4. Discussion
such behaviors, HIV viral suppression, viral suppression, HIV management behavior
SAID
The goal of ending the HIV epidemic in the United States cannot be reached without addressing the complex impediments that African American/Black and Latino PLWH experience to consistent engagement along the HIV care continuum. Clearly, efficient and effective behavioral interventions are an essential aspect of supporting these populations of PLWH in making use of and benefitting from HIV care and medications (We apply the MOST framework and use an efficient factorial design to explore three behavioral intervention components directed at African American/Black and Latino PLWH with non-suppressed HIV viral load. All three components are delivered virtually, and two of them (TMQQ and financial rewards for viral suppression) are low-touch and require minimal staff time to administrate. The factorial design used in the present study allows for a more precise understanding of the components' acceptability, feasibility, and preliminary evidence of effects compared to the classical approach of testing multi-component “packaged” interventions in randomized controlled trials. This factorial design, combined with the mixed methods approach, produced findings that advance research on low-touch and virtual interventions for American/Black and Latino PLWH with serious barriers to the HIV care continuum. In particular, the sequential explanatory mixed-method approach provided vital richness, depth, and context to the study results, and also enhanced the study's validity (The challenges inherent in managing HIV in the context of structural violence, including chronic poverty, cannot be overstated, as the present study highlights. Structural violence is defined as the social forces that harm certain groups of people, producing and perpetuating inequality in health and wellbeing (As noted above, and contrary to expectations, participants' motivation to reach HIV viral suppression was high at the time they were enrolled in the study and increased during the study. In our previous study, motivation for high HIV medication adherence was somewhat lower at enrollment (Mean = 73.1 on a 0–100 scale, SD = 26.6) (While reaching HIV viral suppression may be difficult in the context of structural violence, and complicated by the COVID-19 pandemic, behavioral interventions are clearly an essential aspect of ending the HIV epidemic (The field of behavioral economics, including the study of the types, magnitude, duration, and timing of conditional economic incentive approaches to supporting HIV management and “nudging” participants toward their personal health goals, are relatively new areas of study. In general, financial incentives work best when applied close in time to the desired behavior (The present pilot study provides evidence for the acceptability and feasibility of both types of financial rewards, and we did not find any social harms or negative effects related to this component. About half the participants said the financial reward played a role in decisions about HIV medication or led them to try achieving undetectable viral load, regardless of whether a participant was assigned to the fixed compensation or lottery prize. Qualitative results were consistent with behavioral economic theory in that PLWH generally did not experience the financial reward as directly causing their decisions and behavior. But, the financial reward could align with participants' intrinsic motivation and goals to support HIV management behavior, consistent with behavioral economic theory (The TMQQ component was automated and intended in motivate viral suppression, to support engagement in the study during the period where participants might increase HIV medication use to reach viral suppression, and to foster study retention. The feasibility of this component was reasonable. Acceptability was moderate in quantitative results and appeared high in qualitative results, highlighting the utility of the mixed methods approach for enhancing validity of findings. One major factor affecting this component was participants' severe financial hardship, which interfered with consistent access to a working cell phone that could receive the TMQQs. Thus, many participants wished to complete the TMQQ component but were unable to, reducing participation rates. In some cases, the TMs were experienced positively, perhaps as a form of connection to the study, and served as a reminder to take HIV medications. We found it is challenging for research teams, even in collaboration with a Community Advisory Board, to create TMQQs with the right level of difficulty for participants. Although as an engagement tool, the QQs were not intended to be difficult, some participants reported the TMQQs were too simplistic given their extensive experiences living with HIV, suggesting that advanced HIV information is needed and welcomed. It is possible that allowing participants to choose between a set of basic vs. advanced messages would have utility in future research, along with providing cell phones, as we note below. Alternately, messages could vary in level of difficulty, and participants can receive more difficult messages if they respond correctly to easier ones.As noted above, the intervention components are grounded in a conceptual model that incorporates critical race theory and that includes autonomy support and harm reduction. Participants' views on the MI counseling session component were consistent with the elements of this model. For example, they reported the component provided an opportunity to reflect on and/or reconsider their attitudes toward HIV management and the non-judgmental, pressure-free approach that stimulated participants' feelings of connectedness with the study. The MI sessions component was highly acceptable and feasible, even virtually and carried out over the phone. Most participants assigned to the MI counseling sessions component said in the acceptability ratings that the sessions played a role in their HIV medication decisions and led them to increase HIV medication adherence. Most participants assigned to this component also said the MI counseling sessions led them to try achieving undetectable HIV viral load. However, quantitative results (MI is designed in large part to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion (These findings have implications for the design of this MI component: it should be flexible and individualized to spend little time on strengthening personal motivation for change in cases where such motivation is strong, and more time on uncovering, understanding, and resolving barriers to related behavioral concerns such as mental health treatment and substance use patterns. Indeed, these were important barriers to viral suppression in the present study and MI approaches are effective with such behaviors (As interventionists, in addition to exploring acceptability and feasibility in early-stage research, we are interested in whether intervention components “work.” The main purpose of conducting a pilot study such as this pilot optimization trial is to examine the acceptability and feasibility of an approach that is intended to be used in a larger scale study (