Comparative Workflow Modelling of HIV Status-Neutral Care Implementation in Six High-Burden Jurisdictions in the...

Status-neutral approaches to HIV treatment and prevention, which link all individuals to tailored, comprehensive services following HIV testing, are promising strategies for reducing HIV service delivery inequities and improving clinical outcomes. However, transferable, feasible models of status-neutral service delivery are poorly understood, particularly in the United States, where implementation contexts are geographically and institutionally disparate. To guide expanded implementation, we identified difference-making attributes of status-neutral implementation workflows in a diverse sample of public sector-funded HIV clinical organizations in U.S. jurisdictions prioritized in the Ending the HIV Epidemic (EHE) Initiative.

In March-June 2024, we invited frontline HIV service providers across six EHE jurisdictions (Alabama, Baltimore, Chicago, Dallas, Los Angeles, San Diego) to participate in virtual focus group discussions (FGDs), segmented by ongoing or planned status-neutral implementation. We depicted an HIV status-neutral workflow and elicited discussants' perspectives on (in)consistencies between the illustration and their implementation practices. Applying comparative workflow modelling, we re-illustrated status-neutral implementation pathways and identified workstream features distinguishing service delivery across clinical organizations.

We facilitated eight FGDs with 56 providers across 20 organizations. Status-neutral implementation processes varied substantially across clinical organizations-distinguished by the roles and responsibilities of clinical (i.e. physicians, nurses) and non-clinical (i.e. navigators, case managers) staff as well as by the sequence and timing of activities within workflows. We identified four workflow attributes that distinguished clinical organizations: (1) the timing of health insurance review (whether insurance assessments and navigation occurred earlier vs. later in the implementation pathway); (2) the magnitude of activity integration (whether services were delivered concurrently vs. sequentially); (3) the presence of implementation partnerships (whether HIV testing was conducted in-house vs. externally); and (4) the extent of workforce task-shifting (whether services were primarily delivered by clinical vs. non-clinical staff).

Workflow heterogeneities reflected jurisdictional and organizational differences in funding, staffing and infrastructure. Generalizable attributes, including the degree of workflow integration and staff role delineation, can inform scalable implementation models. Enhanced cross-training and increased involvement of non-clinical staff (especially in HIV prevention workflows) are critical to enable adaptable, timely and person-centred HIV service delivery across diverse care settings.