Moving beyond research settings to strengthen HIV services: determinants of intervention sustainability and community-generated implementation strategies

Abstract

The sustainment of evidence-based interventions (EBIs) that have implementer, beneficiary, and decision-maker buy-in is critical for maximizing long-term population health impacts. However, fewer than half of public health interventions are integrated into routine practice following a successful research trial, limiting their reach to communities who would benefit most—particularly communities who have been historically and continue to be under-resourced and marginalized. This persistent research-to-practice gap not only reduces anticipated public health impacts but also presents substantial ethical concerns. Planning for sustainability early in the research process, not just after implementation, and building equitable partnerships with communities through community-based participatory research (CBPR) approaches to ensure research is aligned with and driven by community priorities are essential for facilitating long-term implementation of EBIs. The limited and delayed translation of EBIs into routine practice is particularly salient for HIV programming, where despite global advances, significant inequities persist and effective interventions often remain confined to research settings.This dissertation applied a combination of participatory methods, strategy mapping, mixed-effects regression models, and a configurational comparative method (coincidence analysis) to examined sustainability from three complementary perspectives, drawing from two projects focused on improving HIV outcomes in the United States and Kenya. The primary objectives were to: (1) identify and characterize strategies to facilitate integrated HIV services and social determinants of health programming at three community-based organizations (CBOs) in King County, Washington; (2) assess implementation outcomes (acceptability, appropriateness, feasibility, fidelity, and sustainability) of the Adolescent Transition Package (ATP) that supports youth living with HIV (YLH) across 20 health facilities in Kenya one year after the effectiveness trial, examining associations between early implementation outcomes, fidelity, and intervention sustainability; and (3) identify combinations of multi-level determinants associated with high ATP sustainability in health facilities in Kenya one year post trial. Results from the first aim suggest that sustainable implementation of integrated services within CBOs may require systems-level approaches to strengthen organizational infrastructure and respond to community priorities. This community-academic partnership highlighted that implementation science frameworks may be unnecessary for strategy and determinant identification with CBOs, and instead, may be valuable for translating highly tailored strategies into potentially generalizable takeaways in similar contexts. Additionally, we observed patterns suggesting that examining feasibility and effectiveness of strategy types addressing unique combinations of determinants may strengthen barrier-strategy mapping. In the second aim, we observed high levels of acceptability, appropriateness, and feasibility of the ATP among healthcare workers (HCWs). These qualities likely contributed to the high perceived sustainability of the ATP, with each implementation outcome showing distinct and independent effects on sustainability. These results also suggest that after a research trial, intervention and control sites may require different implementation strategies to facilitate continued implementation. Intervention appropriateness emerged as particularly influential for sustainability for both intervention and control sites, while feasibility was more critical for control sites and acceptability more relevant for intervention sites. Lastly, the coincidence analysis conducted for the third aim highlighted fidelity as a necessary component of high ATP sustainability one year after the research trial, although it was not sufficient on its own. Instead, high ATP sustainability was a result of a combination of facility level factors (high adolescent client load, high awareness of the ATP across the health facility, and patterns in staff tenure) and fidelity. Two distinct pathways for achieving high sustainability were identified, emphasizing the need for scale-up and sustainability plans to reflect that there are likely multiple approaches that can lead to successful long-term implementation of EBIs. This research provides pragmatic, empirically grounded insights for policy development regarding EBI sustainability, health system supports for integrating social determinants of health into HIV services, and advancing our understanding and application of implementation science frameworks across contexts. Facilitating the translation of research findings into sustainable programming in routine practice settings will require embracing the dynamic complexity of implementation contexts and planning for sustainability throughout the entire research process. This work contributes meaningfully to bridging the know-do gap, ultimately working to ensure that effective interventions reach the communities that need them most.