Implementation Science
Economic Justice Interventions to Address HIV and HIV Syndemic Factors in California (2025)
CHRP awarded approximately $2,000,000 to three investigators testing the impact of interventions that support economic security on HIV outcomes. The studies will each focus on distinct, marginalized groups of people living with HIV including those who have experience with the criminal justice system, transgender women, and people who are experiencing homelessness.
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Project CARE: Californians Access to Resources for Housing and Economic Security to Promote HIV Care
Principal Investigator: Wei-Ti Chen
Budget: $675,000
Start Date: March 1, 2025 End Date: February 28, 2027
Project Abstract: California is facing a homelessness crisis. In LA County alone, the homeless population increased by 9% between 2022 and 2023. A major contributor to homelessness is income insecurity: fluctuating and inadequate income heightens vulnerability to homelessness, particularly in urban areas like LA County where inflation has sharply increased housing and living costs. Often, individuals with unstable and insufficient incomes must make difficult decisions and choose between housing and other essentials like food and transportation.
Homelessness significantly elevates the risk of HIV infection to at least 3 times that of the general population. This increased risk disproportionately affects marginalized groups, including sexual and gender minorities and people of color, who are more likely to face income inequality and homelessness. Additionally, homelessness severely impedes the ability of people living with HIV (PLH) to engage in HIV treatment, with many homeless PLH dropping out of the care continuum, resulting in increased likelihood of unsuccessful viral suppression and higher mortality rates. Economic insecurity and homelessness force PLH into survival mode, where daily needs like housing, food, and transportation take precedence, leaving out resources for managing health.
Integrating housing services with universal basic income (UBI) is emerging as a promising approach for mitigating the adverse effects of homelessness and income insecurity on care engagement among PLH. However, most current research examines the impacts of housing services or UBI separately, leaving a notable gap in our understanding of their combined effects. To address this gap, the aim of this study is to pilot test an economic intervention for its acceptability, appropriateness, feasibility, and preliminary efficacy in promoting healthcare engagement among 24 PLH experiencing housing instability in the LA metropolitan area. This intervention will consist of UBI, housing services, and the combination of UBI and housing service, allowing for a more accurate evaluation of their implementation outcomes and impacts on health care engagement, both as individual components and in combination. Comparative studies to better understand the potential synergies of these interventions in promoting care engagement among Californian PLH with housing instability are urgently needed.
Trans Wealth: An Economic Justice Intervention for Trans and Nonbinary Persons with HIV
Principal Investigator: Erik Storholm
Budget: $591,351
Start Date: March 1, 2025 End Date: February 28, 2027
Project Abstract: Economic marginalization significantly impacts racially and ethnically diverse transgender and nonbinary (TGNB) individuals in the Ending the HIV Epidemic (EHE) priority region of Los Angeles County (LAC), leading to high levels of housing insecurity, homelessness, and poverty. Poverty is a fundamental driver of elevated HIV prevalence, poor HIV care engagement, lower viral suppression, and syndemic conditions such as violence and mental health burdens. TGNB individuals are more likely to engage in criminalized sex work, increasing risk for both violence and adverse HIV outcomes. Preliminary findings from our work with TGNB persons in LAC reveal significant economic and structural barriers to HIV care engagement and viral suppression such as transportation difficulties, employment and housing insecurity, undocumented immigration status, and stigma in employment and healthcare settings. Overall, there is an urgent need for innovative economic justice interventions that support care for HIV and related syndemic conditions among diverse TGNB populations in LAC. Leveraging a 7-year partnership between the Los Angeles LGBT Center’s Trans Wellness Center (TWC) and local researchers, we propose to develop and rigorously pilot-test Trans Wealth, a guaranteed income (GI) intervention for TGNB persons affected by HIV and poverty. We will enroll 30 TGNB individuals who are living with HIV, experiencing poverty and/or homelessness, and virally unsuppressed. Volunteers will either receive 6 monthly payments of $1,000 or a one lump sum payment of $6000, combined with supportive programming from the TWC’s Transgender Economic Empowerment Program to set goals, gain financial literacy, engage in educational and/or employment planning, and legal services. GI interventions have shown evidence of producing positive health and financial outcomes. We will use community-engaged implementation science frameworks to guide the development and delivery of Trans Wealth. Quantitative measures will include biospecimen collection (viral load, CD4 cell count), and assessments of mental health, quality of life, and violence exposure at baseline, 2, 4 and 6-month follow up visits. We will gather qualitative feedback from participants, staff, and community advisory board members to gather data on the acceptability, appropriateness, safety, and feasibility of the Trans Wealth intervention.
Guaranteed Income to Boost HIV Care Continuity and Suppression Post-Jail Release
Principal Investigator: Paul Wesson
Budget: $576,840
Start Date: March 1, 2025 End Date: February 28, 2027
Project Abstract: One-in-seven people living with HIV (PWH) experience incarceration annually. HIV prevalence among those with criminal legal involvement (CLI) is 3x higher than the general population. Upon release, PWH-CLI encounter competing priorities and structural barriers to addressing unmet basic needs, resulting in suboptimal care cascade outcomes. Guaranteed income (GI) through unconditional cash transfers can improve mental health, meet basic needs, and boost employment prospects. However, its effects on PWH-CLI, who face unique post-release challenges affecting HIV treatment retention and viral suppression, remain uncharacterized.
Our three-arm pilot study will assess the feasibility, acceptability, implementation requirements, and preliminary efficacy of a GI intervention to improve HIV care in PWH-CLI released from the San Francisco County (SFC) jail. We will randomize 39 very low-income patients (income <30% of area median income) discharged to a SFDPH network HIV clinic, to 1 of 3 arms: A) one lump-sum payment of $6,750; B) 9-monthly installments of $750; or C) “preference” (patient chooses either A or B). We will offer up to 4 opt-in financial mentoring (FM) sessions during the pilot to bolster GI impacts. Clinical appointment and viral load outcome data will be collected from medical records. All patients will complete quantitative surveys (1 baseline, 2 follow-up) to assess GI experience, patient context, and acceptability. Baseline and endline qualitative interviews with patients (n=12; 4/arm) will explore the GI experience, impacts on HIV treatment, and critical implementation questions to inform future research and policy. Qualitative interviews with system partners (n=10) will explore community perceptions of GI and opportunities to integrate GI in HIV programming and policy.
Given PWH-CLI’s economic and social marginalization, we will leverage our existing retrospective cohort of PWH-CLI released from SFC jail (n~700 patients; 2018-2022) as historical controls to test preliminary efficacy against pilot participants – comparing clinical appointments and viral load – instead of utilizing a concurrent no-GI control group. Variation in GI disbursement will provide needed data on acceptability and preliminary efficacy of distribution modes and the role of patient agency in pilot outcomes and overall engagement – filling a critical gap in the GI literature.
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Low Barrier Technology Interventions for HIV Prevention and Care (2025)
CHRP invested over $1,000,000 in eleven innovative projects that will explore the feasibility of developing and/or implementing technology-based interventions to improve equitable access to HIV prevention and care. The studies will reach highly marginalized populations and health care deserts in Riverside, San Diego, Orange, Humboldt, Lake and Mendocino Counties and beyond with interventions including public health vending machines, mobile health and improved service delivery using novel approaches including artificial intelligence and large language modeling.
Low Barrier Technology Mobile HIV Primary Care for People Who Use Drugs
Principal Investigator: Laura Bamford
Budget: $108,000
Start Date: March 1, 2025 End Date: February 28, 2026
Project Abstract: The overarching goal of this project is to increase retention in care in people who use drugs with HIV in San Diego Conty through low barrier technology mobile HIV primary care. Individuals who report injection drug use as their HIV transmission risk factor have the lowest rates of viral suppression of all demographic groups in San Diego. Further, individuals with HIV who use methamphetamine in San Diego have lower retention in care and HIV viral suppression rates compared to individuals with HIV who do not use methamphetamine. Traditional HIV care models that require patients to secure transportation, schedule appointments, and navigate burdensome administrative processes are especially challenging for people who use drugs. Novel implementation strategies, including low barrier technology mobile HIV primary care services that transcend traditional care models, are necessary to better engage this population in HIV primary care. The University of California, San Diego (UCSD) Owen Clinic which is the largest and most comprehensive HIV Medicine Clinic in San Diego aims to establish and evaluate low barrier technology mobile HIV primary care services in close collaboration with the County of San Diego Harm Reduction Services Program. We propose parking a UCSD mobile unit adjacent to the newly established County of San Diego Harm Reduction Services Program with the goal of increasing engagement in HIV primary care in people who use drugs. This project will support the establishment of key infrastructure (telehealth, electronic storage lockers with keypads for participant medication and substance use equipment storage, and vein finding equipment for phlebotomy in people who inject drugs) trained personnel, and data recording systems to enable the implementation and evaluation of low barrier technology mobile HIV primary care to address the ongoing HIV public health crisis and work toward ending the HIV epidemic in San Diego. The implementation of the ‘Owen Low Barrier Care Mobile HIV Clinic’ will leverage the community collaboration with the County of San Diego and evidence-based low barrier mobile HIV primary care treatment and technology strategies to strive to overcome the multiple socio-structural barriers to HIV primary care faced by people who use drugs in San Diego.
Expanding the Reach of HIV Prevention and Care through Harm Reduction Vending Machines
Principal Investigator: Angela Bazzi
Budget: $123,000
Start Date: March 1, 2025 End Date: February 28, 2026
Project Abstract: With ongoing opioid and polysubstance use crises in California and nationwide, HIV transmission has increased among people who use and inject drugs (hereafter, PWUD). HIV testing is a critical entry point into the HIV prevention and care cascades, yet stigma and additional multilevel barriers limit access to facility-based HIV testing for PWUD. Even within syringe services programs (SSPs), competing priorities and resource constraints challenge the consistent provision of HIV testing. Harm reduction vending machines (HRVMs) are a promising approach for extending SSPs’ delivery of a range of HIV prevention supplies to PWUD, including syringes and other sterile drug use equipment, condoms, and HIV self-test kits. However, despite several decades of successful HRVM implementation internationally, this low-barrier technology has only recently gained traction among U.S. harm reduction programs, and important knowledge gaps persist regarding acceptability, feasibility, and factors that support equitable reach for HIV prevention, including among racially and ethnically diverse and unhoused PWUD. Furthermore, the acceptability of specific innovations in HRVM technology (e.g., biometric identification, data collection systems, telehealth capabilities) remain understudied among PWUD. Our research partner, DAP Health, operates one HRVM in downtown Palm Springs, CA, and hopes to expand to additional locations (e.g., public spaces) to better reach diverse communities (e.g., unhoused, rural, and tribal) across the medically-underserved Ending the HIV Epidemic (EHE) priority jurisdictions of Riverside and San Bernadino Counties. Leveraging our ongoing research partnership (between DAP Health, UC San Diego, and San Diego State University; NIH grant R34DA058389), we will purchase another HRVM and conduct a one-year study comparing locations and investigating implementation barriers, facilitators, and optimal strategies to help equitably and sustainably expand the reach of DAP Health’s HRVMs. By engaging a diverse range of implementation partners, including PWUD, harm reduction specialists, HIV service providers, community organizers, health department representatives, and policymakers, findings will directly inform efforts to expand HRVM implementation as a promising low-barrier technology for addressing HIV prevention and care in this region and beyond.
SIHLEapp: Modernizing HIV Prevention for Black Adolescent Girls with Mobile Technology
Principal Investigator: Brittany Bryant
Budget: $108,000
Start Date: March 1, 2025 End Date: February 28, 2026
Project Abstract: California’s Ending the Epidemic Strategic Plan identifies Black adolescent girls as disproportionately affected by HIV and STIs, with Black adolescents representing 51% of HIV diagnoses among U.S. adolescents aged 13-19 in 2020. Given the high rates of chlamydia, gonorrhea, and syphilis among Black girls, there is an urgent need for accessible, culturally tailored prevention interventions. The SIHLE (Sisters Informing, Healing, Living, and Empowering) intervention has proven effective in reducing HIV-related sexual risk behaviors through culturally relevant programming. Originally adapted to a web-based format (SIHLEweb) in 2013, further modernization is required to align with current technological trends, particularly mobile health solutions. Our overarching research goal is to design and test the effectiveness of a culturally tailored HIV prevention intervention mobile app for young Black girls (SIHLEapp) using the IDEAS Framework. As a preliminary step towards this goal, our aims for the current research study are to 1) explore preferred adaptation and implementation options of SIHLEapp through qualitative interviews with Black girls aged 13-18; and 2) explore potential targets for modernization of the SIHLE intervention through qualitative interviews with key stakeholders, including Black mothers or maternal figures and sexual health providers.
Findings will guide the development of SIHLEapp and support future funding applications to CHRP or NIH.
Spatial optimization of dynamic low barrier HIV interventions for housing insecure SMM in LA
Principal Investigator: Susan Cassels
Budget: $94,435
Start Date: March 1, 2025 End Date: February 28, 2026
Project Abstract: This proposal aims to address the ongoing HIV epidemic among sexual minority men (SMM) who are experiencing housing insecurity in Los Angeles (LA) by 1) collating the current access to low barrier spatially-variable HIV prevention and care, 2) mapping geographic prevention and care deserts in LA county, and 3) conducting a rapid needs assessment so that the most accurate and beneficial low barrier technologies can be strategically placed across the county.
Spatial approaches to improving health of minoritized populations is critical since geographic access can pose significant barriers to uptake of interventions. Given the vast geography of the LA county region, it is imperative to better understand how different technologies will work in differing areas so that relevant needs are addressed adequately. Preliminary research by the PI has identified unique geo-spatial patterns that suggest different low barrier technologies will be relevant in different areas based on social behaviors (e.g., where PLWH experiencing homelessness sleep, where SMM engage in sexual encounters, and where SMM engage in substance use, etc.). Low-barrier HIV prevention and care must be geographically and temporally-specific, in order to maximize efficacy.
Low barrier technologies for HIV prevention and care are especially important for people who are insecurity housed. Sexual minority populations experience housing insecurity at rates higher than heterosexual populations, especially SMM of color. Housing insecurity is predictive of poor self-rated health among SMM (5), poor mental health, and poor HIV-related outcomes. The mechanisms that link housing insecurity to poor HIV outcomes include delayed, reduced or postponed health care or medications, higher rates of mental health disorders, substance use, and poor adherence to antiretroviral treatment. However, geographically responsive HIV treatment and care services, including mobile HIV testing vans or street-based PrEP outreach that meets people where they need services, can improve HIV-related outcomes.
Software for Precision HIV Therapy: Leveraging Genomics for Enhanced Drug Resistance Prediction
Principal Investigator: Indrani Choudhuri
Budget: $143,000
Start Date: March 1, 2025 End Date: February 28, 2026
Project Abstract: The advent of antiretroviral therapy (ART) has substantially improved the management of HIV/AIDS, yielding greater viral suppression, transmission prevention, and improved health outcomes for patients. However, drug resistance, including to the latest generation ART, is becoming a more pervasive clinical problem. Because resistant viruses typically replicate less efficiently than non-resistant viruses, whether a drug-resistant mutation (DRM) persists in the viral population depends on the intricate tradeoff between resistance and fitness. Here, we note one important and novel consideration. The occurrence and effect of DRMs in response to ART are strongly dependent on the specific genetic sequence background in which the mutation occurs. Previously, we showed that the fitness effect of primary DRMs can vary widely within and between patient populations due to epistatic interactions of the DRM with the sequence background of the virus. Accordingly, laboratory-derived molecular HIV clones, such as NL4-3, HxB2, or LAI IIIB, often fail to accurately reflect the complex genetic backgrounds of patient-derived viral sequences. Unfortunately, current methods for evaluating fitness effects of patient-derived DRMs rely on these same laboratory-derived molecular viral clones. To address this discrepancy, we propose to develop a novel machine-learning-based lightweight and ready-to-use software to predict the differential effects of DRMs premised on individual patient sequence backgrounds. The proposed software will leverage comprehensive HIV sequence data from patients in the Stanford and Los Alamos HIV databases to predict the fitness effects of DRMs in various patient-derived sequences. We aim to provide an accurate, easy-to-use, and reliable tool that can be developed as an application for clinicians for the potential assessment of drug resistance in patients, thus facilitating the development of tailored treatment strategies, including but not limited to the prescription of better combination regimens. This tool would represent a significant advance in bridging the gap between laboratory-based predictions and real-world patient scenarios. Its implementation could make costly DRM testing alternatives available to underserved communities, optimize treatment efficacy in diverse patient populations, and yield more effective personalized treatment strategies for HIV.
Low-Barrier Access to HIV Prevention and Harm Reduction for Tribal Communities
Principal Investigator: Tommi Gaines
Budget: $129,440
Start Date: March 1, 2025 End Date: February 28, 2026
Project Abstract: While substantial progress has been made in preventing and treating HIV, American Indians and Alaska Natives (AI/AN) continue to be overlooked. From 2018 to 2022, the rate of new HIV diagnoses remained stable or decreased for most racial/ethnic groups in the United States except for AI/AN who experienced a 30% increase in new diagnoses. Approximately 20% of AI/AN living with HIV are unaware of their infection status compared to 13% of the general US population living with an undiagnosed infection. Adding to the HIV burden is the disproportionate rate of sexually transmitted infections. Compared to other racial/ethnic groups, AI/AN have the highest rate of syphilis and the second highest rate of chlamydia and gonorrhea, indicating sexual practices that could heighten HIV vulnerabilities.
To advance health equity in HIV prevention and treatment, our academic team partnered with a Southern California Tribe. We examined the feasibility of integrating HIV self-testing within their tribal wellness program. We found that most community members preferred home-based testing over clinic-based options, with nearly half interested in obtaining self-test kits through the tribal wellness program. Recently, we launched a new collaboration to evaluate a public health vending machine (PHVM) that freely dispenses naloxone and fentanyl testing strips on the Tribe. In its first year, the PHVM has been utilized over 100 times, indicating strong community engagement and the potential to expand its utility. We will build upon this collaboration by examining the appropriateness and feasibility of offering low-barrier access to HIV prevention and other harm reduction resources through an interactive touchscreen vending machine. In contrast to the PHVM currently installed on the Tribe, the touchscreen vending machine will be able to provide on-demand training, offer resources for continuum of care, provide referrals, and collect non-identifying data. The resources, training and materials can be updated on demand to keep up with the latest information available. In addition, a touchscreen vending machine is video capable and can hold telehealth appointments.
Machine learning to enhance data-to-care initiatives
Principal Investigator: Thomas Martin
Budget: $108,000
Start Date: March 1, 2025 End Date: February 28, 2026
Project Abstract: Over 40% of people with diagnosed HIV (PWH) in San Diego County have unsuppressed viral load (VL) putting them at risk of the complications of HIV and transmission of HIV to others. Strategies to improve the identification of PWH who are out of care could lead to improved resource allocation and provision of preventive services.
Existing strategies to identify PWH who are out of care include ‘data-to-care’ programs that use data reported routinely to public health. Typical algorithms prioritize PWH with no HIV VL or CD4 T-cell measurement in the prior 12 months. However, this strategy identifies many PWH that have moved, receive care at a non-reporting institution, are incarcerated, or are deceased. It is also retrospective in nature and results in delays in outreach or difficulty contacting individuals. This leads to inefficient use of public health resources.
Machine learning (ML) algorithms incorporate multi-dimensional data with the ability to not only find pertinent associations but to also make predictions of future outcomes. Preliminary work by our group indicates that applying ML to county HIV data can provide prediction of which PWH are likely to fall out of care, defined by future unsuppressed VL. Our work incorporates novel HIV testing pattern variables such as frequency of VL tests, variance in test intervals, VL trends, and VL blips in addition to traditional risk factors. In our preliminary work, the ML algorithm has a positive predictive value over 60% meaning that for over half the identified PWH, their next VL will be unsuppressed indicating they are either out of care or poorly engagement with care.
We propose to develop our ML tool comparing different statistical approaches and to evaluate which provides the best predictive power. We will develop the novel variables used to optimize variable selection to capture details of VL testing such as blips, variability in testing intervals, and testing frequency. Finally, we propose to compare the performance of traditional ‘data-to-care’ algorithms with ML algorithms for the identification of PWH who are out of care.
By developing ML, we aim to improve public health identification of PWH who are at risk of falling out of care. With improved identification, we will provide the groundwork for novel, timely, intensive, and multi-modal interventions to improve care for PWH in California.
Exploring the Feasibility & Acceptability of Harm Reduction Vending Machines in Orange County, CA
Principal Investigator: Stephanie Myers-Pantele
Budget: $100,000
Start Date: March 1, 2025 End Date: February 28, 2026
Project Abstract: California continues to have co-occurring opioid-related overdose and infectious disease transmission (e.g., HIV and Hepatitis C [HCV]) epidemics. State-level data indicate there were substantial increases (33.2%) in opioid-related overdose deaths between 2020-2021,1 and that people who inject drugs (PWID) comprise 5% and 68% of new HIV and HCV diagnoses, respectively. Orange County, an Ending the HIV Epidemic (EHE) priority jurisdiction, has notably seen a 13.3% increase in the number of HIV cases among PWID between 2013 and 2022 despite seeing significant decreases among other exposure categories (e.g., men who have sex with men and heterosexual contact). Research also suggests that PWID experience numerous social and structural barriers to healthcare (e.g., stigma, homelessness, transportation challenges) that limit their ability to engage in HIV and overdose prevention services. Compounding these barriers further, Orange County’s political climate has been hostile towards state-approved, evidence-based harm reduction strategies for people who use drugs (PWUD; e.g., syringe service programs). As such, there is a critical need for novel HIV prevention and other harm reduction efforts to improve health outcomes for PWUD in this region. In response, the proposed research seeks to explore the feasibility and acceptability of harm reduction vending machines (HRVMs) among PWUD and relevant service providers, law enforcement, and community members in Orange County, California. HRVMs are innovative, low-barrier, technology-based options that expand access to supplies and engage harder to reach populations, by dispensing harm reduction materials such as syringes, naloxone, fentanyl test strips, condoms, and HIV, HCV, and STI self-test kits. Guided by the Consolidated Framework for Implementation Research (CFIR), the proposed research will employ qualitative methods to assess the perceived barriers and facilitators to HVRM adoption and implementation, potential HVRM locations, and desired materials via in-depth interviews with ~20-30 PWUD (Aim 1) and via key informant interviews with ~20-30 staff, clinicians, and health care professionals serving PWUD, law enforcement, and community members (Aim 2), in Orange County. This information will be critical for seeking potential funding for a future Hybrid Type I pilot of HVRMs in this context.
Low Barrier Technology Implementation at Safe Sleeping Sites for People Experiencing Homelessness
Principal Investigator: Jennifer Nations
Budget: $100,000
Start Date: March 1, 2025 End Date: February 28, 2026
Project Abstract: Unhoused individuals have poorer HIV health outcomes, perpetuating disparities in California even as the HIV epidemic slows in the state. These findings suggest that current strategies for ending the epidemic, including the use of low-barrier technologies for prevention and treatment, are not reaching unhoused individuals at the same rate they reach those with stable housing. Unhoused individuals face daily challenges to meeting basic needs that make HIV prevention and treatment a last priority. Continual displacement of unsheltered homeless people further disrupts their ability to access care: encampment sweeps lead to the loss of belongings and create literal and relational distance between healthcare providers and clients, both of which can disrupt access to HIV interventions.
Safe sleeping, or sanctioned encampment, sites may minimize the disruption in access to HIV technologies. Such sites provide individuals with a place to sleep without fear of being ticketed, pushed out, or arrested. Safe sleeping sites are low-barrier, meaning that individuals do not need identification to enter and do not need to adhere to sobriety rules (although they cannot use substances on-site). Clients are able to access a range of services, including showers, laundry, food, and medical care. Because safe sleeping provides individuals with a settled location, they may be an important site for mobile health services and the implementation of low barrier technology HIV interventions, including the use of medication adherence phone apps, vending machines for HIV testing kits, or safe boxes for storing belongings.
This study will take place in the City of San Diego. San Diego is one of 50 jurisdictions that account for more than half of all new HIV diagnoses in the U.S. High transmission rates in the city may in part be connected to the high volume of people experiencing homelessness. San Diego opened two safe sleeping sites in October 2023 after the city policymakers banned homeless encampments in public places. This study will engage a partnership between UC San Diego researchers, the City of San Diego, and program providers at the city’s safe sleeping sites. Our project will employ focus groups and individual interviews with providers and clients to determine if safe sleeping sites can overcome the problems inherent in utilizing low barrier technology HIV interventions.
Use of Vending Machines to Deliver Oral Rapid HIV Self-Tests to Veterans: A Pilot Study
Principal Investigator: Tessa Rife-Pennington
Budget: $108,000
Start Date: March 1, 2025 End Date: February 28, 2026
Project Abstract: In 2022, California had the highest prevalence of people living human immunodeficiency virus (HIV) of all states. There were 4,882 new HIV diagnoses, and rates were highest in cisgender men, Black/African American and Latinx individuals, and men who have sex with men (MSM). HIV prevalence is also high among Veterans with history of opioid/alcohol use disorders, hepatitis B/C virus and sexually transmitted infections, and homelessness. HIV testing is essential for early detection and to reduce morbidity, mortality, and costs. Yet in 2020, approximately 12% of people living in California with HIV were unaware of their infection. As of 2023, 50% of Veterans in care had never been tested for HIV.
Barriers to HIV testing include stigma, racism, homophobia, and lack of cultural competence in healthcare settings; lack of knowledge or access; cost and confidentiality concerns; low income, education, or perceived benefit; unemployment; and incarceration. Despite barriers, Veterans often want HIV testing and to know their results. Use of HIV self-tests (HIVST), where a person self-collects an oral fluid sample, tests, and reads the results, is an evidence-based strategy to increase testing uptake and address barriers. Further, distribution via vending machines (VMs) is an innovative, low barrier, technology-based approach demonstrated to increase confidentiality, privacy, and convenience. It is feasible, acceptable, and preferable over in-clinic testing, which facilitates engagement with first-time testers and hard-to-reach individuals, and those with a positive test often seek further testing/treatment.
Most evidence for VM-dispensed HIVSTs is among MSM, in the United Kingdom, Africa, and Los Angeles, California, and in commercial sex venues/public spaces. No studies have examined impacts of Veteran self-administered HIV tests or distribution via VMs. We aim to bridge this gap by evaluating the first VM-dispensed HIVSTs designed for Veterans, located in Northern California, and in healthcare and supportive housing settings. We will collect Veteran self-report data via electronic surveys and HIVST distribution data via software from 15 VMs to evaluate Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM). Study results may inform expansion of HIVST availability and delivery via VMs for Veterans and in healthcare and community-based settings.
ConversHIVe: Decreasing Implicit Bias in HIV Prevention and Care Teams through AI-based Coaching
Principal Investigator: Nadir Weibel
Budget: $97,223
Start Date: March 1, 2025 End Date: February 28, 2026
Project Abstract: Effective communication between healthcare teams and patients is crucial for reducing barriers to prevention and care. Good communication leads to better healthcare access, engagement in prevention efforts, effective diagnoses, treatment adherence, and emotional well-being. However, implicit bias, linked to factors like sexual orientation and race, can negatively impact patient access to care, especially for people living with HIV (PLWH). Addressing implicit bias requires self-awareness and practice in difficult communication situations.
This project aims to design, develop, and validate an AI-based tool to help HIV care teams — including providers, nurses, social workers, counselors, and researchers — improve communication practices and reduce biases. Building on our recent UnBIASED project, which explored using social signals as indicators of implicit bias, ConversHIVe will leverage Generative AI through Large Language Models (LLMs) to provide rapid simulation and feedback. ConversHIVe will offer easy access to AI-driven simulated patients and an interface that detects, quantifies, and visualizes the user’s social signals during interactions.
ConversHIVe aligns with the California HIV/AIDS Research Program (CHRP) mission by addressing barriers in HIV prevention and care, particularly for marginalized communities. By enhancing service providers' communication and reducing implicit bias, ConversHIVe supports CHRP’s priorities of improving healthcare delivery and access. The project also aligns with national strategies for ending the HIV epidemic, focusing on diagnosing, treating, preventing, and responding to HIV.
The study will use a mixed-methods design, integrating quantitative and qualitative approaches, and will be conducted with the HIV Owen Clinic at UCSD, the AntiViral Research Center (AVRC) Community Advisory Board (CAB), and community-based organizations in San Diego. The study population includes healthcare providers in HIV clinics serving marginalized communities. The intervention involves using ConversHIVe, an AI-driven web interface providing simulated patient interactions and real-time feedback. Primary outcomes include improved communication skills, reduced implicit bias, and enhanced patient-provider interactions.
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COMMUNITY-CENTERED DEMONSTRATION PROJECTS TO SUPPORT IMPLEMENTATION OF LONG-ACTING INJECTABLE PREP ADOPTION ACROSS CALIFORNIA (2024)
CHRP has invested more than $9,000,000 in five outstanding projects that will each increase equity in provision of LAI PrEP across California. The “learning collaborative” model, community-based recruitment techniques, and policy research conducted by CHRP’s HIV Policy Research Centers are centerpieces of many of the new projects.
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Breaking Barriers: Building Equitable Access to Long-Acting Injectable PrEP in Sacramento & Fresno Counties
Principal Investigator: Kimberly Koester, PhD, UC San Francisco
Budget: $1,987,789
Start Date: February 1, 2024 End Date: January 31, 2028
Project Abstract: Our community centered demonstration project, Breaking Barriers: Building Equitable Access to Long-Acting Injectable PrEP in Sacramento and Fresno Counties seeks to support widespread access to and uptake of long-acting injectable PrEP (LAI-PrEP). The goal of this project is to build equitable access to LAI-PrEP among gay, bisexual, and same gender loving men, heterosexual women, and transgender persons, particularly among racial and ethnic minoritized communities. To do this, we will deliver and evaluate a non-traditional provider-facing capacity building strategy using lessons learned in our recent community-academic project which includes members of the Sacramento Zero Together and implementation scientists from UC, San Francisco. We carried out a study of preferences for sexual health services in Sacramento among gay, bisexual and same gender loving men. We used innovative methods to elucidate service priorities and revealed a strong interest in LAI-PrEP. Results showed that men face intense challenges to accessing LAI-PrEP. Building on this research, we seek to dramatically increase the capacity of traditional and non-traditional providers to make LAI-PrEP available in Sacramento and Fresno Counties, under-resourced areas facing a pernicious HIV and STI syndemic. Collaborators range from county health departments, community-based organizations, specialty pharmacy, federally qualified health centers, syringe exchange programs, and mobile health units. We envision a tiered plan to initiate in Sacramento and then scale to Fresno. In Aim 1 we will leverage the Consolidated Framework for Implementation Research, a determinants framework, to conduct a formative assessment of the barriers and facilitators to LAI-PrEP implementation and uptake in Sacramento and Fresno Counties. In Aim 2 we will convene a PrEP navigator advisory board to develop resources specific to the navigator workforce eg, payer source tools, patient education materials. In Aim 3 we will establish and evaluate a Learning Collaborative designed to facilitate peer-to-peer learning and tailored strategies to overcome LAI-PrEP implementation barriers. Aims will be carried out with two traditional and two non-traditional Sacramento organizations in Tier 1; extend to three traditional and one non-traditional Fresno organizations in Tier 2; and scale community-wide in both counties in Tier 3.
Community and Clinic-Based Collaboration to Engage People Who Use Drugs to receive LAI-PrEP
Principal Investigator: Robert Deiss, MD MA, UC San Diego
Budget: $1,479,991
Start Date: February 1, 2024 End Date: January 31, 2028
Project Abstract: Despite an increased risk for HIV acquisition, PrEP uptake remains unacceptably low among people who use drugs (PWUD). Long-acting injectable (LAI) PrEP offers a promising and preferred strategy for PWUD, yet effective interventions to improve linkage and retention in care are urgently needed. To develop best practices for engaging PWUD in LAI-PrEP services, we propose comparing outcomes (LAI-PrEP linkage and retention in care at 12 months) of participants recruited via two novel methods: (1) community-based recruitment implemented in collaboration between the Harm Reduction Coalition of San Diego (HRCSD) and UCSD’s Owen Clinic and (2) hospital-based recruitment and referral to the Owen Clinic with a patient care navigator. First, the community-based outreach method will consist of mobile LAI-PrEP services provided at various community locations in conjunction with harm reduction services provided by the HRCSD. This partnership will support expanding the HRCSD’s services to include LAI-PrEP, which will be offered to all eligible and interested PWUD in the community. Second, our hospital-based recruitment method will leverage the Owen Clinic’s proximity to UCSD’s Hillcrest Medical Center, where hospital admissions represent a critical moment for individuals experiencing complications from substance use disorders (SUD). For instance, during the 12-month period between July 2020-2021, there were 6,231 admissions among HIV-negative PWUD, primarily involving drug-related overdose or serious bacterial infections. Our study team, which possesses extensive expertise in addressing the intersection between HIV and SUD, will assign a patient care navigator to identify and recruit patients with SUD at risk of HIV acquisition; eligible participants interested in PrEP will be linked to the Owen Clinic and receive referrals to HRCSD’s harm reduction services and medications for treatment of SUD that are also known to promote improved retention in HIV services. The Owen Clinic is San Diego’s oldest and largest provider of HIV primary care services with wrap-around supports for socio-economically diverse communities, including 300 persons receiving PrEP (45% non-white). It has an on-site pharmacy, behavioral health/substance use counselors, on-site social work, psychiatry, gender health care, and referrals to other needed social services.
Community-Based Assessment and REalignment for Long-Acting PrEP (CARE-LA)
Principal Investigator: Sheldon Morris, MD MPH, UC San Diego
Budget: $1,756,178
Start Date: February 1, 2024 End Date: January 31, 2028
Project Abstract: Long-acting injectable HIV Pre Exposure Prophylaxis (LAI PrEP) is now available with injectable cabotegravir, and options will increase as new agents receive FDA approval. Our published research (Yeager et al., 2022) indicates a highly favorable appeal of LAI PrEP to enhance adherence, thereby conferring therapeutic coverage against HIV infection. However, logistical challenges at multiple points within the health care delivery system have limited LAI PrEP uptake. This project aims focus on implementation from both the supply and demand perspectives. As an early adopter of LAI PrEP, the UCSD Owen Clinic is positioned to share lessons related to supply challenges with other pharmacies in the region. To this end, we will engage community pharmacies in a coalition to foster shared learning to overcome barriers to pharmacy-delivered LAI PrEP using the Owen Clinic pharmacy as a model (i.e., blueprint) that can be adapted to fit the context of other communities and then piloted in their respective environments. Given that infrastructure, resources, and barriers will differ from site to site, but by keeping the implementation blueprint “living and accessible,” this will prepare settings to adopt, implement, and scale up LAI PrEP more efficiently. This flexibility will enable us to respond to new injectable formulations of PrEP that may come online during the project period and to policy changes that may impact the implementation of LAI PrEP. Furthermore, our engagement with Black and Latinx MSM and transgender communities will uncover social determinants influencing demand for LAI PrEP. Throughout the project we will closely monitor both the supply and demand of LAI PrEP in Southern California.
Field-Based Delivery of Long-Acting PrEP to Women at Elevated Risk for HIV in LA County
Principal Investigator: Risa Hoffman, MD MPH, UC Los Angeles
Budget: $2,022,247
Start Date: February 1, 2024 End Date: January 31, 2028
Project Abstract: We propose to partner with the Los Angeles County (LAC) Division of HIV and STD Programs (DHSP) and two of their long-term community partners, The Sidewalk Project (TSP) and Downtown Women’s Center (DWC), on a demonstration project of field-based delivery of long-acting cabotegravir (CAB) PrEP to cisgender women (CGW) and transgender women (TGW) who are being reached for syphilis treatment due to challenges with accessing facility-based care. We will evaluate uptake of CAB and persistence over 52 weeks and perform key informant interviews with DHSP leadership, field-based staff, and community leaders as well as cost analyses to understand the scalability and sustainability of this approach. CAB has been shown to be superior to daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for the prevention of sexual HIV acquisition. In recent randomized clinical trials, CAB was associated with an 89% reduction in incident HIV infection in CGW and a 66% reduction in TGW and MSM, compared to TDF/FTC. California is one of five states that account for half of all women living with HIV in the US, and LAC represents a hyper-localized epidemic within California. Additionally, the prevalence of HIV in TGW in LAC is 17%, rising to 27% in Black TGW, and 28% in TGW with substance use disorders. Syphilis is a biologic risk factor for HIV acquisition and is increasing among CGW and TGW in LAC. Almost one-quarter of new HIV diagnoses in LAC have a diagnosis of syphilis. Therefore, any CGW or TGW without HIV who has been diagnosed with syphilis is an ideal candidate for CAB PrEP – and a focus on this population will be essential for ending the HIV epidemic in LAC. Our proposed demonstration project uses a mobile model to address the critical barrier of health access for clients who face challenges in seeking care at health facilities. It leverages expertise of leaders in public health, academics, and community. The study has been designed to understand aspects of scalability and sustainability that will optimize the translation of knowledge to program and policy changes in LAC and similar high burden, resource-constrained settings in the United States.
Harnessing the Potential of Pharmacy Provision of Long-Acting Pre-Exposure Prophylaxis (PrEP)
Principal Investigator: Betty Dong, PharmD, UC San Francisco
Budget: $1,751,000
Start Date: February 1, 2024 End Date: January 31, 2028
Project Abstract: The CDC recognizes pharmacists as key in ending the HIV epidemic by 2030. Pharmacist provision of long acting injectable (LAI) and oral pre-exposure prophylaxis (PrEP) has the potential to reduce persistent disparities in PrEP uptake by reducing access barriers. California has over 5,500 pharmacies, the most of any state. About 90% of the U.S. population reside within five miles of a community pharmacy. In 2022, we conducted a study of >900 California pharmacists and found that 96% of pharmacists supported providing PrEP and 65% were interested in providing LAI PrEP if enabled to do so. Despite the favorable policy environment in California, only 11% of pharmacists reported that their pharmacy was currently providing oral PrEP. Implementation strategies tailored to the unique opportunities and constraints of community pharmacies are, therefore, urgently needed. Our proposed project will facilitate LAI PrEP access and uptake in California pharmacies by implementing a comprehensive model of LAI PrEP administration, HIV testing, and counseling that can be incorporated into existing workflows and align with current pharmacy business models. We will first co-create an implementation strategy for LAI PrEP which will be implemented in California pharmacies in Years 1-2 (Aim 1) . Concurrently, we will evaluate (Aim 2) its success at reaching high-priority groups with PrEP throughout the study period (Years 1-4). In addition, to measure the statewide evolution of pharmacist-delivered PrEP, we will conduct a population-based, representative statewide pharmacy survey of approximately 1,000 pharmacies in Year 3 to describe trends in pharmacy-based HIV prevention services; identify ‘PrEP deserts’; and uncover implementation successes, challenges, and opportunities related to such services (Aim 3).
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MEASURING THE IMPACT OF RACISM ON THE HIV EPIDEMIC IN CALIFORNIA (2024)
We recognize racism as one of the root causes of health inequities and need validated measures of the impact of racism to craft interventions and policies which will move us closer to equity. In California, racism impacts the HIV and sexually transmitted infections (HIV-STI) epidemics in disproportionate incidence, prevalence, and sequalae among our communities of color, through pathways such as access to sexual health services, sexual stigma, and sexual health decision making. We awarded three grants for pilot studies to develop methods of measuring the impact of racism on HIV-STI related outcomes among communities in California that are highly impacted by HIV.
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Geographies of Structural Racism and Intersectional Oppression and the House and Ballroom Community
Principal Investigator: Sean Arayasirikul, PhD, UC Irvine
Budget: $321,204
Start Date: February 1, 2024 End Date: January 31, 2026
Project Abstract: While literature evidencing racial disparities may be numerous, measurement that addresses the complex totalitizing nature of structural racism in relation to HIV-STI epidemics is conceptually thin. This study uses mixed-methods to examine how geographies and social spaces – as well as the policies and practices embedded therein - are racialized. All spaces are social; they involve people and practices; they hold meaning, carry history, transmit cultural norms and ideology, and provide critical context for understanding HIV-STI risk. This study seeks to understand how structural racism vis-à-vis communities’ racialized geographies are enacted through social spaces, driving structural vulnerability among sexual and gender minoritized people of color (SGMPoC) inequitably placed at risk for HIV-STI infection. This study is intentionally and explicitly intersectional, operating on the notion that all oppressions are linked in a matrix of domination. As a result, although our focus will be to measure geographic and spatial determinants of structural racism, we will account for other structural oppressions specifically structural homophobia, cissexism or transphobia, sexism, and xenophobia and their intersections. The House and Ball Community (HBC) emerged in the 1970s as an underground sub-culture of SGMPoC to combat structural racism. Because the HBC is at the confluence of intersectional oppression, this study will not only further our understanding of HIV-STI vulnerability and anti-Black racism, but also racism and xenophobia that Latine HBC members face, as well as homophobia, transphobia, and misogyny that SGMPoC face. SGMPoC in the HBC have not only navigated racialized spaces out of survival, they have created spaces out of resilience for their own liberation. This Public Health Critical Race praxis informed study uses diverse, critical, intersectional approaches and meaningful engagement through CBPR to center the experiential knowledge of minoritized communities. It examines structural racism in a multi-level, multi-faceted, interconnected, systemic, ecologically valid way. No studies have focused on spatial and geographical determinants of structural racism in this population in relation to HIV-STI epidemics. Further, the PI of this study is a member and national leader in the HBC; this study is not just community-based, but GROUNDED IN community.
Project COMPA (Comunidades Ofreciendo Más Prevenciones Agradables)
Principal Investigator: Moctezuma Garcia, PhD MSSW, San Jose State University
Budget: $336,999
Start Date: February 1, 2024 End Date: January 31, 2026
Project Abstract: In 2022, San Francisco AIDS Foundation (SFAF) tested 11,519 people and 93% of 2,906 identified as Latino/a/x sexual and gender minorities (LSGM). SFAF indicates that Latino/a/x are less likely to be virally suppressed and greater efforts are needed to increase PrEP enrollment. The plan to End the HIV Epidemic (EHE) must address Latino/a/x HIV disparities to achieve its goal of reducing new HIV diagnoses by 90% for 2030. EHE relies on Molecular HIV Surveillance (MHS) for Cluster Detection and Response (CDR) to reduce HIV transmission by facilitating access to HIV testing, preexposure prophylaxis (PrEP), and treatment as prevention (TasP). EHE has prioritized MHS without addressing structural racism or meaningful involvement of community stakeholders. MHS has fueled government mistrust among highly marginalized populations due to concerns about lack of informed consent, HIV criminalization, and persecution of immigrants. Public health staff have indicated that MHS will discourage people from getting tested because they are “afraid of being tracked.” We seek to explore: How does structural racism influence MHS/CDR interventions to enhance access to HIV services for Latino/a/x in the Bay Area? Project COMPA is innovative by taking a community-based approach on exploring how race, racism, and power influence government mistrust related to MHS activities for Latino/a/x. A public health critical race (PHCR) methodology will be applied to understand how racial consciousness influence HIV disparities among Latino/a/x. We will administer a community based participatory research framework with SFAF to enhance research decision-making process to elevate PHCR. The investigators insider LSGM perspective will strengthen endeavors exploring the implications of racial consciousness, supplemented by their experience addressing HIV/AIDS among Latino/a/x. PHCR foci will guide the mixed methods approach: AIM 1, in-depth interviews with LSGMs and HIV service providers will enhance our understanding of racial relations (Focus 1) and knowledge production (Focus 2) for EHE. Qualitative findings on racial relations will increase knowledge production for AIM 2, the quantitative phase will develop standardized measures (Focus 3) to determine implications of structural racism for Latino/a/x and HIV. AIM 3, develop a community-centered action plan (Focus 4) to mitigate HIV outbreaks.
Refining Measures of Medical Mis/Trust and Positive Coping for Racialized People Affected by HIV
Principal Investigator: Nina Harawa, PhD MPH, UC Los Angeles
Budget: $299,294
Start Date: February 1, 2024 End Date: January 31, 2026
Project Abstract: Issue: Many people of color with and at risk for HIV legitimately mistrust health care systems and providers because of intersectional discrimination, including structural racism, yet still achieve and maintain positive outcomes in the face of such inequities. We seek to understand the nature of both protective and harmful medical mistrust and trust and the role of positive coping in helping sexual minority men (SMM) who are racialize navigate healthcare systems and prevent HIV or adhere to treatment and achieve viral suppression in spite of marginalization, stigmatization, and racism. For example, we will examine how Black and Latino SMM frame their experiences; communicate with care providers; and respond to having a condition that disproportionately affects their racial, ethnic, sexual, and gender groups. What strategies do they employ to overcome negative healthcare perceptions and experiences -- including lack of trustworthiness? What key support systems do they use and how? Despite the availability of several published measures on medical mistrust and positive coping, they do not fully capture the complexities of either for Black or Latino men. Frameworks: Public Health Critical Race Praxis (PHCRP) and Positive Deviance. Approach: Building on our established community partnerships with Bienestar Human Services and APLA Health, we propose a strengths-based, qualitative study to address this measurement limitation by examining positive coping strategies most relevant to HIV care engagement and delineating nuances related to mistrust among Black and Latino SMM. We will leverage existing data from approximately 160 audio recordings of the Still Climbin' and Siempre Seguire' group intervention sessions to identify, develop, and refine survey items for positive coping, hazardous medical mistrust (i.e., may impede healthcare engagement), and protective medical trust and mistrust (i.e., may promote patient self-advocacy and healthcare engagement). We propose to use the Positive Deviance Framework and PHCRP to underpin our research on the measurement of coping with intersectional stigma (particularly racism) and of medical mistrust. Positive Deviance refers to exhibiting good health-related outcomes in the face of extreme barriers. PHCRP illuminates the mechanisms by which racism contributes to health disparities and provides guidance for critical inquiry.
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SOCIAL AND BEHAVIORAL INTERVENTION PILOT STUDIES TO SUPPORT HIV PREVENTION AND CARE (2024)
Recognizing the persistent social, behavioral, and/or psychological health factors associated with HIV/AIDS prevention and care, CHRP is supporting one early career stage researcher to conduct a groundbreaking pilot study of a revolutionary treatment modality.
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Pilot Trial of Ketamine-Assisted Psychotherapy for Methamphetamine Use Disorder & HIV Risk Behaviors
Principal Investigator: Nicky Mehtani, MD MPH, UC San Francisco
Budget: $269,723
Start Date: February 1, 2024 End Date: January 31, 2026
Project Abstract: Methamphetamine use was involved in over half of San Francisco’s overdose deaths in 2021, is associated with 1 in 3 HIV seroconversions among sexual and gender minority individuals, and is increasingly prevalent among Black, Latinx, and unstably housed residents—priority populations of regional efforts to End the HIV Epidemic (EHE). Yet there are no FDA-approved pharmacotherapies for methamphetamine use disorder (MAUD), and existing behavioral therapies are limited in scope and efficacy. This constitutes a major barrier in progressing toward EHE goals, highlighting a critical need to investigate innovative approaches to treat MAUD. In recent years, ketamine—an FDA-approved drug with psychedelic-like properties—has been demonstrated to induce ultra-rapid remission of depression, suicidal ideation, and anxiety at sub-anesthetic dosages, and studies have suggested the preliminary efficacy of ketamine-assisted psychotherapy in treating cocaine, alcohol, and opioid use disorders. Ketamine’s anti-addictive effects are thought to result from prefrontal cortex glutamate modulation, which may enhance neuroplasticity, ultimately supporting psychological flexibility and one’s ability to learn new, healthier behaviors. However, ketamine therapy is largely inaccessible among low-income patients—including MediCal enrollees in the San Francisco Health Plan—and no studies have examined the utility of ketamine in MAUD. In an open-label pilot clinical trial, we will evaluate the feasibility, safety, and preliminary efficacy of ketamine-assisted psychotherapy to treat MAUD among publicly insured, treatment-seeking patients enrolled in residential drug treatment programs. N=12 patients with MAUD meeting study eligibility—including co-morbid HIV or engagement in HIV risk behaviors within the past 90 days and abstinence from stimulants for at least 7 days—will be administered intramuscular ketamine (0.4-0.7 mg/kg) at 3 weekly visits in combination with 7 sessions of trauma-informed psychotherapy over a 35-day period. We hypothesize that administering this novel, integrative, and low-cost intervention will be feasible among publicly insured MAUD patients engaged in residential drug treatment and that pilot findings will demonstrate preliminary safety and efficacy of ketamine-assisted psychotherapy in reducing methamphetamine use and HIV risk behaviors among study participants.
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Implementation Science for Ending the HIV Epidemic (2021)
Owing to decades of groundbreaking research, there is a robust toolkit of interventions documented to improve prevention, testing, and treatment outcomes for HIV. Identifying effective strategies to bring those tools to scale, for sustained and cost-effective impact, is a critical next step.
We awarded four grants to support HIV implementation science that have the potential to be scalable for sustained impact on the HIV epidemic in California.
Telemedicine to Improve Engagement in HIV Care and Viral Suppression in Los Angeles County
Principal Investigator: Risa Hoffman, Ph.D., UC Los AngelesBudget: $775,849
Start Date: 2/1/2021 End Date: 1/31/2024
People living with HIV have different needs in terms of the type of health care delivery that works best for them. Adapting the standard way that HIV care is delivered can help patients who are struggling with care to overcome certain barriers, such as finding the time to come to clinic, or avoiding the stigma associated with coming to frequent medical appointments for a chronic illness. Telemedicine, or the use of telephone and/or video to perform health services, is one adaptation of standard health care delivery that has been shown to be beneficial for certain conditions, like diabetes and heart disease. While telemedicine has been used in a limited capacity for HIV care (such as for counseling), it has not been commonly used as a replacement for in-person primary care visits.
The proposed research will develop a telemedicine program within two HIV clinics in Los Angeles County. We will replace two of four in-person HIV primary care visits with a telephone or video visit that the patient can participate in from home. By reducing the frequency of in-person visits, we hope that HIV patients in these two clinics will have an easier time remaining in HIV care and taking HIV medications, and that telemedicine will be cost-saving for patients, because they won’t have to spend money on transportation to come to clinic, or spend time away from work or other household duties for clinic visits. Our study will first interview patients and providers to learn their thoughts and opinions about telemedicine, and then use this information to develop a telemedicine program that patients can participate in over ~18 months. At the end of 18 months, we will measure whether the telemedicine program helps patients have better clinical outcomes (such as undetectable viral load in the blood) and whether they miss fewer appointments over the course of the study. We will also measure how patients and providers feel about telemedicine at the end of the 18 months, to see if they liked it and what challenges they experienced, and also whether telemedicine is cost-saving for patients and for the clinics.
Implementing HIV PrEP among Latino men who have sex with men and transgender women
Principal Investigator: Jeffrey Klausner, Ph.D., University of Southern CaliforniaBudget: $777,994
Start Date: 2/1/2021 End Date: 1/31/2024
Telemedicine offers a great opportunity for HIV prevention, as it has the potential to increase access to pre-exposure prophylaxis (PrEP). PrEP, if used as directed, could virtually eliminate the risk of HIV acquisition among high risk populations. In addition to the brick and mortar sites, the state of California provides PrEP delivered through telemedicine (telePrEP) at no cost for those enrolled in their PrEP Assistance Program (PrEP-AP). Program participants enroll by visiting a local enrollment site once and then follow up visits, testing, and prescription filling occur remotely without visiting a clinic. However, this option is underutilized, with only a small number of people using telemedicine to get PrEP. The goal of this implementation science proposal is to develop an intervention which increases uptake of California’s telePrEP program (referred to as “Cal telePrEP” for this proposal). The study will occur in two phases. First, we will work with community based organizations, health policy stakeholders, industry stakeholders and prospective patients to identify barriers and facilitators to the uptake of telePrEP among Latinx MSM and transwomen. Data on barriers and facilitators will be collected through qualitative data collection methods (focus groups and in-depth interviews), and the development of interview/focus group guides, as well as the analysis of subsequent data, will be guided by the Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. We will then analyze the data and present our findings to a stakeholder board. This board will consist of community organizations and health policy organizations that will help us develop a set of recommendations for increasing access to telePrEP.
During the second phase, we will select local PrEP-AP enrolling sites in Los Angeles, Riverside and San Bernandino counties and we will work closely with their staff to implement the recommendations from the first phase. We will use a second framework called the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) to evaluate our intervention by monitoring telePrEP uptake on a quarterly basis.
Finally, project findings and a set of recommendations will be shared with local sites, stakeholders and PrEP providers to assist with expanding telePrEP use among Latinx populations in California.
Consumer Preferences for the Delivery of Prevention Services Among Individuals Leaving Jail
Principal Investigator: Janet Myers, Ph.D., UC San FranciscoBudget: $787,500
Start Date: 2/1/2021 End Date: 1/31/2024
At this time, there is little information about people’s preferences for the way they receive treatment and services for substance use disorders (SUDs) and HIV prevention. For example, there are now injectable forms of medication available for both purposes that may be preferable to pills. The purpose of this project is to understand what individuals leaving jail would like to see in terms of strategies to optimize their access to HIV prevention and SUD treatment. People leaving jail have higher rates of opiate use, SUDs and associated infections than those in the general population. Recent changes in the availability of treatments and reductions in access to prevention services due to COVID-19 have created changes in how these individuals might want to receive treatment. In this project, we hope to organize and work with a group of providers, public health officials. and people in jail themselves to advise us on: a) designing and conducting a survey to measure the best ways to deliver treatment for SUDs and HIV prevention; b) understanding the existing service delivery system to assess where we can integrate more consumer or client-friendly strategies; c) advising on the design of a pilot program able to best serve people leaving jail based on the group’s input and on the results of the survey, and, finally; d) on the development, delivery, and evaluation of this pilot program. By involving stakeholders throughout the life of the project, we expect to be able to find and integrate the best strategies for SUDs and HIV prevention for people leaving jail in San Francisco. Notably, we will be collaborating with the clinical group that provides care to people in jail in San Francisco – Jail Health Services - and with the Sheriff’s department who will work with us to provide enhanced linkage to care at release to make sure that the strategies we identify and the program that results will have the best chance at being sustainable in this setting and in others interested in a model that emerges from the preferences of the people it serves.
Strategies for Implementing PrEP Services in a Trans Community Center
Principal Investigator: Erik Storholm, Ph.D., San Diego State University Research FoundationBudget: $678,955
Start Date: 2/1/2021 End Date: 1/31/2024
PrEP or pre-exposure prophylaxis is an important HIV prevention tool for individuals with elevated risk for HIV. However, use of PrEP is lower among transgender and non-binary (TGNB) identified individuals, especially among Black and Latinx TGNB individuals who are also shown to be at higher risk for HIV. Our preliminary work with trans women in Los Angeles has found significant structural barriers to PrEP utilization including transportation difficulties, employment and housing insecurity, and frequent prior experiences of stigma in healthcare settings. In 2018, the first-of-its-kind Transgender Wellness Center (TWC) opened with the express goal of reducing structural and individual barriers to trans healthcare by creating a welcoming, safe, and affirming environment. The culmination of a decade of collaboration between Los Angeles County Department of Public Health (DPH) and numerous trans community-based organizations (CBOs), DPH-funded agencies, and community stakeholders, the TWC occupies 3,000 square feet in an accessible central location in Los Angeles. The Los Angeles LGBT Center is the lead agency overseeing and coordinating five CBOs focused on TGNB services and resources including housing, workforce development, financial literacy, economic empowerment, and HIV prevention. Although PrEP education is part of the HIV risk reduction package offered at the TWC, PrEP services are not provided onsite, resulting in a significant gap in HIV prevention services for TGNB individuals in Los Angeles. This implementation science proposal represents a collaboration with TWC leadership and key community stakeholders in response to the structural barriers that continue to impede the provision of PrEP as part of an integrated trans wellness care model that includes hormone therapy for TGNB individuals. We are proposing a 3-year project to implement and pilot test TransPrEP, a comprehensive implementation strategy that addresses structural barriers by integrating PrEP into existing services for TGNB individuals at the TWC. This application represents an academic-community partnership between the following collaborating institutions: Los Angeles LGBT Center, Los Angeles Department of Public Health, San Diego State University, RAND Corporation; Friends Research Institute; UCLA Center for HIV Identification, Prevention, and Treatment Services; and TWC.