Significant progress has been made over the past 30 years in the prevention and treatment of HIV/AIDS. Yet, despite growing optimism about this potentially achievable outcome, the epidemic remains a major and increasing cause of morbidity and mortality, particularly among adolescents and young adults (hereafter called “youth”) and ethnic and racial minorities. Globally, youth living with HIV (YLH) are significantly less likely to receive antiretroviral therapy (ART) than adults (23% compared to 38%; United Nations Development Programme, 2014). In the USA, while the overall HIV incidence from 2003–2014 decreased by 25%, among youth ages 13–24, it has increased by 43% (Frieden, Foti, & Mermin, 2015). Compared to 75% of adults, <2/3 of YLH are linked to care within 6 to 12 months after diagnosis. Further, effectiveness trials report viral suppression rates among YLH receiving ART of >80%, but observational studies (i.e., real world occurrence) find much lower rates, closer to 50% (Zanoni & Mayer, 2014).
Motivational interviewing (MI) and the youth HIV cascade
Every step of the HIV treatment cascade requires at-risk or YLH to make decisions to engage with the system and/or to modify their behaviors. MI has been particularly successful in this regard, providing a clear framework for improving patient-provider communication and promoting behavior change using client-centered but goal-oriented methods for enhancing motivation and self-efficacy (Naar-King & Suarez, 2011). High quality patient-provider relationships consistent with MI are associated with greater likelihood of patients receiving ART, ART adherence, attending appointments, and having lower viral load (e.g., Christopoulos et al., 2015; Hightow-Weidman et al., 2011; Jensen et al., 2011; Naar-King, Outlaw, Green-Jones, Wright, & Parsons, 2009; Outlaw et al., 2010; Parsons, Golub, Rosof, & Holder, 2007). MI-consistent approaches produce behavior change and treatment engagement across multiple behaviors, in multiple formats, by multiple disciplines when delivered with adequate fidelity (Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010). Fidelity procedures include workshop training by a member of the Motivational Interviewing Network of Training, follow-up coaching with review and systematic coding of audio recorded interactions.
MI is the only intervention approach to demonstrate success across the youth HIV cascade with regard to knowledge of HIV status (Outlaw et al., 2010) and retention in care (Naar-King, Outlaw, et al., 2009). The Healthy Choices trial demonstrated that four sessions of Motivational Enhancement Therapy compared to standard care significantly improved viral load (Naar-King, Parsons, et al., 2009) and reduced risky sex (Chen, Murphy, Naar-King, & Parsons, 2011) and alcohol and other substance use (Murphy, Chen, Naar-King, Parsons, for the Adolescent Trials Network, 2012) among youth at highest risk.
Patient-provider interactions in youth HIV clinics
Literature reviews of MI’s mechanisms of effect (Apodaca & Longabaugh, 2009) have concluded that clients’ motivational statements about their own desire, ability, reasons, need for or commitment to change (“change talk”: CT) during MI interactions consistently predict actual client behavior change. We are beginning to have evidence supporting this hypothesis in young people (Carcone et al., 2013). In a study of coded recordings of real patient-provider interactions in a multidisciplinary adolescent HIV clinic (Carcone, Naar, Clark, MacDonell, & Zhang, 2019), the counselor communication behaviors most often leading to change talk included asking open-ended questions specifically to elicit adolescent change talk and statements emphasizing adolescents’ autonomy. Sequential analysis also identified counselor communication behaviors to avoid because they most often lead to counter-CT or statements against change (e.g., “I don’t want to have to come to this clinic for the rest of my life”). These behaviors included open questions to elicit counter-CT, neutral open-ended questions about the target behavior, and reflections of ambivalence. These findings have been translated into a tailored MI intervention for HIV-related behaviors in young people (Naar et al., 2019).
Future directions
Despite the success of the CDC program for disseminating evidence- based HIV-related behavioral interventions, a growing body of literature highlights substantial barriers to the effective implementation of these interventions in real-world settings (Norton, Amico, Cornman, Fisher, & Fisher, 2009). Implementation science in youth HIV care settings is in its infancy. A center grant Scale It Up (Naar,U19HD089875. 2016-2021)in the Adolescent Trials Network for HIV/AIDS Interventions is committed to testing the effectiveness and implementation of MI-based HIV prevention and care interventions to accelerating the translation of research to practice (National Institute of Health, 2013). Future directions include using implementation science to test strategies to promote the delivery of MI with fidelity in real-world settings (Naar et al., 2019). Critical questions include how much training is necessary to deliver MI with fidelity, how to developmentally tailor training based on communication science findings, how to efficiently and effectively measure fidelity, and what are the barriers and facilitators to sustaining MI practice in youth HIV prevention and care contexts nationally and globally.
