A Mixed Methods Analysis of Southern HIV Service Organizations' Implementation of Harm Reduction to Address the HIV and Opioid Syndemic.

Southern HIV Service Organizations (SHSOs) are promising sites for the adoption and implementation of harm reduction as a means for addressing the HIV and opioid syndemic. However, little research to date has examined exactly how harm reduction is operationalized within and among SHSOs. Using program evaluation data (i.e., organizational assessment data and semi-structured qualitative group interview data with SHSO staff), this study aimed to characterize organizational implementation of harm reduction among SHSOs that sought harm reduction capacity-building assistance (i.e., training, coaching, funding) from the SUSTAIN Center. Authors utilized a convergent mixed methods design in which quantitative and qualitative approaches were employed in parallel to gain simultaneous insights into how harm reduction was operationalized in SHSOs and how the local context influenced implementation. Means and proportions of each organizational assessment domain were compared. Thematic analysis of group interview transcripts examined SHSO staff perceptions of harm reduction implementation in their respective communities. Quantitative results revealed that SHSOs most commonly operationalize harm reduction in the Outreach, Advocacy, and Principles domains but struggle to do so in terms of Services and Organizational Infrastructure. Qualitative results revealed that various factors in SHSOs' local context, such as the community's lack of knowledge and understanding of harm reduction, limited harm reduction services, and a challenging socio-political context, influence SHSOs implementation of harm reduction. Taken together, analyses reveal that (1) SHSOs expend significant effort conducting outreach activities because Southern communities are generally unaware of harm reduction, (2) SHSOs continually advocate for harm reduction in the midst of a challenging socio-political context, and (3) SHSOs offer fewer harm reduction services and integrate harm reduction into their organizational infrastructure to a lesser extent due to external, contextual factors. The combination of organizational-level data and SHSO staff insights provided by this mixed methods study have implications for policy advocacy, funding initiatives, and capacity-building efforts.

Operationalizing Equity-centered Implementation Through Person-centered Care Capacity-building with HIV Service Organizations: The SUSTAIN Approach.

Capacity-building in trauma-informed care and harm reduction approaches with Southern HIV service organizations must be implemented in ways that foster trust and spur organizational change. Using an equity-centered implementation science framework, this study examines implementation strategies of the SUSTAIN COMPASS Coordinating Center's person-centered care (PCC) capacity-building interventions. METHODS: Fifty-eight (58) in-depth qualitative interviews with staff (N=116) who received PCC capacity-building were analyzed using modified grounded theory. RESULTS: Analysis identified four factors of equity-centered implementation that facilitated PCC capacity-building implementation. 1) Innovation factors: SUSTAIN models PCC approaches when implementing PCC capacity-building. 2) Inner factors: SUSTAIN employs PCC approaches. 3) Outer factors: SUSTAIN highlights socio-political factors that may influence PCC implementation. 4) Bridging factors: SUSTAIN facilitates partnerships to promote PCC learning and sustainability. CONCLUSION: SUSTAIN PCC capacity-building advances health equity through operationalizing personcentered care in capacity-building implementation.

Addressing Traumatizing Environments: A Case Study of the Showing up for Black Power, Liberation, and Healing Initiative.

Effectively combating HIV will require southern HIV Service Organizations (SHSOs) to support Black staff while they navigate traumas related to structural racism driving the epidemic. HIV organizational capacity-building research lacks effective community-led approaches to anti-racist organizational change centered on Black people's experiences. This participatory case study examines "Showing Up for Black Power, Liberation and Healing," an organizational capacity-building initiative that leads to individual and organizational change, developed and implemented by the SUSTAIN, an intermediary purveyor organization (IPO). Evaluation data include participant observation notes and in-depth, open-ended evaluation reports analyzed using interpretive phenomenological analysis. The intervention consisted of a two-part shared learning collaborative. Qualitative impact themes highlighted: 1) the power of defining and valuing Black-centered spaces to address trauma; 2) reframing self-care from an individualistic responsibility to an institutionally supported, communal means of healing; and 3) the role of the intervention in spurring organizational changes related to dismantling White supremacy work culture in SHSOs.

Harm reduction implementation among HIV service organizations (HSOs) in the U.S. south: a policy context analysis and results from a survey of HSOs.

BACKGROUND: HIV service organizations are integral to serving communities disproportionately impacted by the HIV and opioid epidemics in the U.S. South. Addressing these intersecting epidemics requires implementation of evidence-based approaches, such as harm reduction. However, little is known about the extent to which Southern HIV service organizations implement harm reduction. This manuscript examines: 1) the implementation context of harm reduction in the South, 2) Southern HIV service organization implementation of harm reduction, and 3) the impact of different contexts within the South on HIV service organization implementation of harm reduction. METHODS: To examine implementation context, authors analyzed nation-wide harm reduction policy and drug-related mortality data. To examine HIV service organization implementation of harm reduction, authors performed frequency distributions on survey data (n = 207 organizations). Authors then constructed logistic regressions, using state mortality data and policy context as predictors, to determine what contextual factors predicted HIV service organization implementation of harm reduction. RESULTS: Drug-related mortality data revealed an increased need for harm reduction, and harm reduction policy data revealed an increased political openness to harm reduction. Frequency distributions revealed that approximately half of the HIV service organizations surveyed reported that their organizations reflect a harm reduction orientation, and only 26% reported providing harm reduction services. Despite low utilization rates, HIV service organizations indicated a strong interest in harm reduction. Logistic regressions revealed that while increased mortality rates do not predict HIV service organization implementation of harm reduction, a harm reduction-friendly policy context does. DISCUSSION: This study highlights how regions within a high-income country can face unique barriers to healthcare and therefore require a unique understanding of implementation context. Study findings indicate a rapidly changing implementation context where increased need meets increased political opportunity to implement harm reduction, however there is a lag in HIV service organization adoption of harm reduction. Financial resources, capacity building, and continued policy advocacy are required for increased HIV service organization adoption of harm reduction.

A typology of power in implementation: Building on the exploration, preparation, implementation, sustainment (EPIS) framework to advance mental health and HIV health equity.

Background: Persistent inequities in HIV health are due, in part, to barriers to successful HIV-related mental health intervention implementation with marginalized groups. Implementation Science (IS) has begun to examine how the field can promote health equity. Lacking is a clear method to analyze how power is generated and distributed through practical implementation processes and how this power can dismantle and/or reproduce health inequity through intervention implementation. The aims of this paper are to (1) propose a typology of power generated through implementation processes, (2) apply this power typology to expand on the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to advance HIV and mental health equity and (3) articulate questions to guide the explicit examination and distribution of power throughout implementation. Methods: This paper draws on the work of an Intermediary Purveyor organization implementing trauma-informed care and harm reduction organizational change with HIV service organizations. The expanded framework was developed through analyzing implementation coaching field notes, grant reporting, and evaluation documents, training feedback, partner evaluation interviews, and existing implementation literature. Results: The authors identify three types of power working through implementation; (1) discursive power is enacted through defining health-related problems to be targeted by intervention implementation, as well as through health narratives that emerge through implementation; (2) epistemic power influences whose knowledge is valued in decision-making and is recreated through knowledge generation; and (3) material power is created through resource distribution and patterns of access to health resources and acquisition of health benefits provided by the intervention. Decisions across all phases and related to all factors of EPIS influence how these forms of power striate through intervention implementation and ultimately affect health equity outcomes. Conclusions: The authors conclude with a set of concrete questions for researchers and practitioners to interrogate power throughout the implementation process. Plain language summary: Over the past few years, Implementation Science researchers have committed increased attention to the ways in which the field can more effectively address health inequity. Lacking is a clear method to analyze how implementation processes themselves generate power that has the potential to contribute to health inequity. In this paper, the authors describe and define three types of power that are created and distributed through intervention implementation; discursive power, epistemic power, and material power. The authors then explain how these forms of power shape factors and phases of implementation, using the well-known EPIS (exploration, preparation, implementation, sustainment) framework. The authors draw from their experience working with and Intermediary Purveyor supporting HIV service organizations implementing trauma-informed care and harm reduction organizational change projects. This paper concludes with a set of critical questions that can be used by researchers and practitioners as a concrete tool to analyze the role of power in intervention implementation processes.