Tailored Motivational Interviewing: E2i

Tailored Motivational Interviewing (TMI) delivers brief motivational interviewing (MI) counseling sessions customized to encourage people with HIV to engage in HIV care, take HIV medications as prescribed, and improve other health-related behaviors. Three sites implemented TMI as part of Using Evidence-Informed Interventions to Improve Health Outcomes among People Living with HIV (E2i), an initiative funded by the Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) program from 2017 to 2021. Clients who participated in TMI had significant improvement in engagement in care, prescription of antiretroviral therapy (ART), retention in care, and viral suppression.

Fort Lauderdale, FL

Macon, GA

Jackson, MS

Evidence-Based Intervention
Support service delivery model
Linkage to HIV medical care; Retention in HIV medical care; Prescription of antiretroviral therapy; Viral suppression
Treat
Young Black men who have sex with men
RWHAP SPNS
Community-based organization/non-clinical setting; City/county health department; University-based clinic
Need Addressed

Black men who have sex with men (MSM) with HIV experience persistent gaps along the HIV care continuum, such as engagement in care, retention in care, adherence to ART, and viral suppression.1 They are also among the priority populations most in need of interventions that promote high quality and culturally-tailored services. TMI is designed to address barriers and concerns specific to young people of color, including Black, Indigenous, and Hispanic/Latino people and has demonstrated effectiveness in improving HIV health outcomes for young Black MSM.2-4 

“Through TMI, we have had meaningful conversations with clients that raise their morale. We have seen clients take control of their lives and equip themselves with what they need to achieve an undetectable viral load.”

Core Elements
Tailored Motivational Interviewing (TMI) sessions

MI is “a collaborative conversation style for strengthening a person’s own motivation and commitment to change.”5,6TMI is customized for people with HIV and is developmentally tailored for youth with HIV based on communication science studies. Clients participate in one to six sessions with a TMI provider that last anywhere from 15 to 60 minutes.

There are four main components:

  • Change Talk—moving clients toward a particular goal
  • Spirit—collaborative and empathetic interaction
  • Skills—using “you” statements, providing information, using reflections, and using open ended questions
  • Processes—engaging, focusing, evoking, and planning
Address key behaviors for people with HIV

TMI sessions address key behaviors for people with HIV by encouraging them to:

  • Engage in HIV care
  • Adhere to ART
  • Reduce or stop unhealthy substance use
  • Reduce sexual risk behaviors

“TMI has helped us save lives, and that was the biggest goal. When you increase contact with someone, it motivates that person to live their best life, and increases their ability to achieve viral suppression.”

Outcomes

During a 12-month period, 177 clients enrolled in TMI across the three sites. The enrolled MSM were young (aged 25–33 years), and nearly all (97%) identified as Black; with 2% identifying as Hispanic/Latino. From enrollment through 12 months later, engagement in care, prescription of ART, retention in care, and viral suppression all improved significantly.

Category Information
Evaluation data Client medical record data
Measures
  • Engagement in HIV care (at least one primary care visit in the last 12 months
  • Retention in HIV care
  • Receipt of ART
  • Viral suppression at the last viral load test
Results
  • Engagement in care increased from 65% to 95%*
  • Retention in care increased from 36% to 75%*
  • ART prescription increased from 81% to 100%*
  • Viral suppression increased from 42% to 71%*

*statistically significant

Source: Tailored Motivational Interviewing (TMI): E2i Implementation Guide. Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau; 2021.

“TMI is an approach that has worked for our clients. Prior to implementing TMI, these clients were struggling. With TMI, we can see them really adhering to their medications and maintaining viral suppression.”

Planning & Implementation

Provider skills. TMI providers can come from a wide range of backgrounds and disciplines. It was important for sites to identify providers with excellent communication skills, empathy for people with HIV, and experience in care and outreach. Peers are especially good candidates for TMI providers.

Staff training. Staff training included a two-day virtual or in-person experiential training, at least six coaching sessions over three months, quarterly fidelity monitoring, and an annual one-day booster training. Training may be provided through an external vendor or a local trainer. TMI providers may also need additional training to ensure that they have adequate knowledge of HIV and related topics like screening and referring for other needs and/or trauma-informed care. Coaching and training approaches across the three sites varied based on internal capacity and familiarity with MI.

Outreach and recruitment. Sites developed outreach and recruitment plans to identify potential clients through internal referrals from clinical and non-clinical staff, internal data analysis, outreach through other organizations and targeted communications, and community referrals.

Process flow development. Sites developed a process flow that is flexible but clearly lays out the roles of the TMI team members; how clients will move through the intervention; where sessions will be held (in private space); and incorporates feedback from staff on the process. Sites needed to address barriers to appointment adherence by considering options such as transportation and telehealth options or non-traditional meeting times and places.

Three sites participated in the TMI E2i initiative. Learn more about their implementations below.

Broward House (Fort Lauderdale, FL)

COMPASS Cares/HOPE Center (Macon, GA)

University of Mississippi Medical Center (Jackson, MS)

Sustainability
  • Weeks to months of ongoing work in implementing TMI is necessary for staff to develop an intermediate level of competency in MI. Additional time may also be necessary for sites to identify an expert MI trainer who can provide coaching and ongoing training sessions.
  • Fidelity measures that assess how closely the implementation adheres to protocols can help ensure ongoing quality of the intervention. Measurement that is too complex is not feasible for real-world implementation. Sites found that quarterly fidelity monitoring was challenging, given time and resource constraints.
  • The costs associated with the TMI are related to planning, recruitment, implementation, and supervision and management. See the implementation guide for more information.
Lessons Learned
  • Peers are well suited to deliver this intervention and, if possible, they should represent the clients served by the implementing clinic. However, asking peers to juggle multiple roles may diminish their ability to effectively provide TMI, and finding peers may be challenging. Giving peer counselors access to electronic health records can be a powerful tool for recruitment.
  • Having an existing expert in MI who can provide training and ongoing support made this intervention substantially easier.
  • Clients eligible for this intervention often have other concerns such as housing, transportation and substance use treatment needs. TMI may be effective in engaging clients in case management and referrals to other services. Two sites indicated the need for support groups in tandem with the intervention.
  • The TMI model fits well with organizations that have a philosophy of harm reduction and “meeting clients where they are.”
Contact
COMPASS Cares
University of Mississippi Medical Center, Adult Special Care Clinic

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