Project Summary The scope of this study is to engage Ryan White HIV/AIDS Program (RWHAP) funded organizations in Ending the HIV Epidemic (ETHE) areas in the South/East US to co-develop context-responsive programs utilizing evi- dence-informed interventions to reduce structural racism and discrimination (SRD) against Black, Indigenous, People of Color (BIPOC) living with HIV (PLH) and BIPOC healthcare workers. SRD directly impacts access to and uptake of healthcare for BIPOC, including engagement in HIV services across the continuum of prevention and care. The proposed intervention, titled TRAnscenDS, draws on the evidence-based Health Policy Plus (HP+) ‘total’ facility HIV stigma-reduction intervention and Contact Theory, which have demonstrated efficacy in reducing race-related intergroup prejudice. TRAnscenDS targets the clinics’ organizational (e.g., anti-racist and diversity, equity and inclusion [DEI] policies) and systems (e.g., staff attitudes/behaviors) levels to affect patient (e.g., experienced and perceived discrimination, HIV care, mental health) outcomes and staff (e.g., job satisfaction) wellbeing, at the individual level. In Aim 1, we will rigorously select 6 clinics from ETHE areas evi- dencing full commitment to dismantling SRD (mos 3-9). In Aim 2, after a baseline assessment (N=180; mos 11-12), we will conduct a stepped wedge cluster randomized trial of the SRD reduction intervention. At each of the 3 steps, two randomized clinics will receive TRAnscenDS. The intervention will support clinics to 1) identi- fy/create organizational-level anti-racist policies and practices (e.g., clear definitions of racist behavior, ade- quate training and monitoring systems, and prompt responses for constructive redress) to reduce SRD and increase race-based equity for BIPOC patients and provider/staff, and 2) deliver race-specific trainings to all staff (e.g., history of SRD, health consequences of bias and discrimination, cultural humility, intersectional dis- crimination at the confluence of race, ethnicity, sexuality and gender). Each cluster will receive the intervention for 6 mos, starting with Cluster Group 1 (mos 13-18), followed by Cluster Groups 2 (mos 19-24) and 3 (mos 25-30). In Aim 3, we will evaluate multi-level outcomes using the CFIR, including within the organization (pri- mary outcome of SRD Index – ratings of mission/vision statements, anti-racist policy, workforce diversity, equi- ty and inclusion [DEI], clinic environment), systems (secondary outcomes of provider/staff attitudes; behavior; DEI indicators), and individual patient level (tertiary outcomes of clinic-level HIV indicators, reports of discrimi- nation, medical distrust, anxiety, depression, and trauma) outcomes. Assessments will take place every 6 months, with the clinics randomized to the second or third step having multiple assessments before the inter- vention (with final data collection being in month 49). BIPOC patients at the clinics will be surveyed at each as- sessment (N=2,100). Findings will yield a manual for implementing total-facility SRD-reduction processes and content (mos 52-60). Other RWHAP-funded clinics and facilities serving marginalized groups may be able to adopt this manualized, yet highly adaptable intervention packet to support BIPOC.

Project Narrative The proposed research aligns with the priority objectives and goals in the HIV National Strategic Plan for the United States: A Roadmap to End the Epidemic 2021–2025, which states that “[…] to successfully achieve the goal of ending the HIV epidemic, issues such as discrimination and systemic racism that contribute to differences in health care quality and access […] and lead to ongoing disparities among racial, ethnic, and sexual and gender minority populations, must be addressed.” By targeting structural racism and discrimination at the organizational (clinic) and systems (provider/staff) levels, we will indirectly impact its downstream manifestations affecting processes and co-morbidities for Black, Indigenous, and People of Color at the individual level. Findings will support the creation of a manual for SRD reduction and racial equity promotion that may be adopted by other RWHAP-funded clinics and facilities serving marginalized groups.