1. Introduction
HIV infections, HIV viral suppression, ambivalence
HIV INFECTIONS, DISEASE
Ending HIV transmission in the United States hinges on preventing new HIV infections (The COVID-19 pandemic has complicated HIV management and exacerbated existing barriers to HIV care, including for African American/Black and Latino PLWH. Although the Centers for Disease Control and Prevention (CDC) reported expanding measures to support the continuity of HIV care, particularly in high HIV prevalence settings, the COVID-19 pandemic has caused substantive disruptions to engagement along the HIV care continuum (The field of intervention science had focused on virtual and “low-touch” interventions prior to the COVID-19 pandemic, and the COVID-19 pandemic, during which travel on public transportation and in-person contact in professional settings was curtailed, highlighted the importance of such approaches (In prior research we developed and explored the acceptability and feasibility of a “lower-touch” intervention for African American/Black and Latino PLWH with non-suppressed HIV viral load. The intervention was called the Silver Community Action Project (S-CAP) and was grounded in motivational interviewing (MI) and behavioral economics and designed to be culturally and structurally relevant by attending to the main barriers to HIV viral suppression experienced by this population, as described above (The S-CAP intervention was grounded in a conceptual model that integrates critical race theory, harm reduction, and self-determination theory, as described in more detail elsewhere (First, MI is an evidence-based directive and collaborative counseling approach for behavior change that elicits participants' values, perspectives, and questions, identifies ambivalence and discrepancies, and corrects misinformation with permission, to thereby foster durable intrinsic motivation and readiness for change (Galarraga and colleagues carried out a substantive review of programs that used conditional economic incentives to improve HIV treatment adherence, mainly programs in clinical settings and including those grounded in behavioral economics (Financial rewards in the form of lottery prizes or fixed compensation amounts have been used in past research to reward longer-term behavior change. Prize drawings leverage the cognitive bias of overestimating small probabilities (leading individuals to participate in the prize drawing because they overestimate their chance of winning) and also increase salience (prizes keep a behavior high on a person's mental priority list) (Overall, the results from our past study highlighted that the conceptual approach taken and the intervention activities in the S-CAP intervention warranted further exploration. We also identified a number of ways the intervention could be improved. For example, results indicated that the lottery prize structure was overly complicated, some participants would have preferred a fixed compensation amount for viral suppression over a lottery prize (although fixed compensation vs. a lottery prize have not yet been directly compared in the literature), participants requested additional MI counseling sessions, and the TMQQ period may have been too brief. We applied these lessons learned to the present study.As is common in intervention research, the S-CAP intervention tested in the previous study consisted of a number of intervention components that were combined into a single “packaged” intervention. One disadvantage of testing packaged interventions in what is often called the classical approach (generally using the randomized controlled trial design) is that, if found efficacious/effective, it is not possible to determine which of the components contributed to its efficacy, if some components performed better than others, or if some components had counter-productive effects on others. Further, when packaged interventions are not found efficacious/effective in a randomized controlled trial, it is not possible to determine if any of the components showed promise, or to determine what the next steps in the program of research should be. The multiphase optimization strategy (MOST) framework solves these problems through the systematic testing of individual intervention components and their interactions using a variety of designs (The MOST framework is inspired by engineering and has three stages: preparation (identifying intervention components, developing a conceptual model, and identifying the “optimization objective” to guide future decisions about whether or how to combine components), optimization (evaluating the effects of components, applying the optimization objective to create a new multi-component intervention, if appropriate), and evaluation (testing the new optimized intervention in a randomized controlled trial) (