Rise

APLA Health—a community-based organization offering medical and support services formerly known as AIDS Project Los Angeles—in partnership with the RAND Corporation, implemented Rise to address antiretroviral therapy (ART) adherence issues among Black people with HIV. Through Rise, peer counselors used motivational interviewing techniques, leveraged Medication Event Monitoring System (MEMS) data to monitor and promote adherence, and connected participants to support services to address unmet needs. Rise was implemented and studied through a National Institutes of Health (NIH) grant from 2018 to 2021. A randomized controlled trial showed that Rise participants were more likely to be adherent to ART than non-participants. 

Los Angeles County, CA

Implementation Guide
False
Evidence-based intervention
Evidence-based intervention
Icon for Intervention Type
Support service delivery model
Icon for HIV Care Continuum
Prescription of antiretroviral therapy
Icon for Focus Population
Black/African American people
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Non-RWHAP
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RWHAP-funded clinic or organization
Need Addressed

Due to structural inequities, Black Americans with HIV are less likely to be virally suppressed than the overall population of people with HIV.1 Black people face specific barriers to HIV care, including social and economic marginalization, discrimination in the healthcare system, and intersectional stigma related to their race and HIV status.2 However, many interventions that promote ART adherence use a “one size fits all approach,” instead of directly addressing the unique needs of different groups of people with HIV.  

Core Elements
Peer counseling sessions leveraging motivational interviewing

Rise peer counselors were Black individuals with knowledge of HIV and the communities served by APLA Health. Over six months, peer counselors hosted one-on-one sessions with each client, including three core intervention sessions and two follow-up sessions. During the sessions, peer counselors used a motivational interviewing style (using open-ended questions and reflective listening), and offered information. The first core intervention session focused on building rapport between the client and counselor. The counselor also conducted a needs assessment for social determinants of health, and provided education on HIV, ART, and the importance of adherence. During the second session, the counselor and client discussed strategies that would work best for each client to adhere to daily routines, including taking medication. The third session involved conversations around social support and the quality of the provider-client relationship. Clients who continued to experience ART adherence challenges were offered two additional booster sessions.

Medication Event Monitoring System (MEMS)

Clients received a MEMS bottle cap to allow continuous monitoring of medication adherence. MEMS is a cap that fits a standard pill bottle and records the date and time the bottle is opened and closed. Rise counselors downloaded the data from the client’s MEMS cap, allowing the counselor and client to review, discuss, and improve adherence patterns.

Cultural tailoring

Counseling sessions were “culturally tailored,” with integrated discussions of race, stigma, and discrimination, particularly for Black gay men. These conversations centered around medical distrust, disclosure, and Black communities’ long history of resiliency; these constructs have been shown to be associated with adherence in prior research involving Black communities.

Outcomes

The study was conducted from January 2018 through December 2021 and compared the outcomes of Rise participants with a control group receiving ‘usual care’ (245 individuals enrolled in total). Rise participants needed to be 18 years or older, self-identify as Black or African American, and report challenges with ART adherence (e.g., missed a dose in the last month). The randomized controlled trial found that Rise participants were significantly more likely to be adherent to their HIV medications. While a higher percentage of Rise participants were virally suppressed, this finding was not statistically significant.  

CategoryInformation
Evaluation data
  • Data from MEMS caps on medication adherence
Measures
  • ART adherence was defined as at least 75% of required doses taken
Results
  • Rise participants experienced higher levels of ART adherence than the control group (Odds Ratio, [OR] = 2.0; 95% Confidence Interval [CI]: 1.1 - 3.6)* 

*statistically significant

Source: Bogart LM, Mutchler MG, Goggin K, et al. Randomized controlled trial of RISE, a community-based culturally congruent counseling intervention to support antiretroviral therapy adherence among Black/African American adults living with HIV. AIDS Behav. 2023;27(5):1573-1586.

Planning & Implementation

Community input.  A community advisory board (CAB) consisting of Black APLA Health clients and program staff from APLA Health and other local organizations provided input into program design and the evaluation methods. CAB members met in person two or three times a year during the project period to develop program recruitment materials, monitor implementation, and help interpret data.

Client recruitment. Participants were identified and recruited through presentations to staff and clients at APLA Health and other local HIV service organizations and clinics, client referrals from APLA staff, participant referrals, social media advertisements, local events, and street outreach.

Training of peer counselors. Rise peer counselors participated in a two-day training on basic motivational interviewing, which included asking open-ended questions and practicing reflective listening, conveying empathy, and respecting client autonomy. Peer counselors were also equipped with an intervention manual, needs assessment protocol and procedures, HIV-related medical information, and more.

Ongoing support and supervision. Peer counselors were supported throughout the program by a supervisor (at a Master of Public Health level) and PhD-level clinical psychologists. The supervisor reviewed recorded sessions between counselors and participants and provided feedback on strategies to maintain consistency with the motivational interviewing method. Clinical psychologists checked in regularly with peer counselors to help solve problems, and reviewed session transcripts to provide feedback and support.

Sustainability

The cost of Rise was estimated to be $335 a person in 2021 dollars over the course of the intervention period. In addition to staff time (e.g., counselors, supervisor, clinical psychologist), the program costs included materials and equipment (such as MEMS caps, bottles, and software, and tablets for downloading MEMS data) and participant remuneration costs.

Lessons Learned
  • Rise was built around the unique needs of Black people with HIV, who may have a higher risk of non-adherence and also face intersectional stigma and discrimination related to their race and other characteristics. By including a representative CAB, Rise ensured that the recruitment materials and resources offered through the counseling sessions would be helpful to meet this population’s needs.
  • In addition to improving adherence, Rise led to a reduction in HIV-related stigmatizing beliefs and HIV-related medical mistrust (e.g., of ART). However, the findings for stigmatizing beliefs were not statistically significant when controlling for gender, given the association between gender and such beliefs.
  • This study showed that Rise had an effect on adherence using MEMS data. Monitoring ART adherence through MEMS is more accurate than using self-reports of medication taking; individuals may have poor recall or may not want to disclose certain behaviors (e.g., missing a dose or stopping medication altogether). 
Resources & Tools
Contact
RAND Corporation
Laura M. Bogart, PhD, MS

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