My program of research focuses on optimizing the delivery of HIV care and prevention services. This work encompasses studies of health policies and systems of care, as well as projects investigating the impact of stigma among people living with or affected by HIV.
A major component of the research centers on how the HIV workforce can be mobilized to implement new technologies and service delivery models to improve care outcomes. This constitutes an important line of inquiry within HIV implementation science, which seeks more generally to understand and reduce the barriers to the widespread uptake and dissemination of proven-effective interventions. I began the line of inquiry when serving as the Co-Principal Investigator of the Evaluation and Technical Assistance Center of the Information Technology Networks of Care Initiative, a Health Resources and Services Administration (HRSA) Special Project of National Significance (SPNS). The SPNS program is a unique component of the Ryan White HIV/AIDS Program. SPNS supports the implementation and evaluation of promising new interventions to understand how such programs can be implemented effectively across Ryan White-supported clinical care settings. Each SPNS initiative funds multiple demonstration projects, as well a multi-site evaluation center. The five-year Networks of Care Initiative was focused on the implementation of HIV-related electronic health information exchanges (HIE) in six regions of the United States. Over the course of the project, I led the development of assessments to measure HIE implementation, was responsible for overseeing evaluation activities in four of the six regions, and led analyses to understand organizational characteristics that facilitated successful HIE implementation. These findings indicated that HIE success was dependent on sites capacities for reconfiguring their workflows. The technology could make additional patient health information available to providers, but in order for it to meaningfully influence clinical care, demonstration projects had to establish and implement procedures for using the HIE in regular day-to-day operations.
These findings helped drive a four-year investigator-initiated project to examine the effectiveness of implementing patient-centered medical homes (PCMH) in HIV care settings. This care delivery model, which originated in pediatric oncology and has since been adopted in family medicine as an approach for primary care, seeks to fundamentally alter the organizational structure and workflows within a clinic. It redistributes patient care responsibilities among physicians, mid-level providers, clinical care staff, and even patients themselves to better align the delivery of services with each patients unique set of needs. Much like the HIEs in the earlier project, the PCMH incorporates health information-sharing technologies, but it moves beyond the HIEs in the attention it gives to re-designed provider teams and tools to enhance patient engagement. For this project, I collaborated with the California HIV/AIDS Research Program (CHRP), a special state appropriation that funds peer-reviewed scientific research, to develop an initiative to implement and evaluate PCMH models in five HIV clinical sites statewide. As principal investigator, I led a multi-component, longitudinal study that examined the impact of PCMH-related changes on the quality of care in the funded sites. Our research findings suggest that the PCMH model is an effective tool for improving HIV related outcomes. Across the sites during the project period, there was an increase in the proportion of patients who were virally suppressed, with the most robust findings occurring in those clinics that have evidenced the strongest improvements in PCMH-related workflows. At the same time, the research suggests that aspects of the PCMH model may need refinement in HIV settings, particularly those serving safety net populations. Providers and patients were most receptive to PCMH elements focused on coordinating and tracking care. There was far less attention to or interest in the model components to facilitate better access to care (e.g., longer clinical hours, patient portals in the electronic health record) or increase patient activation (e.g., collaboratively developed care plans, use of shared decision making). Many HIV patients in safety net settings have faced a history of stigma, and a primary concern when seeking care is knowing that they can trust their providers. To this end, providers and clinical staff have developed their own informal mechanisms for keeping patients engaged, including use of personal phone lines or email, and making themselves available to answer questions and address anxieties as they arise. Whether such strategies are sustainable is subject to debate and further research (as provider burnout is high), but it is clear that the PCMHs traditional strategies for engaging patients are not likely to fully meet the needs of this patient population.
Building off of the expertise gained in the course of the PCMH study, I am now leading another SPNS initiative to examine the uptake of practice transformations to enhance HIV care outcomes. The four-year initiative responds to current demographic and temporal trends suggesting that there may soon be a shortage of HIV specialists, relative to the growing demand for their services. In collaboration with colleagues from the Pacific AIDS Education and Training Center (PAETC) and the UCSF Center for Excellence in Primary Care (CEPC), my team and I have adopted the CEPCs Building Blocks of Primary Care as a model for understanding the practice transformations taking place in the 15 funded demonstration project sites. We have identified three primary transformational strategies, each of which responds to workforce challenges in its own way. First, some sites are seeking to expand the overall workforce by training new providers to deliver services to HIV patients and by pairing those new providers with established HIV specialists to co-manage patients or serve as an expert resource. Second, other sites are seeking to improve the efficiency of service delivery by task shafting, or sharing the care. This strategy, which aligns with PCMH tenants, involves developing clinical staff members skills and furthering their responsibilities, thereby freeing up primary care providers to focus on patients most complex needs. Third, still other sites are seeking to better engage patients, most specifically by ensuring that they are reliably receiving HIV primary care services in order to reduce the need for urgent, emergency, inpatient, or long-term care. This last strategy is of particular interest, given the challenges that sites in the PCMH initiative faced in implementing patient engagement strategies. Based on lesson learned in our prior work and in the work of colleagues in the CEPC and PAETC, we developed a comprehensive checklist for launching a practice transformation, which guided demonstration project work in the first year of the initiative. Sites subsequently launched their projects successfully. We are now wrapping up the multi-year evaluation. Preliminary findings suggests that the practice transformations were successful at increasing patient retention in HIV care and viral suppression.
My domestic research agenda also includes several projects utilizing community collaborations to respond more effectively to the HIV epidemic. Through a CHRP-supported HIV Policy Research Center grant, I lead a UCSF team of researchers who work in close consultation with two local HIV services organizations (the San Francisco AIDS Foundation (SFAF) and Project Inform) and a parallel research center in southern California to identify policy issues likely to affect care and services in the state. We then design and implement research projects intended to answer key questions of relevance to those policy issues. Recent studies have focused on the best design for a state-funded assistance program for pre-exposure prophylaxis (PrEP), a biomedical prevention intervention, and the potential impact to HIV care for safety net populations of restricting pharmacies' savings from the federal 340B monies. I also collaborated with SFAF to lead an evaluation of its Magnet clinic, a sexual health services center and community space for gay men. The study sought to understand if the visibility of this centrally located clinic influenced community norms around HIV testing and sexual health.
My research in international environments has tackled similar themes, but with a somewhat stronger emphasis on the role of stigma in patients lives. I have been collaborating on a cluster randomized trial of a text messaging and peer navigation intervention in South African primary health facilities. This work, which is funded by the Health Resources and Services Administrations Global HIV/AIDS Program, looked at whether the interventions could improve patients retention in HIV services. My primary roles as a co-investigator were to design the navigation intervention component and monitor its implementation, and now to analyze and publish the trials retention findings. Our analyses indicate that the text messaging component improved patients initial linkage to HIV services after diagnosis. But, on its own, the messaging was not sufficient to enhance retention. The addition of the peer navigation program, however, led to significant increases in linkage to and retention in care over a one-year follow-up period. The navigation intervention was successful in part because it was able to respond to the influence of stigma in patients lives, which served as a major barrier to services.
I have also partnered as a collaborator in multidisciplinary teams studying HIV stigma in India and China. My contribution to these projects has focused on forms of stigma that affect people living with or at risk of HIV. A now-concluded NIMH-funded study in southern India examined the impact of prejudice on health and wellbeing of HIV-infected men and women. As co-investigator, I collaborated on the development of instruments to assess HIV stigma in Indian contexts and took the lead in publishing multiple papers that used the scales to document how stigma affects HIV disclosure, mental health, and care-seeking behaviors. A new, ongoing NIMH-funded study is examining the impact of an intervention on reducing stigmatizing attitudes among healthcare workers. As co-investigator, I have contributed content to the intervention modules. And a recently concluded project in China focused on prejudice against men who have sex with men (MSM). As co-investigator of this NIMH-funded project, I led the development of quantitative assessments to measure MSM stigma. The measures were administered to participants in Beijing, China, and used to examine how stigma affects the mens HIV risk behaviors and the kinds of HIV-related services they are willing to access.