Evaluation of HIV Prevention and Care Interventions that Address Select Social and Structural Drivers of Inequities among Communities Disproportionately Affected by HIV

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HIV surveillance data continue to document disproportionate HIV incidence and prevalence rates among sexual, gender, and racial/ethnic minority groups, including gay, bisexual and other men who have sex with men (collectively referred to as MSM), Black women, and transgender women [5-7]. Interventions designed to address these disparities have largely focused on psychosocial factors and individual HIV-related risk behaviors [2]. Yet, it has become increasingly clear these approaches are, by themselves, unlikely to be sufficient in halting the spread of HIV and reducing disparities [2,8]. They fail to adequately account for the impact and intersection of broader social and structural factors (e.g., racism, discrimination, stigma, unemployment/underemployment, housing instability, among others) [3,9]. Thus, the literature calls for upstream interventions that address larger social and structural factors that drive HIV disparities [2,3,7,8,10]. Structural interventions are programs and policies designed to reduce risk and/or facilitate behavioral change by modifying factors external to and outside of the control of individuals. 2 Structural interventions have been developed that are associated with preventing HIV infection [3,4], decreasing HIV transmission [2], and increasing engagement in and continuation of HIV care [2]. However, there is a need to further adapt, implement and evaluate such interventions in a real world, rather than a research setting, informed by input from the community [1-4,8]. The current NOFO seeks to address this need.   The purpose of this NOFO is to adapt, implement and conduct rigorous evaluations of interventions that would reduce select social and structural drivers of inequities in HIV (i.e., structural racism, homelessness/housing instability and unemployment/underemployment) among disproportionately affected racial and ethnic minority persons (specifically Black, Hispanic/Latino, American Indian/Alaska Native MSM and Black women) and transgender women, preferably in Ending the HIV Epidemic (EHE) priority jurisdictions [5]. As part of the approach, community members, including priority groups, will be engaged as partners throughout the intervention design/revision, implementation, evaluation, and dissemination of findings. NOFO recipients will conduct evaluability assessments prior to intervention implementation and will develop and implement a protocol to rigorously evaluate the interventions and conduct economic evaluations.   Several outcomes are expected. Short-term outcomes include, but are not limited to, increased community and priority group engagement, and high-quality evaluation protocols. Intermediate outcomes relevant to intervention and evaluation implementation include, but are not limited to, increased availability and accessibility of effective and community-driven social and structural interventions, gains in health relative to the costs of evaluated interventions, increased intervention acceptability, and decreased social determinants of health as barriers to HIV prevention and care. Intermediate HIV prevention and care outcomes are the following: community-wide increase of awareness, knowledge, attitudes, and beliefs pertaining to HIV prevention and care; and increased HIV testing, linkage to HIV care, retention in HIV care, early initiation and adherence to ART, re-engagement in HIV care, and increased PrEP screening, referral, linkage, prescription and adherence.  This NOFO responds to the literature which calls for a comprehensive, equity-based approach to the HIV epidemic that would address larger social and structural factors [2,8-10]. The NOFO builds upon past and current CDC program activities, with regard to community engagement, programs/activities addressing health equity, status neutral approaches, social determinants of health, and rigorous evaluation strategies [11].