Optimizing a Bio-behavioral Intervention for Sustained Viral Suppression

Study Overview
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Brief Summary
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The study will test four behavioral intervention components to identify the combination of the four components that best supports people who inject drugs to achieve and sustain HIV viral load suppression. The study design is a 2-to-the-4 factorial experiment. The 2 represents the level of each component: 0 (receive) or 1 (don't receive). The 4 represents the number of components being tested. The four components are: 1) receiving (or not receiving) peer support services for medication-assisted treatment (MAT) uptake and persistence, 2) behavioral activation therapy for depression (BAT), 3) Life-Steps Program for medication adherence, and 4) patient navigation for HIV care. Therefore, in order to test which combination of components produce the best outcome, this factorial design randomizes people to 1 of 16 conditions. Each condition represents a possible combination of the 4 components above.

Detailed Description
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Participants will be randomly assigned to one of 16 experimental conditions. Each condition will represents every possible combination of 4 components (e.g., 1-4, 2-4, 4 only). Participants complete a survey assessment at baseline, complete their assigned intervention components, and then return to complete follow-up assessment surveys at 3-, 6-,9-, and 12-months. The primary outcome is sustained viral suppression defined as viral load test results of <400 copies per mL on all 6-,9-, and 12-month follow-up visits. Results of Aim 1 will yield estimates of the unique impact of each intervention component, as well as each combination of components, on sustained viral suppression. The research team and partners will make decisions about what constitutes the optimized intervention by judging the observed effect sizes and statistical significance against real-world constraints that go into the delivery of the interventions. The secondary aims are to test mediators to explain component 1-4 and its relationship to viral suppression. We will also test moderators of these relationship between each component and outcome of viral suppression.

Official Title
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Optimizing a Bio-behavioral Intervention to Promote Viral Suppression Among HIV+ People Who Inject Drugs on the U.S.-Mexico Border

Conditions
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HIV Viremia

Intervention / Treatment
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* Behavioral: Peer support to promote uptake and persistence of medication assisted treatment (MAT)
* Behavioral: Behavioral Activation Treatment (BAT) to reduce depression
* Behavioral: Patient Navigation to promote linkage and engagement in HIV care
* Behavioral: Life Steps educational and skill building session to promote adherence to HIV medication


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: be at least 18 years of age be able to provide informed consent be eligible to receive free HIV care services in Mexico be HIV positive have injected drugs in the last 30 days not be on methadone replacement therapy be willing to discuss MAT uptake with a peer sign a medical release form to have medical data abstracted agree to submit and describe locator information agree to return to follow-up visits able to communicate in Spanish screen positive for depression on the PHQ-2 have no plans of moving outside the study area in the next 12-months meet one of the following: not currently in possession of ART or not taking ART but prescribed ART or sub-optimal ART adherence as at least one 4-day treatment interruption in the past 90 days or sub-optimal retention in HIV care - never engaged or disengaged from HIV care as 2 or more missed clinic appointments in the last 9 months or no viral load test done in the past six months or self-reports a detectable viral load within the past 6 months Exclusion Criteria: has not injected drugs in the last 30 days or do not have a verifiable opioid use disorder is not HIV positive is receiving methadone is unwilling to discuss methadone uptake with a peer does not screen positive for depression is not able to provide informed consent does not speak Spanish has plans to move out of the city does not qualify to receive free HIV care services in Mexico has an appearance of psychological disturbance or severe cognitive impairment that could limit understanding of study procedures as determined by study staff

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Randomized
Intervention Model: Factorial Assignment
Interventional Model Description: The factorial experiment is guided by the Multiphase Optimization Strategy (MOST). The 4 intervention components are: Component 1. Peer recovery coaching to promote uptake and persistence of medication assisted treatment in the form of methadone. Component 2. Behavioral activation therapy to reduce depression. Component 3. Patient navigation to promote linkage and engagement in care. Component 4. Life steps educational and skill building intervention to promote medication adherence. Participants will be randomly assigned to receive a total of 0 or up to 4 components. There are 16 conditions because there are 16 possible combinations of the 4 components (e.g., Condition 1 = Delivery of 1, 2, 3, and 4 whereas Condition 4 = Delivery of 1 and 2 only). All participants will receive a standard of care package which will consist of referral to HIV treatment services and linkage to a peer support group, and harm reduction education and materials.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Condition 1: Components 1, 2, 3 and 4<br>Participants will be assigned to receive all of the four intervention programs: Peer-Support for Medication-Assisted Treatment Behavioral Activation Therapy Patient Navigation for HIV Care Life Steps Program for Medication Adherence | Behavioral: Peer support to promote uptake and persistence of medication assisted treatment (MAT)<br>* Participants will be assigned to receive peer support to promote uptake of MAT and persistence. This component will consist of two informational sessions, a tailored recovery plan, and on-going support from a peer for the first 6 months.<br>Behavioral: Behavioral Activation Treatment (BAT) to reduce depression<br>* Participants will be assigned to receive BAT treatment for depression. This component will consist of 8 sessions where participants will identify short and long-term goals, values, and the activities unrelated to substance use that were previously enjoyed or are likely to increase a feeling of well-being. This intervention component focuses on making a plan to troubleshoot barriers to re-engage in these activities. Sessions are delivered weekly. The content includes psycho-education about what depression is, the intervention rationale, and the activities and monitoring of activities, building social contracts to engage networks, and discussion of potential barriers to following through with activities.<br>Behavioral: Patient Navigation to promote linkage and engagement in HIV care<br>* Participants will be assigned to receive patient navigation services. A patient navigator will provide information about the process of obtaining HIV care and provide instrumental support to access care as needed for six months. The navigator will assist with obtaining government sponsored insurance if the participant does not have employer sponsored insurance, including processing needed documents, monetary resources, transportation and clerical support to obtain required documents, such as state ID and birth certificates. Navigators will meet with participants to go over what to expect during their clinic appointment and explain in lay terms medical terminology likely to be discussed by providers to facilitate patient-provider interaction. Other instrumental support provided will be scheduling appointments, providing clean clothing, a place to shower, and transportation to attend medical appointments.<br>Behavioral: Life Steps educational and skill building session to promote adherence to HIV medication<br>* Participants assigned to this component will participate in a single session that includes one follow-up phone-call or visit. Participants will be exposed to cognitive-behavioral techniques and will learn about the importance of HIV treatment and the strategies and skills needed to take HIV treatment as prescribed. The session consists of strategies for problem solving transportation barriers, skills to improve communication with providers, strategies for dealing with side-effects, reminder cues, and managing lapses.<br>|
| Experimental: Condition 2: Components 1, 2, 3<br>Peer-Support for Medication-Assisted Treatment Behavioral Activation Therapy Patient Navigation for HIV Care | Behavioral: Peer support to promote uptake and persistence of medication assisted treatment (MAT)<br>* Participants will be assigned to receive peer support to promote uptake of MAT and persistence. This component will consist of two informational sessions, a tailored recovery plan, and on-going support from a peer for the first 6 months.<br>Behavioral: Behavioral Activation Treatment (BAT) to reduce depression<br>* Participants will be assigned to receive BAT treatment for depression. This component will consist of 8 sessions where participants will identify short and long-term goals, values, and the activities unrelated to substance use that were previously enjoyed or are likely to increase a feeling of well-being. This intervention component focuses on making a plan to troubleshoot barriers to re-engage in these activities. Sessions are delivered weekly. The content includes psycho-education about what depression is, the intervention rationale, and the activities and monitoring of activities, building social contracts to engage networks, and discussion of potential barriers to following through with activities.<br>Behavioral: Patient Navigation to promote linkage and engagement in HIV care<br>* Participants will be assigned to receive patient navigation services. A patient navigator will provide information about the process of obtaining HIV care and provide instrumental support to access care as needed for six months. The navigator will assist with obtaining government sponsored insurance if the participant does not have employer sponsored insurance, including processing needed documents, monetary resources, transportation and clerical support to obtain required documents, such as state ID and birth certificates. Navigators will meet with participants to go over what to expect during their clinic appointment and explain in lay terms medical terminology likely to be discussed by providers to facilitate patient-provider interaction. Other instrumental support provided will be scheduling appointments, providing clean clothing, a place to shower, and transportation to attend medical appointments.<br>|
| Experimental: Condition 3: Components 1, 2 and 4<br>Peer-Support for Medication-Assisted Treatment Behavioral Activation Therapy 4) Life Steps Program for Medication Adherence | Behavioral: Peer support to promote uptake and persistence of medication assisted treatment (MAT)<br>* Participants will be assigned to receive peer support to promote uptake of MAT and persistence. This component will consist of two informational sessions, a tailored recovery plan, and on-going support from a peer for the first 6 months.<br>Behavioral: Behavioral Activation Treatment (BAT) to reduce depression<br>* Participants will be assigned to receive BAT treatment for depression. This component will consist of 8 sessions where participants will identify short and long-term goals, values, and the activities unrelated to substance use that were previously enjoyed or are likely to increase a feeling of well-being. This intervention component focuses on making a plan to troubleshoot barriers to re-engage in these activities. Sessions are delivered weekly. The content includes psycho-education about what depression is, the intervention rationale, and the activities and monitoring of activities, building social contracts to engage networks, and discussion of potential barriers to following through with activities.<br>Behavioral: Life Steps educational and skill building session to promote adherence to HIV medication<br>* Participants assigned to this component will participate in a single session that includes one follow-up phone-call or visit. Participants will be exposed to cognitive-behavioral techniques and will learn about the importance of HIV treatment and the strategies and skills needed to take HIV treatment as prescribed. The session consists of strategies for problem solving transportation barriers, skills to improve communication with providers, strategies for dealing with side-effects, reminder cues, and managing lapses.<br>|
| Experimental: Condition 4: Components 1 and 2<br>Peer-Support for Medication-Assisted Treatment Behavioral Activation Therapy | Behavioral: Peer support to promote uptake and persistence of medication assisted treatment (MAT)<br>* Participants will be assigned to receive peer support to promote uptake of MAT and persistence. This component will consist of two informational sessions, a tailored recovery plan, and on-going support from a peer for the first 6 months.<br>Behavioral: Behavioral Activation Treatment (BAT) to reduce depression<br>* Participants will be assigned to receive BAT treatment for depression. This component will consist of 8 sessions where participants will identify short and long-term goals, values, and the activities unrelated to substance use that were previously enjoyed or are likely to increase a feeling of well-being. This intervention component focuses on making a plan to troubleshoot barriers to re-engage in these activities. Sessions are delivered weekly. The content includes psycho-education about what depression is, the intervention rationale, and the activities and monitoring of activities, building social contracts to engage networks, and discussion of potential barriers to following through with activities.<br>|
| Experimental: Condition 5: Component 1, 3, and 4<br>1) Peer-Support for Medication-Assisted Treatment 3) Patient Navigation for HIV Care 4) Life Steps Program for Medication Adherence | Behavioral: Peer support to promote uptake and persistence of medication assisted treatment (MAT)<br>* Participants will be assigned to receive peer support to promote uptake of MAT and persistence. This component will consist of two informational sessions, a tailored recovery plan, and on-going support from a peer for the first 6 months.<br>Behavioral: Patient Navigation to promote linkage and engagement in HIV care<br>* Participants will be assigned to receive patient navigation services. A patient navigator will provide information about the process of obtaining HIV care and provide instrumental support to access care as needed for six months. The navigator will assist with obtaining government sponsored insurance if the participant does not have employer sponsored insurance, including processing needed documents, monetary resources, transportation and clerical support to obtain required documents, such as state ID and birth certificates. Navigators will meet with participants to go over what to expect during their clinic appointment and explain in lay terms medical terminology likely to be discussed by providers to facilitate patient-provider interaction. Other instrumental support provided will be scheduling appointments, providing clean clothing, a place to shower, and transportation to attend medical appointments.<br>Behavioral: Life Steps educational and skill building session to promote adherence to HIV medication<br>* Participants assigned to this component will participate in a single session that includes one follow-up phone-call or visit. Participants will be exposed to cognitive-behavioral techniques and will learn about the importance of HIV treatment and the strategies and skills needed to take HIV treatment as prescribed. The session consists of strategies for problem solving transportation barriers, skills to improve communication with providers, strategies for dealing with side-effects, reminder cues, and managing lapses.<br>|
| Experimental: Condition 6: Component 1 and 3<br>1) Peer-Support for Medication-Assisted Treatment 3) Patient Navigation for HIV Care | Behavioral: Peer support to promote uptake and persistence of medication assisted treatment (MAT)<br>* Participants will be assigned to receive peer support to promote uptake of MAT and persistence. This component will consist of two informational sessions, a tailored recovery plan, and on-going support from a peer for the first 6 months.<br>Behavioral: Life Steps educational and skill building session to promote adherence to HIV medication<br>* Participants assigned to this component will participate in a single session that includes one follow-up phone-call or visit. Participants will be exposed to cognitive-behavioral techniques and will learn about the importance of HIV treatment and the strategies and skills needed to take HIV treatment as prescribed. The session consists of strategies for problem solving transportation barriers, skills to improve communication with providers, strategies for dealing with side-effects, reminder cues, and managing lapses.<br>|
| Experimental: Condition 7: Component 1 and 4<br>1) Peer-Support for Medication-Assisted Treatment 4) Life Steps Program for Medication Adherence | Behavioral: Peer support to promote uptake and persistence of medication assisted treatment (MAT)<br>* Participants will be assigned to receive peer support to promote uptake of MAT and persistence. This component will consist of two informational sessions, a tailored recovery plan, and on-going support from a peer for the first 6 months.<br>Behavioral: Patient Navigation to promote linkage and engagement in HIV care<br>* Participants will be assigned to receive patient navigation services. A patient navigator will provide information about the process of obtaining HIV care and provide instrumental support to access care as needed for six months. The navigator will assist with obtaining government sponsored insurance if the participant does not have employer sponsored insurance, including processing needed documents, monetary resources, transportation and clerical support to obtain required documents, such as state ID and birth certificates. Navigators will meet with participants to go over what to expect during their clinic appointment and explain in lay terms medical terminology likely to be discussed by providers to facilitate patient-provider interaction. Other instrumental support provided will be scheduling appointments, providing clean clothing, a place to shower, and transportation to attend medical appointments.<br>|
| Experimental: Condition 8: Component 1<br>1) Peer-Support for Medication-Assisted Treatment | Behavioral: Peer support to promote uptake and persistence of medication assisted treatment (MAT)<br>* Participants will be assigned to receive peer support to promote uptake of MAT and persistence. This component will consist of two informational sessions, a tailored recovery plan, and on-going support from a peer for the first 6 months.<br>|
| Experimental: Condition 9: Components 2, 3, and 4<br>2) Behavioral Activation Therapy 3) Patient Navigation for HIV Care 4) Life Steps Program for Medication Adherence | Behavioral: Behavioral Activation Treatment (BAT) to reduce depression<br>* Participants will be assigned to receive BAT treatment for depression. This component will consist of 8 sessions where participants will identify short and long-term goals, values, and the activities unrelated to substance use that were previously enjoyed or are likely to increase a feeling of well-being. This intervention component focuses on making a plan to troubleshoot barriers to re-engage in these activities. Sessions are delivered weekly. The content includes psycho-education about what depression is, the intervention rationale, and the activities and monitoring of activities, building social contracts to engage networks, and discussion of potential barriers to following through with activities.<br>Behavioral: Patient Navigation to promote linkage and engagement in HIV care<br>* Participants will be assigned to receive patient navigation services. A patient navigator will provide information about the process of obtaining HIV care and provide instrumental support to access care as needed for six months. The navigator will assist with obtaining government sponsored insurance if the participant does not have employer sponsored insurance, including processing needed documents, monetary resources, transportation and clerical support to obtain required documents, such as state ID and birth certificates. Navigators will meet with participants to go over what to expect during their clinic appointment and explain in lay terms medical terminology likely to be discussed by providers to facilitate patient-provider interaction. Other instrumental support provided will be scheduling appointments, providing clean clothing, a place to shower, and transportation to attend medical appointments.<br>Behavioral: Life Steps educational and skill building session to promote adherence to HIV medication<br>* Participants assigned to this component will participate in a single session that includes one follow-up phone-call or visit. Participants will be exposed to cognitive-behavioral techniques and will learn about the importance of HIV treatment and the strategies and skills needed to take HIV treatment as prescribed. The session consists of strategies for problem solving transportation barriers, skills to improve communication with providers, strategies for dealing with side-effects, reminder cues, and managing lapses.<br>|
| Experimental: Condition 10: Components 2 and 3<br>2) Behavioral Activation Therapy 3) Patient Navigation for HIV Care | Behavioral: Behavioral Activation Treatment (BAT) to reduce depression<br>* Participants will be assigned to receive BAT treatment for depression. This component will consist of 8 sessions where participants will identify short and long-term goals, values, and the activities unrelated to substance use that were previously enjoyed or are likely to increase a feeling of well-being. This intervention component focuses on making a plan to troubleshoot barriers to re-engage in these activities. Sessions are delivered weekly. The content includes psycho-education about what depression is, the intervention rationale, and the activities and monitoring of activities, building social contracts to engage networks, and discussion of potential barriers to following through with activities.<br>Behavioral: Life Steps educational and skill building session to promote adherence to HIV medication<br>* Participants assigned to this component will participate in a single session that includes one follow-up phone-call or visit. Participants will be exposed to cognitive-behavioral techniques and will learn about the importance of HIV treatment and the strategies and skills needed to take HIV treatment as prescribed. The session consists of strategies for problem solving transportation barriers, skills to improve communication with providers, strategies for dealing with side-effects, reminder cues, and managing lapses.<br>|
| Experimental: Condition 11: Component 2 and 4<br>2) Behavioral Activation Therapy 4) Life Steps Program for Medication Adherence | Behavioral: Behavioral Activation Treatment (BAT) to reduce depression<br>* Participants will be assigned to receive BAT treatment for depression. This component will consist of 8 sessions where participants will identify short and long-term goals, values, and the activities unrelated to substance use that were previously enjoyed or are likely to increase a feeling of well-being. This intervention component focuses on making a plan to troubleshoot barriers to re-engage in these activities. Sessions are delivered weekly. The content includes psycho-education about what depression is, the intervention rationale, and the activities and monitoring of activities, building social contracts to engage networks, and discussion of potential barriers to following through with activities.<br>Behavioral: Patient Navigation to promote linkage and engagement in HIV care<br>* Participants will be assigned to receive patient navigation services. A patient navigator will provide information about the process of obtaining HIV care and provide instrumental support to access care as needed for six months. The navigator will assist with obtaining government sponsored insurance if the participant does not have employer sponsored insurance, including processing needed documents, monetary resources, transportation and clerical support to obtain required documents, such as state ID and birth certificates. Navigators will meet with participants to go over what to expect during their clinic appointment and explain in lay terms medical terminology likely to be discussed by providers to facilitate patient-provider interaction. Other instrumental support provided will be scheduling appointments, providing clean clothing, a place to shower, and transportation to attend medical appointments.<br>|
| Experimental: Condition 12: Component 2<br>2) Behavioral Activation Therapy | Behavioral: Behavioral Activation Treatment (BAT) to reduce depression<br>* Participants will be assigned to receive BAT treatment for depression. This component will consist of 8 sessions where participants will identify short and long-term goals, values, and the activities unrelated to substance use that were previously enjoyed or are likely to increase a feeling of well-being. This intervention component focuses on making a plan to troubleshoot barriers to re-engage in these activities. Sessions are delivered weekly. The content includes psycho-education about what depression is, the intervention rationale, and the activities and monitoring of activities, building social contracts to engage networks, and discussion of potential barriers to following through with activities.<br>|
| Experimental: Condition 13: Component 3 and 4<br>3) Patient Navigation for HIV Care 4) Life Steps Program for Medication Adherence | Behavioral: Patient Navigation to promote linkage and engagement in HIV care<br>* Participants will be assigned to receive patient navigation services. A patient navigator will provide information about the process of obtaining HIV care and provide instrumental support to access care as needed for six months. The navigator will assist with obtaining government sponsored insurance if the participant does not have employer sponsored insurance, including processing needed documents, monetary resources, transportation and clerical support to obtain required documents, such as state ID and birth certificates. Navigators will meet with participants to go over what to expect during their clinic appointment and explain in lay terms medical terminology likely to be discussed by providers to facilitate patient-provider interaction. Other instrumental support provided will be scheduling appointments, providing clean clothing, a place to shower, and transportation to attend medical appointments.<br>Behavioral: Life Steps educational and skill building session to promote adherence to HIV medication<br>* Participants assigned to this component will participate in a single session that includes one follow-up phone-call or visit. Participants will be exposed to cognitive-behavioral techniques and will learn about the importance of HIV treatment and the strategies and skills needed to take HIV treatment as prescribed. The session consists of strategies for problem solving transportation barriers, skills to improve communication with providers, strategies for dealing with side-effects, reminder cues, and managing lapses.<br>|
| Experimental: Condition 14: Component 3<br>3) Patient Navigation for HIV Care | Behavioral: Life Steps educational and skill building session to promote adherence to HIV medication<br>* Participants assigned to this component will participate in a single session that includes one follow-up phone-call or visit. Participants will be exposed to cognitive-behavioral techniques and will learn about the importance of HIV treatment and the strategies and skills needed to take HIV treatment as prescribed. The session consists of strategies for problem solving transportation barriers, skills to improve communication with providers, strategies for dealing with side-effects, reminder cues, and managing lapses.<br>|
| Experimental: Condition 15: Component 4<br>4) Life Steps Program for Medication Adherence | Behavioral: Patient Navigation to promote linkage and engagement in HIV care<br>* Participants will be assigned to receive patient navigation services. A patient navigator will provide information about the process of obtaining HIV care and provide instrumental support to access care as needed for six months. The navigator will assist with obtaining government sponsored insurance if the participant does not have employer sponsored insurance, including processing needed documents, monetary resources, transportation and clerical support to obtain required documents, such as state ID and birth certificates. Navigators will meet with participants to go over what to expect during their clinic appointment and explain in lay terms medical terminology likely to be discussed by providers to facilitate patient-provider interaction. Other instrumental support provided will be scheduling appointments, providing clean clothing, a place to shower, and transportation to attend medical appointments.<br>|
| Experimental: Condition 16: No Components<br>Participants not assigned to any of the 4 components. They are placed on a wait list and will receive components after the primary data collection period. | Behavioral: Peer support to promote uptake and persistence of medication assisted treatment (MAT)<br>* Participants will be assigned to receive peer support to promote uptake of MAT and persistence. This component will consist of two informational sessions, a tailored recovery plan, and on-going support from a peer for the first 6 months.<br>Behavioral: Behavioral Activation Treatment (BAT) to reduce depression<br>* Participants will be assigned to receive BAT treatment for depression. This component will consist of 8 sessions where participants will identify short and long-term goals, values, and the activities unrelated to substance use that were previously enjoyed or are likely to increase a feeling of well-being. This intervention component focuses on making a plan to troubleshoot barriers to re-engage in these activities. Sessions are delivered weekly. The content includes psycho-education about what depression is, the intervention rationale, and the activities and monitoring of activities, building social contracts to engage networks, and discussion of potential barriers to following through with activities.<br>Behavioral: Patient Navigation to promote linkage and engagement in HIV care<br>* Participants will be assigned to receive patient navigation services. A patient navigator will provide information about the process of obtaining HIV care and provide instrumental support to access care as needed for six months. The navigator will assist with obtaining government sponsored insurance if the participant does not have employer sponsored insurance, including processing needed documents, monetary resources, transportation and clerical support to obtain required documents, such as state ID and birth certificates. Navigators will meet with participants to go over what to expect during their clinic appointment and explain in lay terms medical terminology likely to be discussed by providers to facilitate patient-provider interaction. Other instrumental support provided will be scheduling appointments, providing clean clothing, a place to shower, and transportation to attend medical appointments.<br>Behavioral: Life Steps educational and skill building session to promote adherence to HIV medication<br>* Participants assigned to this component will participate in a single session that includes one follow-up phone-call or visit. Participants will be exposed to cognitive-behavioral techniques and will learn about the importance of HIV treatment and the strategies and skills needed to take HIV treatment as prescribed. The session consists of strategies for problem solving transportation barriers, skills to improve communication with providers, strategies for dealing with side-effects, reminder cues, and managing lapses.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Achievement of Viral Suppression | Viral suppression is defined as a laboratory test result showing HIV viral load as less than 400 copies per mL. To meet our definition of achieved viral suppression, viral load must be below 400 copiers per mL at 6-month follow-up. | Viral load below or above 400 copiers per mL at the 6-month follow-up assessment | 
| Viral Suppression at 9-month follow-up | Viral suppression is defined as a laboratory test result showing HIV viral load as less than 400 copies per mL. To meet our definition of viral suppression, viral load must be below 400 copiers per mL at 6-month follow-up. | Viral load below or above 400 copiers per mL at the 9-month follow-up assessment | 
| Viral Suppression at 12-month follow-up | Viral suppression is defined as a laboratory test result showing HIV viral load as less than 400 copies per mL. To meet our definition of viral suppression, viral load must be below 400 copiers per mL. | Viral load below or above 400 copiers per mL at the 12-month follow-up assessment | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Drug use | Will be measured through urine analysis and participants will self-report the frequency (yes vs no), quantity (how much typically consumed when using), and duration of use (how may days in the last 30 days did the participant use and how many times did the participant use yesterday) of various drugs in last 30 days. | 3-,6-,9-, and 12-month follow-up assessments | 
| Methadone uptake and persistence | Information about date of first dose, current dosage, and number of days on Methadone will be extracted from the medical record. | 3-,6-,9-, and 12-month follow-up assessments | 
| Drug use frequency and severity of withdrawal and cravings | Opioid Withdrawal Scale - This is a clinician administered scale that assesses the extent opiate withdrawal symptoms based on 11 symptoms (resting pulse rate, sweating, restlessness, pupil size, bone or joint aches, runny nose, GI upset, tremors, yawning, anxiety or irritability, gooseflesh skin. | 3-,6-,9-, and 12-month follow-up assessments | 
| Depressive Symptoms (Clinician-assisted rating) | The Montgomery-Asberg Depression Rating Scale will be used, which is a 10-item scale and is clinician-assisted. interview participants and clinicians will rate their level of depression. Symptoms assessed include: apparent sadness, reported sadness, inner tension, reduced sleep, reduced appetite, concentration difficulties, lassitude, inability to feel, pessimistic thoughts, suicidal thoughts | 3-,6-,9-, and 12-month follow-up assessments | 
| Depressive Symptoms (Self-report) | The validated nine-item patient health questionnaire will be administered to participants to measure their level of depression. Participants will be asked to rate how many days of the last 2 weeks they have been bothered by having little interest or pleasure doing things, feeling down, feeling tired, having poor appetite, feeling bad about themselves, having trouble concentrating, moving or speaking slowly, and having thought of hurting themselves. | 3-,6-,9-, and 12-month follow-up assessments | 
| Behavioral activation for depression | The validated 25 item questionnaire will be administered to participants to assess changes in the behaviors in the past week that underlie their depression such as staying in bed too long, inability to do things that needed to be done, and being active and accomplishing goals. | 3-,6-,9-, and 12-month follow-up assessments | 
| Adherence to antiretroviral medication (ART) | Percent adherent to ART measure will be extracted from medical records | 3-,6-,9-, and 12-month follow-up assessments | 
| Non-adherence to antiretroviral medication (ART) | Non-adherence will be measured as 4-day treatment interruptions (yes vs no) extracted from medical records. | 3-,6-,9-, and 12-month follow-up assessments | 
| Information, motivation, and behavioral skills to adhere to ART | Participants will answer the validated 30-item scale to assess psychological precursors of adherence including information (e.g., knowledge of how current HIV medications should be taken); Motivation (e.g., support from close significant others to take HIV medication); Behavioral skills (e.g, how easy it is to get HIV medications refills on time) | 3-,6-,9-, and 12-month follow-up assessments | 
| Self-efficacy to adhere to ART | Participants will answer the validate 12-items scale assessing perceived self-efficacy to adhere to antiretroviral medication in the last 30 days. The scale asks about the level of confidence the participant has in keeping up with the treatment plan in spite of difficulties such as sided-effects and amid change in sleep and dietary habits and ability to integrate taking medications into the daily routine | 3-,6-,9-, and 12-month follow-up assessments | 
| Retention in HIV care | Retention will be assessed by extracting from the medical record: appointments missed and appointments kept. A ratio will be computed using these two measures. At least one appointment kept in each three-month period will be an index of appointment constancy. | 3-,6-,9-, and 12-month follow-up assessments | 
| Logistical barriers to HIV care | Participants will be asked to indicate whether they have experienced common barriers to HIV care (yes/no) including availability of transportation, being able to access care, clinic hours of operation. | 3-,6-,9-, and 12-month follow-up assessments | 
| Perceived engagement in HIV care | Participants will answer the 10-item validated scale assessing perceived engagement in HIV care including level of trust in provider, feeling respected and understood by provider, degree of comfort in asking questions and interacting with provider, participant's perceived role in his medical care,. | 3-,6-,9-, and 12-month follow-up assessments | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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HIV viral suppression