Medical-Legal Partnerships as Structural Interventions: Integrating Implementation Science and Community-Engaged...

People living with HIV (PLWH) often face health-harming legal needs (HHLNs), including housing instability, discrimination, immigration concerns, benefit denials and interpersonal violence, which can undermine engagement in care and health outcomes. Medical-legal partnerships (MLPs) integrate legal services into healthcare settings to address these drivers of health inequities and improve access to HIV prevention and care.

This study presents mixed-methods implementation findings from three federally funded MLP initiatives serving PLWH in New York City, Philadelphia, Orlando and San Juan. Implementation was evaluated using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework and the Consolidated Framework for Implementation Research (CFIR), with guidance from Community and Scientific Advisory Boards. Quantitative data were derived from standardized HHLN screening tools, while qualitative interviews with clients, healthcare providers and legal professionals explored implementation experiences, contextual factors and perceived impacts.

Across the three initiatives, 928 participants were enrolled between 2022 and 2026. Core intervention components included: (1) workforce training on HHLNs and legal-health integration; (2) routine legal screening; (3) referral to community-based legal services; and (4) co-located legal clinics and preventive legal education. Common HHLNs included housing instability, benefit denials, immigration concerns, criminal record expungement, advance care planning and discrimination. Implementation demonstrated strong feasibility, acceptability, adoption and cultural responsiveness across sites. Participants described reductions in anxiety, improved confidence, greater trust in healthcare systems and improved engagement in HIV care following legal support. Trainings co-developed with community stakeholders enhanced providers' understanding of structural determinants and legal remedies, while interdisciplinary collaboration reduced provider burden and strengthened care coordination. RE-AIM findings demonstrated broad reach and organizational adoption, and CFIR analyses identified leadership engagement, organizational readiness and client-provider trust as key implementation facilitators. Cross-study findings informed development of the equity-centred implementation framework for MLP in HIV care, integrating implementation science, health equity and community engagement principles to guide future adaptation and scale-up.

MLPs are a feasible, equity-focused and scalable strategy for addressing structural barriers that affect HIV outcomes. Findings support continued investment in legal-health integration, workforce development and community-engaged approaches to strengthen HIV care delivery and advance health equity among populations disproportionately affected by HIV.