This mixed methods study evaluated the efficacy of an intervention to increase HIV status disclosure and condom use among 184 women living with HIV/AIDS (WLH/A). Participants were recruited from an HIV clinic and randomly assigned to: (1) a comparison group, who received brief messages from their health care providers (HCPs), or; (2) an intervention group, who received messages from HCPs, a group-level intervention, and peer-led support groups. Participants completed risk surveys at baseline, 6-, 12-, and 18-months. Quantitative analyses using hierarchical generalized linear models within a repeated measures framework indicated that intervention participants had significantly higher odds of reporting condom use with sexual partners in months 6 and 18. Grounded Theory-based qualitative analyses suggested that the opportunity to discuss the social context of their lives in addition to HIV/AIDS, including continued stigma and fear related to disclosure, are also essential components of a prevention strategy for WLH/A.

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In recent years, increased focus on the effectiveness and accountability of prevention and intervention programs has led to greater government funding for the implementation and spread of evidence-based health and human service delivery models. In particular, attention has been paid to programs that require significant infrastructure investment and systems change to support large-scale replication. For conceptual and methodological reasons, such systems change initiatives can be a challenge to evaluate. To overcome these challenges, this article outlines a mixed methods approach to systems change evaluation and offers a case study of how this approach has been used to evaluate the development of system infrastructure supporting the implementation, spread, and sustainability of evidence-based home visiting projects. The approach combined systems concepts (boundaries, relationships, perspectives, ecological levels, and dynamics) and qualitative methods (project site visits, telephone interviews, reviews of project documents and logic models) with quantitative methods (a web-based partner survey) to directly measure the projects' system properties and contextual dynamics, and to assess how these factors were associated with the projects' infrastructure development. In the case study, the projects worked at four ecological levels (organization, community, state, and national) to build eight types of infrastructure (planning, collaboration, operations, workforce development, fiscal capacity, community and political support, communications, and evaluation). The evaluation found that the size of the projects' partner networks was not as important as the quality of their collaboration or their sharing of common goals in the projects' infrastructure development.