Unpacking early organizational development in HIV/AIDS prevention organizations led by young members of key affected populations

In early 2011, clinical research revealed innovative methods of HIV prevention that led global health stakeholders to believe that wholescale elimination of HIV and AIDS was achievable. Effective delivery of new HIV prevention methods, however, would require public health stakeholders to collaborate in unprecedented ways. The strategy of 'task shifting' implores that resources be distributed to community-based organizations and community health workers who can effectively provide outreach to populations that are otherwise marginalized by the formal healthcare system. While these types of organizations are playing an increasingly significant role in public health delivery, they experience disproportionately high rates of organizational failure, and little is known about their intra- and inter-organizational dynamics. Using multiple research methods, this study explores the organizational dynamics of HIV/AIDS service organizations that are designed and managed by young people who are also members of communities that have been deemed 'hard to reach' with HIV prevention and care—people who inject drugs (PWID), men who have sex with men (MSM), sex workers (SW), and people living with HIV (PLHIV). I chose to study these organizations because young sexual minorities account for the highest rates of new HIV infection, and they are also creating new organizations in unprecedented numbers. My goal is to determine how these organizations grow and develop over time, as well as how donor organizations understand and support the growth of these organizations. After gaining access to donor agencies that provide support to youth-led organizations, I orient my research questions using the life cycle literature, a literature that theorizes organizational change using a framework of 'life cycle stages' and 'motors' that drive organizations from one stage to the next. I undertake a systematic review of the conceptual and empirical literatures on the life cycle model of a range of organizational forms, identifying geographical, methodological, and thematic gaps. Using the results of the review as both a justification for further empirical investigation and as a foundation for data analysis, I embark on three distinct case studies. First, I examine early-stage organizational growth patterns in two organizations that were purposively sampled by donor agencies who deemed them to be 'high-performing.' Drawing on interviews, focus groups, participant and non-participant observations, and archival data, I use an emergent fit analytical method to unpack the organizational trajectories of these organizations over the course of their early years of growth. In my third case study, I focus on the relationship between the organizations and their early-stage donors. I argue that the strategy of shifting HIV service delivery to organizations led by hard-to-reach youth has been justified by powerful global health actors on both moral and strategic grounds. While I show that these organizations are providing critical services to at-risk youth who have been 'lost to follow up' in the HIV care system, the main focus of my discussion is on the ways in which these organizations have been able to overcome early stage existential threats. After providing an analysis of the fit of organizational case studies to existing life cycle frameworks, I outline thematic areas in which organizations make critical decisions that affect their early-stage growth and vulnerability—leadership, inter-organizational partnerships, strategic drift, and relationships with the state. I then discuss the ways in which the organizations’ primary donor understands and influences their growth. I incorporate data from multiple cases to extend existing theory about the organizational life cycle and its application to nongovernmental organizations.