From Silos to Systems: A Qualitative Analysis of Braiding Funds for HIV and Syndemic Service Delivery in the United States

Abstract

This doctoral project explores the practice of braiding funds as a strategic approach to improving the coordination and integration of public health funding streams—specifically within the U.S. Centers for Disease Control and Prevention’s National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP). With growing attention to syndemic conditions that intersect with HIV, there is an urgent need to align categorical funding in ways that enhance service delivery, reduce fragmentation, and improve outcomes for disproportionately affected communities. Braiding funds offers a promising solution, allowing public health agencies to coordinate multiple funding sources while maintaining accountability to each. Using a qualitative design informed by implementation science, this study employed 19 key informant interviews with CDC officials and leaders from state and local health departments across the United States. A stratified purposive sampling approach was used to ensure geographic, epidemiological, and jurisdictional diversity. Data were analyzed using a hybrid coding framework, themes were identified to highlight facilitators, barriers, and opportunities in implementing braided funding. The project was guided by three conceptual frameworks: the EPIS (Exploration, Preparation, Implementation, Sustainment) framework, the Positive Deviance model, and Kotter’s Eight Steps for Leading Change. Findings underscore the administrative complexity of managing multiple funding streams and the tension between flexibility and compliance. Participants identified both structural and cultural challenges, as well as innovative strategies used by jurisdictions to align resources. The study concludes with a set of targeted recommendations to strengthen braided funding efforts within CDC’s NCHHSTP and lays the groundwork for broader adoption across federal public health initiatives.