinical perspective allowed peer case managers to feel supported and alleviate stressors to issues that may be difficult to navigate as a frontline peer staff.

In Durham, NC, self-care for HCNs was equally important. The university provided Personal Assistant Services (PAS) that the HCNs had access to whenever they felt stressed or were going through things. However, the project leader and manager also made sure that HCNs took time and did not overwork. They knew the importance of doing balanced work could only happen while being stress free. They also had weekly team meetings that provided a check in for HCNs to discuss things that happened during the week personally or with participants. This check-in proved to be very helpful when one of the participants passed away and the HCN who worked with him did not learn of his passing until 8 months later. This news was also delivered shortly after multiple deaths happened in this HCN's family. As a result, the HCN was asked to take time to focus on dealing with the deaths and was referred to use the PAS system.

In the case of New Orleans, the Plus Love staff were regularly given the opportunity and encouraged to take mental health breaks. The agency created and invited staff to join in online mental health relaxation sessions. Individual breaks and time off were met with approval and encouragement so that the staff could also cope with ongoing pandemic fatigue. Another way that staff were supported during COVID was letting them decide how they would choose to engage with clients. While some of the staff preferred face-to-face and masked interactions with clients, others chose virtual sessions only. The engagement was supported in whatever way was comfortable for the staff member.

Key replication considerations

Frontline staff described several elements that would be necessary for replication in other jurisdictions. In Los Angeles, the resources needed to implement the program at a nonclinical, community-based research site, were funds to have more research personnel, innovative technology, and travel resources for participants. Since 2BU was located at a community-based research site, it was important to have diverse personnel from different departments supporting the project. For example, 2BU identified clinical sites that had on-site behavioral health programs, social workers, outreach workers, and case managers to assist with program implementation. In addition, these sites used mobile health applications to send study reminders and track retention. The 2BU provided participant travel reimbursements or stipends for medical appointments, which supported continuity of care. Enrolling participants directly from clinical sites and using technological support helped boost participant enrollment and retention.

The Oakland, CA site stressed the importance of providing core client services to include case management, linkage, medical, and social services. It was also important to develop protocols for the different services and train current and any new staff on the protocols. In New Orleans, it was beneficial to be housed within a federally qualified health center where most clients received medical care. The direct ability to reach providers and for providers to reach the team helped clients with much more than just their medical needs. The Plus Love team supported the broader holistic needs of clients to include public benefits, medication adherence knowledge and support, and connections to supportive services. CareSignal²¹ and remote patient monitoring also added a higher level of connection to clients to support their medical decisions, health outcomes, and overall quality of life. Access to the daily life of an engaged client was much more telling and insightful than a biweekly or monthly check in with a case manager or therapist alone.

A common contextual finding among all implementation sites was limited and uncoordinated behavioral health services. Many participants did not have access to behavioral health services and/or feared accessing such services. Frontline staff typically had high caseloads with few resources at their disposal to help clients, particularly those who may have critical behavioral health challenges. The challenges inherent to this field suggest that burnout is likely to be common, especially when frontline staff are handling high client caseloads.²⁸ Some participants had anxiety about getting behavioral health services and in some instances self-medicated because it was easier to access street drugs than mental health services when they need it. At the Durham, NC site, the HCN was able to find a community clinic that offered after-hour services to the community to help increase access.

Furthermore, for the Durham, NC site, cultural competency played a significant role in behavioral health seeking behaviors. Some clients stressed that many of the behavioral health specialists they had previously encountered could not relate to their experiences because they did not have the cultural background to understand their circumstances. Some participants recalled their first interactions with a behavioral specialist, which consisted of prescribing them with medication and not really discussing other forms of treatment and/or support.

Discussion

Obtaining and understanding the perspectives of frontline staff involved in conducting HIV and behavioral health interventions for BMSM is critically important for intervention implementation, adaptation, and sustainment.^29,30 This article identified and outlined five key areas for consideration in the implementation of such interventions. The COVID-19 pandemic caused an instant shift in the delivery and engagement of participants for this national initiative. COVID-19 further exacerbated immediate needs and psychological distress for BMSM living with HIV.³¹

Implementation sites had to be nimble and innovative in their delivery of services (e.g., in-person to virtual to hybrid model; reliance on community visits or real-time customized patient engagement system) to respond to the needs of BMSM living with HIV. They had to leverage existing infrastructure (e.g., key staff, CAB members, electronic medical system, key staff) to reach, enroll, and retain participants during the COVID-19 pandemic. At two of the sites, having staff that reflected the population helped facilitate enrollment and recruitment. This is aligned with previous findings from a multisite study among BMSM enrolled in the HIV Prevention Trials Network (HPTN) 061 study.³² Similar to the HPTN 061 study, multiple staffing models were also utilized across the four HRSA-funded sites to recruit and enroll eligible BMSM.³² The HRSA-funded sites also had to test innovative approaches to reach BMSM and drop or modify them based on early results. Implementers should expect to employ navigators, case managers, behavioral health specialists, and other frontline staff members who reflect the demographics and/or are connected to the target audience.

This is especially important for the Black community, whose history with trusting providers and researchers is all but smooth.³³ Finally, implementers should consider early on opportunities to support frontline self-care, which is not only essential for the health and wellbeing of frontline staff but also the delivery of high-quality services for BMSM living with HIV.³⁴ Frontline staff endure unequivocal stress and trauma in response to the COVID-19 pandemic and are often overlooked and do not receive adequate support (e.g., mental health, economic, social support) within their own institutions.³⁵ Structural racism may play a role in the lack of support for frontline workers in the workplace.³⁵ This analytic essay outlined ways in which frontline staff were supported by their agencies during the COVID-19 pandemic. However, such supportive systems for frontline staff should be ongoing and regularly examined for enhancement.

The findings of this study are limited to the experiences of frontline staff in four cities participating in this HRSA-funded project. However, these findings represent an interesting mix of perspectives that are emblematic of HIV service organizations in the United States that are working to end HIV in their respective jurisdictions.³⁶

Footnotes

Authors' Contributions

All authors developed the initial concept and cowrote the article. All authors have read and approved the final article.

Acknowledgments

The authors would like to thank all study participants and community partners involved in the implementation of the study.

Author Disclosure Statement

Several authors (i.e., Brian Goings, Conchita Iglesias-McElwee, Bill Van Le, Kavin Keller, and Damien Sykes) represent agencies that received HRSA funding under the following initiative - “Implementation of Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes for Black Men Who Have Sex with Men (BMSM).” Dr. Brewer served as subject matter expert consultant and his time was supported by NORC, the HRSA-funded Evaluator and Technical Assistance Provider for this initiative.

Funding Information

This project was supported by HRSA as part of the “Implementation of Evidence-Informed Behavioral Health Models to Improve HIV Health Outcomes for Black Men Who Have Sex with Men initiative.”

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