3.13. Component C: MI counseling sessions
depression
SAID
As a reminder, all intervention components were informed by the conceptual model that incorporates critical race theory and that includes autonomy support and harm reduction and aligns with MI, but the counseling session component also used specific MI techniques such as identifying discrepancy, a “readiness ruler,” and training on habit formation. Participants described themselves as knowledgeable about HIV and reported they did not require training on how to manage HIV. In general, MI counseling sessions were experienced as acceptable and useful in that they provided a supportive and non-judgmental experience in which to reflect on behavior patterns. Importantly, this commonly prompted participants to reflect on and/or reconsider their attitudes toward HIV medication adherence and adherence patterns. The supportive, non-judgmental approach engendered participants' feelings of connectedness with the S-CAP2 study while also centering participants' individual health needs, which may or may not have included HIV medication adherence and HIV viral suppression. Further, the sessions allowed for open and honest sharing of their experiences, which further promoted participants' health decision making. This was notable, because participants commonly reported concerns or fears about discussing potentially stigmatized issues such as declining to take HIV medication, along with behaviors such as drug use, selling medications, and other “hustles” in the context of a research study (“I've been selling my medication for so long. I know that this is all confidential, right? Right?” and “I'm being pretty open with you and because, what are you going to do? I'm [not] going to see helicopters over my roof tomorrow, I mean”). Ultimately, participants were clear they made their own decisions about HIV management, consistent with the MI approach. Further, as noted above, taking HIV medication was not a precondition for study participation.One participant who had been living with HIV for over 20 years shared how MI counseling sessions helped maintain a focus on his health. In sessions, the participant shared that, within the context of the staff member-participant relationship, he engaged in self-reflection, and was open and honest with the interventionist, which, in turn, appeared to have played a role in his continuing to avoid heavy drug use and begin to take HIV medication with high levels of adherence (“I'm trying to be undetectable as before”), in conjunction with improvement in his housing placement. Daniel, a 56-year-old cisgender, heterosexual Black man diagnosed with HIV 20 years ago, described:Well, [MI Counseling Sessions] helped me to stay focused on my physical health. You know what I'm saying? My mental health, as far as me, you know, living, living with a medical condition, the one I have. […] I'm not going to be in denial; you know, 20 some years I've been medically disabled. So I look at it like this. If I live this long, I can live longer. Just keep focused, pray, ask God to help me. You know, take my medication, do the right thing, and stay off the drugs. You know what I'm saying? I drink here and there, I smoke a little weed. I don't do all that other shit. You know? I've been there, done that. You know, them days are over with. […] [With staff member], it was like I talked to her like a sister. Anything she wanted to know, I tell her. Whatever's going on in my life, I kick it to her. You know, the only way to get answers, get help, you've got to be honest with yourself. […] Right. I can trust her.Importantly, staff and participants were generally able to construct productive working relationships, despite being unable to meet in-person due to COVID-19, as described by Daniel.A typical constellation of serious barriers to HIV medication adherence for participants comprised persistent mental health issues, substance use challenges, and sub-optimal housing, which, not surprisingly, reduced HIV care and HIV medication as priorities in their lives and interfered with participants' capacity to effectively manage their HIV treatment. MI counseling sessions, which were flexible and individualized and could attend to such barriers along with HIV care engagement and HIV medication served the purpose of supporting participants in centering or re-centering wellbeing along with HIV-related health, with the potential to interrupt periods of distress, heavy substance use, and/or sub-optimal HIV management or solidify a commitment to behaviors and relationships that could support wellbeing. Mary, a 54-year-old Black heterosexual, cisgender woman diagnosed with HIV 25 years ago, described the importance of an improved housing situation in her HIV management, and the role MI counseling sessions played in her articulating and carrying out her own health-related decisions.[I stopped taking HIV medication] because of depression, my mother passing away, me moving from shelter to shelter. And then when I do get the medication at times I just say [forget it] you know? And now I'm staying […] in one place now and I know I'm not going nowhere no time so, yeah. […] I can get back on my program as far as [taking medication] every time—because I used to wake up in the morning—before I put my feet on the ground, I'd take all my medications you know? [S-CAP2 helped with that stability]. And I said now that I've got my place, I could start back taking my medication like I was taking it. […] You know that's what I choose to want to do? Yes. [S-CAP2] encouraged me and it was me that was encouraged to want to do it, you know?