Implementation Science
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.