Application of the RE-AIM framework to evaluate a stepped care intervention for adolescents and youth living with HIV in Kenya: a mixed methods approach.

backgroundRecently expanded WHO guidelines on differentiated service delivery (DSD) include expanded eligibility for adolescents and youth living with HIV (AYLHIV). We evaluated implementation of a stepped care program that included DSD for stable AYLHIV and intensified services, including mental health counseling, for AYLHIV with greater needs.

methodsWe used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to guide evaluation of the Data-informed Stepped Care (DiSC) study, a cluster randomized controlled trial implemented from April 2022 to August 2023 in 24 HIV care facilities in Kenya. We used a mixed methods convergent parallel design to evaluate performance indicators across RE-AIM dimensions. Surveys were analyzed using descriptive statistics and qualitative data using directed content analysis.

resultsOf 3,945 AYLHIV ages 10-24 years old attending care at intervention facilities, 933 AYLHIV were screened and 895 were enrolled, representing an enrollment rate of 96% and 23% reach of the intervention. Distribution by age groups were 10-14 years: 29%; 15-19 years: 48%; 20-24 years: 24%. Perceived effectiveness, including improved retention and viral suppression among AYLHIV, motivated continued implementation throughout the study duration. Providers also identified opportunities to improve AYLHIV outcomes by highlighting the importance of integrating mental health into HIV care programs. Prior to implementation, 49 health providers were trained to deliver the DiSC intervention, representing adoption by 25% of the total facility workforce, including 95% of clinical officers and 56% of nurses. Implementation was facilitated by provider-identified, fidelity-consistent adaptations to optimize contextual fit of the intervention. Key determinants influencing implementation were provider collective efficacy, compatibility with clinic workflows, leadership engagement, and alignment with changing national guidelines. Post-trial, providers supported continued use of the DiSC intervention (maintenance), citing leadership support, training, and material and human resources as key influencers on future sustainment.

conclusionsApplying RE-AIM to evaluate performance indicators of a stepped care program for AYLHIV identified high adoption and perceived effectiveness, and key influences on implementation and maintenance. Providers were motivated to adopt and sustain use of the DiSC intervention because of perceived positive impact on health system efficiencies and AYLHIV outcomes.

trial registrationClinicalTrials.gov, NCT05007717 . Registered 13 July 2021.