More than 55,000 people living with HIV (PLH) in the US live in rural areas, and more than 2,300 rural residents are diagnosed with HIV each year. PLH who live in rural areas have higher mortality rates compared with non-rural PLH. Rural PLH are diagnosed with HIV at a more advanced stage than non-rural individuals and present for medical care later, making them more likely to face comorbidities and need complex medical care. Rural PLH are also less likely than their urban counterparts to remain engaged in HIV care and to be virally suppressed. Compared with younger PLH, older PLH may face additional challenges to maintaining their health and wellbeing, and older PLH who also live in rural areas face the doubly challenging prospect of maintaining adherence to HIV care and managing medical conditions while living in a rural environment. Few interventions aimed at increasing VL suppression and improving health-related quality of life (HRQOL) exist for rural older PLH. Our previous qualitative and survey research with rural older PLH nationwide (N = 476) identified low social support, HIV-related stigma, lack of technology access, and structural barriers (such as difficulties with housing, food, transportation, and insurance) as key predictors of engagement in HIV care, viral load (VL) suppression, and HRQOL for this population. Based on this work, we propose developing an optimized intervention for rural older PLH using the multiphase optimization strategy (MOST). We will evaluate four intervention components, adapted from evidence-based interventions and delivered remotely: (1) counselor-facilitated peer social support, (2) HIV stigma reduction, (3) strengths-based case management, and (4) individually-tailored technology use optimization. We will recruit 400 rural older PLH nationwide through partnerships with community agencies and online advertisements, with an emphasis on persons living in the states prioritized in the US HHS? ?Ending the HIV Epidemic? (EtHE) plan. Following baseline surveys (completed online, by mail, or by phone) and HIV VL testing (via self-collected dried blood spot samples), participants will be randomized to receive or not receive each of the four intervention components in a fractional factorial design. Follow-up surveys will occur at 3, 6, and 12 months, and VL testing at 6 and 12 months. Surveys will assess HRQOL, engagement in care, mental health, covariates, and hypothesized mediators (e.g., social support, HIV stigma, self-efficacy, eHealth literacy). Primary outcomes are VL suppression and HRQOL, and secondary outcomes are engagement in care and depressive symptoms. In line with the MOST framework, each component?s impact on VL and HRQOL will be evaluated, and an optimized intervention identified. We will also assess information related to the acceptability, feasibility, and cost of intervention components. We hypothesize that components will increase (1) the proportion of participants that have VL suppression and (2) HRQOL. Results from this study will provide us with tools to improve health outcomes for rural older PLH and to advance the EtHE plan to eliminate HIV transmission in the US.

Public Health Relevance

Engagement in HIV medical care and adherence to HIV medications are both essential in improving health outcomes among people living with HIV (PLH), but PLH living in rural areas?who suffer higher mortality rates than their urban counterparts?can confront multiple barriers to care engagement and adherence, especially as they face the logistical, medical, and social challenges associated with aging. This project will test four intervention components designed to improve care engagement and medication adherence to determine their impact on health outcomes and quality of life among rural, older PLH. If efficacious, these components could be disseminated by organizations serving rural PLH throughout the US and result in improved health outcomes and quality of life in this population.

National Institute of Health (NIH)
National Institute of Nursing Research (NINR)
High Priority, Short Term Project Award (R56)
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Special Emphasis Panel (ZNR1)
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Henry, Rebecca
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Medical College of Wisconsin
Schools of Medicine
United States
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