Tensions in Implementation: A Mixed-Methods Evaluation of a Lung Cancer Screening Shared Decision-Making Aid for People With HIV

Abstract

People with HIV (PWH) are at increased risk for lung cancer, but lung cancer screening (LCS) is understudied in this population. We previously adapted a shared decision-making (SDM) aid for PWH and demonstrated its efficacy in improving LCS knowledge. In this study, we conducted a mixed-methods evaluation of the implementation of this aid. Participants were LCS-eligible PWH. Forty participants reviewed HIV-adapted and individually tailored decision aids at SDM visits and completed pre-/post-visit surveys. Fifteen completed semi-structured interviews. Interviews were analyzed using thematic analysis guided by the Health Equity Implementation Framework and triangulated with surveys through joint displays. Participants generally approved of the SDM aid as it explained the risks and benefits of screening, but six key implementation tensions emerged: (1) Participants generally trusted clinician recommendations but highlighted how their lived experience with HIV informed some medical skepticism and desire for autonomy. (2) There was appreciation for HIV-focused material, but emphasis on individuality and the variable experiences of PWH. (3) Participants were interested and motivated regarding LCS but highlighted systemic barriers. (4) The aid improved comfort for many, but increased anxiety or confusion for others. (5) Some preferred SDM with their primary care clinician, while others prioritized the opinion of an LCS-focused clinician. (6) Several were motivated to quit smoking after SDM, while others were reassured to continue smoking by lower-than-expected risk estimates. This adapted decision aid was well-received, but interviews highlighted tensions in implementation. Iterative adaptation of the decision aid and communication strategies is needed to optimize SDM for PWH.