HIV Testing, Linkage, and Retention in Care: Contextual Factors and Disparities

Abstract: The purpose of this study is to determine if associations exist between the contexts in which people obtain healthcare (i.e., healthcare context) or live (i.e., residential context) and each of five outcomes (HIV testing, receipt of test results, linkage to HIV/AIDS care, retention in HIV care and HIV viral load). The epidemiology of HIV/AIDS among racial/ethnic minorities (specifically, Blacks and Latinos) and older adults (i.e., 50 and older) suggests they may encounter barriers that contribute to disparities in early detection of HIV and in their prognoses. Hence, we will also examine disparities in the outcomes by race/ethnicity and older age (age >50). Drawing on the sociobehavioral sciences, the study will inform clinical practice in ways that promote equity in care across diverse groups, neighborhood conditions and stages of adulthood. The study’s primary Specific Aims are to: (1) Examine relations between healthcare context, residential context and HIV testing during primary care visits using logistic regression multilevel models with random effects based on primary care patients’ electronic medical records; and, (2) Examine relations between healthcare context, residential context and receipt of HIV test results and linkage to HIV/AIDS care, respectively, among managed care enrollees newly diagnosed as HIV-positive using multilevel logistic regression and Cox proportional hazards models with random effects. The secondary Specific Aim is to determine if racial/ethnic- or age-related (i.e., aged <50 vs. >50 years) disparities exist in these relationships. Building on our work on HIV testing and care, and guided by a model integrating the Public Health Critical Race Praxis and Behavioral Model of Healthcare Utilization, the four-year study based on the electronic medical records (EMRs) of adults enrolled in the largest managed care organization in the region. We will pool data over five years (2007-2011) to examine HIV testing among all patients presenting for primary care, and to examine receipt of HIV test results, linkage to and retention in HIV/AIDS care as well as HIV viral load among all patients newly diagnosed as HIV-positive. The study will comprise four multilevel analyses of patients’ residential contexts (e.g., neighborhood HIV prevalence) and healthcare contexts (e.g., characteristics of the patient population) relative to HIV testing during primary care visits (Aim 1), receipt of HIV test results and linkage to HIV/AIDS care among those diagnosed as HIV-positive (Aim 2), retention in HIV/AIDS care and HIV RNA viral load up to one-year post diagnosis. We will use personal and geospatial codes in the EMRs to link to: (1) files containing detailed information on each provider (e.g., demographics, specialty); (2) public data from the Centers for Disease Control and Prevention on HIV prevalence and HIV test sites in each zip code; (3) 2010 Census socioeconomic data (e.g., concentrated poverty) for each zip code; and, (4) global positioning system software to calculate the distance from a patient’s home to their provider. This interdisciplinary, inter- institutional collaboration leverages the expertise of a diverse team of new and seasoned investigators.

 

Project Number: 5R01NR014789-04

https://reporter.nih.gov/search/IbMfJxDXuUq2-aD5SULsNw/project-details/9215532

 

 

Contact PI/ Project Leader

FORD, CHANDRA L , POSTDOCTORAL SCHOLAR (clford@ucla.edu)

 

 

Organization

UNIVERSITY OF CALIFORNIA LOS ANGELES

 

 

PUBLIC HEALTH RELEVANCE: The goal of the proposed research is to learn why adults, especially racial/ethnic minorities and older adults, who have insurance may nevertheless not receive HIV testing or HIV/AIDS care at the recommended levels. The study compares MCO enrollees based on their medical records, assigned providers and neighborhood social conditions to see if certain patients have a harder time getting testing or care because of the type of provider they see or because of where they live.

 

 

 

Project Start Date: 10-April-2014

Project End Date: 28-February-2019

Budget Start Date: 01-March-2017

Budget End Date: 28-February-2019

 

 

NIH Categorical Spending

Funding IC: NATIONAL INSTITUTE OF NURSING RESEARCH  / FY Total Cost by IC: $371,958

STI Screening as a Combined HIV Prevention Platform for MSM in Peru

Abstract: Periodic counseling, testing, and treatment for rectal sexually transmitted infections (STIs) provides a multi- dimensional platform to integrate behavioral and biological HIV prevention strategies for men who have sex with men (MSM) in Peru. Rectal STIs like gonorrhea and chlamydia are key risk factors for HIV acquisition among MSM, both as indirect behavioral markers of recent unprotected receptive anal intercourse (URAI), and as inflammatory factors that increase cellular risk for HIV co-transmission. However, there have been no prospective studies of interventions addressing the specific behavioral and biological risk factors associated with rectal STI transmission or the potential impact on HIV transmission risk of integrating rectal GC/CT screening with other prevention services. We will use nucleic acid testing to screen 750 behaviorally high-risk MSM for rectal gonorrheal and/or chlamydial (GC/CT) infection. GC/CT-positive subjects will receive single-dose antibiotic treatment and either single-session Personal Cognitive Counseling (PCC) (n=50) or standard post-test counseling (n=50). A GC/CT-negative control group (n=50) will also be enrolled to compare biological outcomes including changes in levels of inflammatory cytokines following rectal STI. Aim 1: To adapt a Personalized Cognitive Counseling (PCC) model for use with MSM in Peru. Aim 2: To adapt and pre-test the SJEI and behavioral assessment instruments for use with MSM in Peru. Aim 3: To pilot a combined HIV prevention intervention based on rectal STI counseling, testing, and treatment for MSM in Peru. Estimates of feasibility/acceptability of the intervention, GC/CT prevalence/re-infection rate and the effect on behavioral and biological mediators of HIV infection will be used to plan an R01 evaluation of rectal STI surveillance as HIV prevention for MSM in Peru.

Project Number: 5R01MH105272-03

Transprep: Social Network-Based PreP Adherence for Transgender Women in Peru

Abstract: The effectiveness of Pre-Exposure Prophylaxis (PrEP) for reducing HIV transmission is strongly dependent on adherence, which is influenced by individual, social, and structural factors. We propose a social network-based intervention to promote PrEP adherence among transgender women (TW) in Lima, Peru: 1) Formative research. To optimize content for a PrEP adherence intervention, we will conduct semi- structured interviews and focus groups. Results will be used to refine the PrEP adherence intervention. 2) To conduct an open evaluation of a social network-based PrEP adherence intervention for TW in Peru. The intervention model will be piloted with a small group of 5-10 TW. Data will be used to finalize the study design and assessment tools for a pilot randomized controlled trial (RCT). 3) To conduct a pilot RCT of a social network-based PrEP adherence intervention for TW in Peru. We plan to randomize 8 social network-based clusters of TW that to either a network-based PrEP adherence intervention or standardized PrEP adherence counseling. The primary outcome will be PrEP adherence. The intervention will use a combination of individual counseling, group workshops, social media-based network interactions, and practical support tools to promote PrEP adherence among TW. Individual Counseling: Participants will complete two biweekly counseling sessions addressing PrEP use and HIV prevention. The goals of individual counseling are to introduce PrEP as an HIV prevention tool and address basic issues of PrEP adherence as part of a comprehensive HIV prevention strategy. Group Workshops. Group workshops will establish a common understanding of PrEP as a central component of comprehensive HIV prevention, address the importance of PrEP adherence, develop practical strategies to support adherence, and generate and maintain norms of HIV prevention and PrEP adherence within the peer group. Biweekly maintenance meetings will address ongoing issues related to PrEP use and adherence. Social Network Interactions. The social network component of the intervention will include structured social media platforms to educate, motivate, and promote discussions of PrEP adherence within the participant network, unstructured participant-generated interactions to articulate and reinforce newly developed social norms within the network, and practical tools to support daily adherence. PrEP Use. Participants will be provided with daily Truvada for the 6-month study period. Assessment Procedures, Timing and Measures. There will be three major assessment points: baseline, short-term outcome (3 month), and long-term outcome (6 month). The primary outcome of the intervention will be a comparison of PrEP adherence in the intervention and control groups. Findings will be used to support an NIH-funded R01 proposal using social networks of TW and social media technologies to generate, implement, and reinforce new social norms of PrEP adherence, sexual risk behavior, and HIV prevention.

 

Project Number: 5R34MH104072-03

https://reporter.nih.gov/search/clOmBeNL3EiQvAvH8MjhLQ/project-details/9119194

 

 

Contact PI/ Project Leader

CLARK, JESSE LAWTON, ASSISTANT PROFESSOR-IN-RESIDENCE (jlclark@mednet.ucla.edu)

 

 

Organization

UNIVERSITY OF CALIFORNIA LOS ANGELES

 

 

PUBLIC HEALTH RELEVANCE: Pre-exposure prophylaxis (PrEP) is an important new tool for HIV prevention, but is highly dependent on patient adherence. Our study the uses social networks of transgender women in Peru as a framework to promote PrEP adherence in socially marginalized communities at high risk for HIV infection.

 

FOA: PAR-11-278/ Study Section:ZMH1-ERB-M(02)

 

Project Start Date: 01-August-2014

Project End Date: 31-July-2018

Budget Start Date: 01-August-2016

Budget End Date: 31-July-2018

 

 

NIH Categorical Spending

Funding IC: NATIONAL INSTITUTE OF MENTAL HEALTH / FY Total Cost by IC: $141,615

The Influence of PreP Stigma Among Black and Latino MSM PreP Adopters

Abstract: Pre-Exposure Prophylaxis (PrEP) is a biomedical HIV prevention strategy with the potential to reduce the rate of new HIV infection among black and Latino men who have sex with men (BLMSM), two populations at the center of the U.S. HIV/AIDS epidemic. However, the social stigma currently associated with the use of PrEP (i.e. PrEP stigma) may negatively influence PrEP disclosure, diffusion, adherence and retention among BLMSM who adopt PrEP. The controversy and contention surrounding the implementation of PrEP in the gay community has led to the stigmatization of PrEP and those who use it. PrEP users may experience PrEP stigma in the form of negative perceptions (e.g., being judged, being unfairly treated), stigmatizing attributions (e.g., promiscuous, sexually irresponsible, mistakenly identified as HIV-positive), and stigmatizing practices (e.g., rejection, prejudice, discrimination) from friends, sex partners, providers and others. The goals of this study are to explore the nature and extent of PrEP stigma among BLMSM who have adopted PrEP and to assess its influence on PrEP disclosure, adherence and retention, and the diffusion of PrEP information to other potential BLMSM PrEP consumers. The specific aims of this study are: 1) to examine how BLMSM PrEP adopters experience PrEP stigma (e.g., anticipated, internalized, enacted); 2) to assess the extent and context of PrEP disclosure and dissemination of PrEP information by BLMSM PrEP users to other potential BLMSM PrEP consumers; and 3) to examine the influence of PrEP stigma, over time, on adherence and retention to PrEP among BLMSM PrEP adopters. To achieve these aims, this qualitative study will involve conducing in- depth interviews with 50 black (N = 25) and Latino (N = 25) MSM PrEP adopters and 20 black (N = 10) and Latino (N = 10) MSM non-PrEP adopters. BLMSM PrEP adopters will complete both a baseline and a 6-month follow-up interview. Follow-up interviews will assess changes in PrEP retention, adherence, disclosure and dissemination. Interviews with BLMSM non-PrEP adopters will elicit information about anticipated PrEP stigma and how this may have influenced decisions to seek or not seek PrEP. Interviews will also be conducted with 20 medical providers to assess their perceptions of PrEP and PrEP stigma and concerns about the implementation of PrEP. The findings from this study will inform the development of intervention activities that seek to prevent or mitigate the negative social experiences associated with PrEP adoption and to optimize diffusion and retention to PrEP among minority MSM.

 

Project Number: 5R21MH107339-02

https://reporter.nih.gov/search/drZGTF3vwkCaElbYrQowKQ/project-details/9266828

 

 

Contact PI/ Project Leader

BROOKS, RONALD ANDREW, ASSISTANT PROFESSOR (rabrooks@mednet.ucla.edu)

 

 

Organization

UNIVERSITY OF CALIFORNIA LOS ANGELES

 

 

PUBLIC HEALTH RELEVANCE: Pre-Exposure Prophylaxis (PrEP) has the potential to reduce the number of new HIV infections among high-risk black and Latino men who have sex with men (BLMSM). However, the stigma attached to the adoption of PrEP may negatively influence PrEP disclosure, diffusion, adherence and retention among BLMSM who adopt PrEP. The findings from this study will inform the development of intervention activities that seeks to prevent or moderate the negative social experiences associated with PrEP adoption and facilitate diffusion, adherence and retention to PrEP among minority MSM.

 

 

Project Start Date:26-April-2016

Project End Date: 31-March-2019

Budget Start Date: 01-April-2017

Budget End Date: 31-March-2019

 

 

NIH Categorical Spending

Funding IC: NATIONAL INSTITUTE OF MENTAL HEALTH / FY Total Cost by IC: $156,526

A Randomized Controlled Trial of an Antiretroviral Treatment Adherence Intervention for HIV+ African Americans

Abstract:  Compared to Whites, Black people living with HIV are less likely to adhere to antiretroviral treatment (ART) and be virally suppressed. Our research has identified culturally relevant factors contributing to disparities among HIV-positive Black Americans, including stigma and medical mistrust (e.g., “conspiracy beliefs,” that ART is poison), in addition to structural and psychosocial factors related to poverty, healthcare access, and mental health. However, ART adherence interventions have rarely been culturally congruent, which may explain why relatively few interventions have shown robust effects on adherence or viral suppression. We propose to conduct a randomized controlled trial (RCT) of Rise, a culturally congruent adherence counseling intervention for HIV-positive Black men and women. Rise counselors possess specialized HIV treatment knowledge and are trained in motivational interviewing (MI) skills to overcome culturally relevant barriers to adherence and retention in care; they also assist with linkage to social services. Rise is ideally implemented in community organizations, enabling clients to seek services in non-medical settings, which helps to overcome mistrust of healthcare, and increase readiness for adherence. In a pilot RCT, Rise led to increased adherence (measured by electronic monitoring) relative to a wait-list control group over time, showing a large effect size (Cohen’s d=.87). However, the pilot did not evaluate effects on viral suppression or include long-term follow-up. Thus, we propose to conduct an RCT of Rise that follows best practices for evidence-based HIV treatment adherence intervention design and testing. The Specific Aims are: (1) To conduct a randomized controlled trial to examine the effects of a culturally congruent adherence intervention on antiretroviral treatment adherence, retention in care, and viral suppression among Black men and women living with HIV; (2) To examine culturally relevant mediators (e.g., medical mistrust, stigma) that may help to explain the effects of the intervention on antiretroviral treatment adherence, retention in care, and viral suppression among Black men and women living with HIV; and (3) To conduct a cost effectiveness analysis of the intervention. A total of 350 Black men and women will be randomly assigned to the intervention or usual care control group (175 per group). Adherence will be electronically monitored daily (and downloaded bi-monthly) from baseline to 12- months post-baseline. Viral load will be assessed through venipuncture at baseline and 6- and 12-months post-baseline. If Rise is found to be effective, the next step would be to conduct research to determine effective and feasible methods for intervention implementation and dissemination to community settings.

 

Project Number: 1R01NR017334-01

https://reporter.nih.gov/search/PdfddKi3BUOnOnbnl4vOTw/project-details/9346334

 

 

Contact PI/ Project Leader

BOGART, LAURA M, SENIOR BEHAVIORAL SCIENTIST (LBOGART@RAND.ORG)

 

 

Organization

RAND CORPORATION

 

 

PUBLIC HEALTH RELEVANCE: Black people living with HIV show lower levels of antiretroviral treatment adherence than do Whites. However, few culturally congruent interventions have been developed and tested. We propose to conduct a randomized controlled trial (RCT) of Rise, an innovative, culturally congruent adherence intervention for HIV-positive Black men and women that targets cultural and structural issues contributing to health disparities. Rise facilitates improved adherence and retention in care through client-centered counseling and assistance with linkage to social services.

 

 

Project Start Date: 01-May-2017

Project End Date:28-February-2022

Budget Start Date:01-May-2017

Budget End Date: 28-February-2018

 

 

NIH Categorical Spending

Funding IC: NATIONAL INSTITUTE OF NURSING RESEARCH/ FY Total Cost by IC:$647,915

Siempre Seguire: A Pilot Intervention to Improve Coping With Discrimination and Adherence Among HIV-Positive Latino MSM

Abstract: HIV-related disparities in diagnosis and disease outcomes persist among Latinos, and Latinos living with HIV show a lower percentage of viral suppression compared to the general HIV-positive population. A growing body of work suggests that stigma and discrimination contribute to health disparities, especially among people living with HIV, who may experience discrimination due to multiple stigmatized identities related to HIV- serostatus, race/ethnicity, and sexual orientation. Internalized stigma and discrimination may lead to health- related disparities by increasing detrimental physiological stress responses, resulting in maladaptive coping and poor health behaviors, including non-adherence to treatment. Moreover, the chronic stress of discrimination may weaken immune function, leading to worse HIV outcomes, including increased HIV viral load. In the proposed research, we will integrate adherence skills-building strategies into a recently developed intervention, Siempre Seguiré, a 7-session group cognitive behavioral therapy (CBT) intervention for HIV- positive Latino men who have sex with men (LMSM) that aims to improve adaptive coping responses to discrimination. In a small pilot of 30 participants, the intervention was associated with improved coping at follow-up as compared to baseline. However, this pilot did not include a control group, did not address or examine HIV-related behaviors and outcomes such as adherence, retention in care, and viral load suppression, and had a very low sample size. Thus, in the proposed research, we will conduct a larger pilot study in which preliminary effects on HIV outcomes can be assessed. The specific aims are: (1) To modify and refine Siempre Seguiré, a newly developed culturally congruent CBT group intervention for HIV-positive LMSM, to include strategies for antiretroviral treatment adherence and retention in HIV care; and (2) To conduct a small randomized pilot of Siempre Seguiré to examine feasibility and acceptability, as well as to explore preliminary effects on: (a) coping responses to discrimination; and (b) antiretroviral treatment adherence, viral load suppression, and HIV care retention, among LMSM living with HIV. In Phase 1, we will work with HIV treatment adherence intervention experts and key stakeholders, including a community advisory board, to refine our pilot intervention as needed and update our manual to integrate information and skills building regarding HIV treatment adherence and retention in care. In Phase 2, we will conduct a small randomized controlled trial of 80 participants (40 intervention participants divided evenly over 4 intervention groups vs. 40 wait-list control participants). To our knowledge, our study will be the first to test an intervention that addresses coping with discrimination from multiple identities. Our proposed research is consistent with the Institute of Medicine report, The Health of Lesbian, Gay, Bisexual, and Transgender People, which recommends developing interventions to address racial disparities and mental health effects of discrimination among sexual minorities.

 

Project Number:  1R34MH113413-01A1

https://reporter.nih.gov/search/NfaaiDsLWUizEGUyXRmd4w/project-details/9407123

 

 

Contact PI/ Project Leader

BOGART, LAURA M, SENIOR BEHAVIORAL SCIENTIST (LBOGART@RAND.ORG)

 

 

Organization

RAND CORPORATION

 

 

PUBLIC HEALTH RELEVANCE:  Latinos in the U.S., especially those who are men who have sex with men, show HIV-related disparities, tending to be diagnosed at a later disease stage, leading to delays in care entry and antiretroviral treatment use, and lower rates of viral suppression. No culturally congruent interventions have been developed to address stress resulting from discrimination, a key contributor to disparities in HIV outcomes among Latino men who have sex with men. We propose to integrate adherence skills-building into a recently developed intervention that addresses coping with discrimination among Latino men who have sex with men.

 

 

Project Start Date:01-August-2017

Project End Date: 31-May-2020

Budget Start Date: 01-August-2017

Budget End Date: 31-May-2018

 

 

NIH Categorical Spending

Funding IC: NATIONAL INSTITUTE OF MENTAL HEALTH/ FY Total Cost by IC: $194,834

A Social Network Analysis of HIV Treatment Partners in Botswana

Abstract: With nearly a fifth of the population living with HIV, Botswana has one of the highest HIV prevalences in the world. Low-cost, scalable interventions are essential to support people living with HIV (PLWH) to adhere to antiretroviral treatment (ART) and remain in care. One such intervention is the use of treatment/adherence partners, which are recommended by HIV treatment guidelines in at least 20 countries world-wide. Specifically, to support adherence and reduce treatment discontinuation, national HIV policies of several countries, including Botswana, recommend that healthcare providers encourage patients initiating ART to identify an individual who can provide support, accompany patients to appointments, and provide reminders for medication. Treatment partners necessarily leverage patients’ social networks, requiring that PLWH select an individual in their social circle to provide social support. Although a large body of work indicates the key role of social support in promoting adherence, research on the effectiveness of treatment partners has shown mixed results. Thus, research is needed to determine the ways in which support from treatment partners can be better harnessed for optimal effects on health outcomes. The proposed research objective is to determine the most effective characteristics of treatment partners from a social network perspective, in order to inform healthcare providers on how to guide PLWH on treatment partner selection. The specific aims are: 1) To conduct a social network analysis of people living with HIV and their treatment partners in Botswana in order to compare retrospectively individual-, dyadic-, and social network-level characteristics that are significantly associated with virologic failure; 2) To qualitatively explore factors related to treatment partner selection, including perceived barriers to and facilitators of selection of effective treatment partners; and 3) To use study results to develop and disseminate messages for healthcare providers to guide people living with HIV about selection of appropriate treatment partners. We will recruit 200 PLWH with treatment partners in Botswana, selected such that half show virologic failure and half show virologic suppression. We will conduct social network assessments of PLWH and their treatment partners and gather qualitative data describing their social networks in order to examine the extent to which individual, dyadic, and social network factors related to treatment partners differ between groups. We will present the results to members of the Committee for the Clinical Care of TB and HIV/AIDS in Botswana, which develops the National HIV and AIDS Treatment Guidelines for the Botswana Department of HIV/AIDS Prevention and Care in the Botswana Ministry of Health. The proposed research presents a unique opportunity to examine ways to improve use of ART in practice, a topic of critical importance to the field.

 

Project Number: 7R01MD006058-06

https://reporter.nih.gov/search/m7ce9xL-70OQ0Y0FbaqRUQ/project-details/9205955

 

 

Contact PI/ Project Leader

BOGART, LAURA M, SENIOR BEHAVIORAL SCIENTIST (LBOGART@RAND.ORG)

 

 

Organization

RAND CORPORATION

 

 

PUBLIC HEALTH RELEVANCE: African Americans with HIV have lower levels of engagement in care and treatment adherence than do Whites with HIV, and the predictors of these behaviors differ by race/ethnicity; however, few culturally relevant interventions have been tested. We propose to conduct a randomized controlled trial (RCT) of an innovative, culturally relevant treatment advocacy (TA) intervention for African Americans with HIV that targets cultural and social issues contributing to health disparities. TA, which has been sustained in communities throughout the HIV epidemic but never been rigorously tested, facilitates medical system navigation and adherence through client-centered counseling and education; advocacy to providers; and referrals for social services.

 

FOA: RFA-MD-11-001/ Study Section: ZMD1-MLS(01)R

 

Project Start Date: 01-May-2011

Project End Date:31-December-2017

Budget Start Date:27-January-2016

Budget End Date: 31-December-2017

 

 

NIH Categorical Spending

Funding IC: NATIONAL INSTITUTE ON MINORITY HEALTH AND HEALTH DISPARITIES/ FY Total Cost by IC: $137,315

Treatment Advocacy Intervention for HIV-Positive African Americans

Abstract: Compared to other races/ethnicities, African Americans with HIV have lower levels of engagement in care, are less likely to be on antiretroviral treatment (ART), and are more likely to delay care and ART initiation; those on ART are less likely to be adherent at high enough levels for the treatment to be effective. We propose to test an innovative, culturally relevant treatment advocacy (TA) intervention for African Americans with HIV that targets social and cultural issues contributing to poor HIV treatment behaviors. TA, which has been sustained in many community organizations throughout the HIV epidemic, has never been systematically evaluated. TA facilitates patient navigation through the medical system and provides tailored HIV treatment education and client-centered counseling to improve adherence and engagement in care. TA targets social and contextual issues in healthcare and patients’ lives by advocating to providers to improve patient-provider relationships, recommending changes in treatment and/or providers (if needed), and referring patients to mental health and social services. TA is particularly appropriate for African Americans with HIV, who may be mistrustful of providers: it can be conducted outside of the medical system in a safe, neutral community setting by individuals not associated with patients’ healthcare. We developed a culturally relevant TA program that additionally discusses factors such as racism that undermine healthcare in Black communities, by acknowledging and directly addressing patients’ medical mistrust and stigma as coping strategies that arise in response to oppression. The specific aims are to (1) conduct a randomized controlled trial to examine the effects of a culturally relevant TA program on adherence among African Americans with HIV; (2) identify culturally relevant mediators that explain the effects of treatment advocacy on antiretroviral treatment adherence among African Americans with HIV (e.g., improved behavioral adherence skills, coping with stress/discrimination, mental health, and patient satisfaction; lower levels of HIV misconceptions, internalized HIV stigma/homophobia, medical mistrust, and substance use); and (3) explore culturally relevant moderators of the effects of treatment advocacy on antiretroviral treatment adherence among African Americans with HIV (e.g., discrimination, incarceration, poverty, social support, spirituality, trauma). A sample of 200 African Americans with HIV will be randomly assigned to a TA intervention or wait-list control group. Participants will complete surveys at screening, and at 3- and 6-months post-baseline, to assess pre-, intra-, and post- intervention effects on adherence.

 

Project Number: 5R01MD006058-05

https://reporter.nih.gov/search/q8ZzR_6Fe0KCXZ41Ef3fWw/project-details/8785040

 

 

Contact PI/ Project Leader

BOGART, LAURA M, SENIOR BEHAVIORAL SCIENTIST (LBOGART@RAND.ORG)

 

 

Organization

BOSTON CHILDREN’S HOSPITAL

 

 

PUBLIC HEALTH RELEVANCE: African Americans with HIV have lower levels of engagement in care and treatment adherence than do Whites with HIV, and the predictors of these behaviors differ by race/ethnicity; however, few culturally relevant interventions have been tested. We propose to conduct a randomized controlled trial (RCT) of an innovative, culturally relevant treatment advocacy (TA) intervention for African Americans with HIV that targets cultural and social issues contributing to health disparities. TA, which has been sustained in communities throughout the HIV epidemic but never been rigorously tested, facilitates medical system navigation and adherence through client-centered counseling and education; advocacy to providers; and referrals for social services.

 

FOA: RFA-MD-11-001/ Study Section: ZMD1-MLS(01)R

 

Project Start Date: 01-May-2011

Project End Date: 01-January-2016

Budget Start Date: 01-January-2015

Budget End Date: 01-January-2016

 

 

NIH Categorical Spending

Funding IC: NATIONAL INSTITUTE ON MINORITY HEALTH AND HEALTH DISPARITIES/ FY Total Cost by IC: $280,511

Structural Pathways for South African Men to Reduce Substance Abuse and HIV

Young men aged 18-25 years in South Africa face the intersecting epidemics of HIV, alcohol and drug abuse, and unemployment. This R34 is designed to reduce young men’s risk by addressing three problems with existing evidence-based programs (EBP): interventions are not designed considering men’s fight-flight coping strategy; donors are unwilling to invest in substance abusing men; and existing job training does not consider young men’s poor habits. Our goal is to apply behavioral economists’ strategies to new delivery formats that are highly attractive to young men: soccer and job training. A neighborhood-level HIV prevention strategy will shape men’s positive daily routines at an organized soccer league: being on time, completing practice, arriving sober & drug free, showing sportsmanship, and being nonviolent. Employment training by artisan trainers/mentors will be contingently offered to young men who demonstrate positive habits-of-daily-living on 80% of days over two months. Young township men in two neighborhoods will be randomized to receive the intervention that includes soccer, job training, and contingency management to shape behaviors (N=1 neighborhood; n=60 males) or to receive the control condition of soccer and job training without contingency management (n=1 neighborhood; 60 males).

Assessments will be at baseline and 6 months follow-up. We hypothesize the program will significantly reduce HIV-related sexual risk acts and substance abuse, and sustain more employment. We will evaluate life goals, consistency of daily routines pro-social acts, & family relationships. We will primarily evaluate intervention feasibility and uptake, and preliminarily evaluate intervention impacts and mediating factors for reducing HIV risk acts & substance use. We will also document stakeholders’ perceptions of the program’s challenges and successes via Key informant interviews, the number of young men in shebeens over time via observations, and the key features of the social movement strategies of the Sonke Gender Justice, a men’s advocacy movement.

HIV prevention efforts for young people in Sub-Saharan Africa have largely been unsuccessful: novel, structural, community level programs that address the social determinants of HIV are needed (Fenton, 2010; NIAID, 2010; Gupta et al., 2008). In particular, young South African men face many barriers, relative to women, to access and utilize HIV prevention programs, including that:

  • Young men are more likely to have concurrent sexual partners, abuse multiple substances, drop-outof school, and be unemployed, compared to women, creating greater challenges for behavior change(Kalichman et al., 2009; Wechsberg et al., 2008).
  • Many donor agencies are only willing to invest in women (Pronyk et al., 2007; Yunus, 2003). Men havegreater interpersonal power, are considered to be substance abusers who squander money and unreliable employees, making interventions difficult (Khandker, 2005; Wong et al., 2008).
  •  Existing prevention programs are more consistent with women’s coping styles “to tend and befriend” (Taylor, 2002). Men’s coping style of fight-flight (Tyrell, 2002) is less compatible with HIV’s current arsenal of evidence-based interventions (EBI) and microfinance program support groups (Kuhanen, 2009). Men are unlikely to attend stigmatized counseling sessions, typical of EBI (Peterson, 2007).
  • The existing R3 billion spent on government job training programs in South Africa (i.e., SETA) deliver didactic lessons. Fewer than 0.9% get on-the-job training or graduate (Bennel & Segrestom, 1998; Akojee & McGrath, 2007; Ziderman, 2003). High demand for relatively low skilled labor is filled by immigrants from neighboring African countries, rather than South Africans, leading to high unemployment and civil unrest.

This R34 aims to design a structural, community-level intervention to sustain self-protective acts among young, South African men aged 18-25 years. A two-pronged intervention is planned to acquire skills-of-daily- living (through soccer) and job skills (through artisan apprenticeships). Over two years, we will demonstrate the feasibility, acceptability, and uptake of the intervention components and outcome measures. We aim to shift four behaviors of young men: to increase consistent habits-of-daily-living, provide job skills and to decrease substance use and HIV-related sexual risk. Young men will be invited to play soccer daily, with contingency management in one neighborhood and not in another neighborhood.  If youth are adherent to the program, they will be offered on-the-job-training and receive artisan tools at graduation.

We will proceed in two phases:

In Phase 1, qualitative interviews will elicit information on men’s developmental pathways. Sonke Gender Justice, a South African NGO advocating for men’s mobilization for gender equity and respect for women, will recruit and train coaches for a daily soccer program and Artisans to deliver a job training program. While soccer is intrinsically rewarding, this pilot will evaluate whether a strategy of behavioral economists (i.e., contingency management) is needed to ensure high program uptake to shape four daily routines: showing up on time, sober & drug free, completing practice, and showing sportsmanship. Coaches will not be counselors or provided with specific scripts, but will be trained in the Street Smart EBI to learn the core intervention tools to problem solve challenges of daily living; create opportunities to dramatically demonstrate key health principles; to form solid bonds with young men; and to be knowledgeable about health risks and community resources. The artisan trainers will be local entrepreneurs making an income, who will receive training and support on how to mentor youth. Artisans will be supported to shape youth’s job behaviors, similar to our successful Uganda program (Rotheram-Borus et al., 2010; Lightfoot et al., 2009).

In Phase 2, a quasi-experimental design with two neighborhoods will be implemented. Neighborhoods have been matched on size, type and quality of housing, number of shebeens (bars), and length of residence. All young men aged 18-25 years in each neighborhood will be recruited to participate in a baseline interview (n=60/neighborhood). One neighborhood will be randomized to the Contingency Management Condition (CMC; n=60 youth) and one to the Control Condition (CC; N=60 youth) and reassessed at 6 months. Coaches will implement the soccer program in both neighborhoods; youth demonstrating consistent habits at soccer for at least two months will be offered access to four months of artisan training. Stakeholder interviews (n=10 at baseline and end of program in each neighborhood) and observations at local shebeens (n= 2/month @ 5 shebeens per neighborhood) will also be conducted to monitor community-level changes over time.

The specific aims of this project are:

  1. To describe perceived challenges of emerging adulthood among young men; and to document perceptions of the program’s challenges and successes, and the key features of the social movement strategies of the Sonke Gender Justice NGO partner that are associated with men’s successes.
  2. To document the program uptake, adherence, prosocial acts, and substance free days in CM vs no-CM.
  3. To examine if young men in the CM vs. no-CM control condition demonstrate significantly:

a. Fewer HIV-related sexual risk acts, less substance use, and more employment;
b. More positive life goals; consistent, healthy daily routines; & greater social support & prosocial acts.
c. To contrast the number of men in shebeens and clean substance use screens across conditions.

Story of Champions League Player Yolani Benge - Report

Promoting Migrant Health Through HIV Awareness

For some Mexican migrants, the opportunities for receiving HIV-related interventions may be quite limited, especially for migrants who are in transition from one locale to another and who may not have the residential stability oftentimes required by HIV prevention programs.  Such transient populations may benefit from HIV prevention programs provided by individuals with similar backgrounds as theirs who are able to provide HIV-related information in informal one-on-one settings in the migrants’ own environments.  This project seeks to determine whether a peer education intervention with Mexican migrants is just as effective as a provider-based small group HIV prevention lecture as measured by the recipients’ HIV knowledge, HIV-related risk reduction skills, self-efficacy with respect to such skills, and intentions to engage in low-risk practices.

A total of 612 Mexican migrants will be recruited.  Mexican migrants from three migrant shelters in Mexicali will be trained as peer educators of a theory-driven HIV prevention intervention.  Each peer educator will conduct individual educational interventions with other Mexican migrants.  An outcome evaluation will be conducted to determine the extent to which those who received the peer education intervention differed from the recipients of the small group HIV prevention lecture with regards to the areas mentioned above and how both interventions differed from a no-treatment control group.