More than 55,000 people living with HIV (PLH) in the US live in rural areas, and more than 2,300 rural
residents are diagnosed with HIV each year. PLH who live in rural areas have higher mortality rates compared
with non-rural PLH. Rural PLH are diagnosed with HIV at a more advanced stage than non-rural individuals
and present for medical care later, making them more likely to face comorbidities and need complex medical
care. Rural PLH are also less likely than their urban counterparts to remain engaged in HIV care and to be
virally suppressed. Compared with younger PLH, older PLH may face additional challenges to maintaining their
health and wellbeing, and older PLH who also live in rural areas face the doubly challenging prospect of
maintaining adherence to HIV care and managing medical conditions while living in a rural environment. Few
interventions aimed at increasing viral suppression and improving health-related quality of life (HRQOL) exist
for rural older PLH. Our previous qualitative and survey research with rural older PLH nationwide (N = 476)
identified low social support, HIV-related stigma, self-efficacy, and structural barriers (such as difficulties with
housing, food access, transportation, and insurance) as key predictors of engagement in HIV care, viral
suppression, and HRQOL for this population. Based on this, we previously piloted two remotely-delivered
interventions for rural older PLH: supportive-expressive peer social support groups and strengths-based case
management. The pilot with older PLH in the rural Southern U.S. found the interventions to be feasible,
acceptable, and to show evidence of preliminary impact. Based on this work, we propose a full-scale trial to
evaluate the efficacy of these two interventions. We will recruit 352 rural older PLH in the Southern U.S.—
including in the states prioritized in the US HHS’ “Ending the HIV Epidemic” (EtHE) plan—through partnerships
with community agencies and online advertisements. Following baseline surveys (completed online, by mail, or
by phone) and HIV viral load testing (via self-collected dried blood spot samples), participants will be
randomized to receive or not receive each intervention in a 2x2 factorial design. Follow-up surveys will occur at
4, 8, and 12 months, and viral load testing at 4 and 12 months. Surveys will assess medication adherence,
depressive symptoms, HRQOL, covariates, and potential mediators (e.g., social support, HIV stigma, self-
efficacy, structural barriers). Primary outcomes are viral suppression, antiretroviral therapy adherence,
depressive symptoms and HRQOL, and secondary outcomes are potential mediating mechanisms. We
hypothesize that both interventions will increase the proportion of participants that have viral suppression,
levels of antiretroviral therapy adherence, and HRQOL and decrease depressive symptoms. Exploratory
analyses will evaluate mediators and moderators of intervention effects. We will also assess the acceptability,
feasibility, and costs of intervention delivery. Results from this study will provide us with tools to improve health
outcomes for rural older PLH and to advance the EtHE plan to eliminate HIV transmission in the U.S.
