A Structural Approach to Improving HIV Pre-Exposure Prophylaxis (PrEP) Implementation among High Risk Men

项目总结 莱夫曼博士的长期职业发展目标是成为一名独立研究员，致力于 减少性少数群体的健康差距，重点是减轻性行为男性中艾滋病毒的负担 与男性(男男性接触者)。美国男男性接触者感染人类免疫缺陷病毒(HIV)的终身风险接近 是与女性发生性关系的男性的80倍，但只有4%的人报告使用暴露前预防措施(PrEP)来 在2014年预防艾滋病毒。基于性取向的结构性污名可能导致PrEP吸收缓慢。Dr。 莱夫曼将评估结构性污名在MSM PrEP意识和吸收中的作用，并将开发和 完善临床层面的干预措施，以减少结构性污名并改善PrEP的摄取。她有以下几点 研究目的：(1)通过以下方式评估国家层面的结构性污名以及男男性行为者对PrEP的认识和接受情况 差异中的差异分析；(2)评估性少数群体在医疗保健中的污名之间的关系 环境和PrEP的意识和接受，以及医疗环境中的耻辱是否中介了任何关系 在国家一级的耻辱和PrEP的认识和吸收之间；以及(3)发展和完善PrEP和结构 初级保健环境的污名干预。莱夫曼博士将利用疾病控制和预防中心 全国21个城市男男性接触者HIV行为监测重复横断面资料 芬威健康2013年收集的全国MSM互联网调查数据。她还将进行定性的 采访马萨诸塞州和佐治亚州的诊所管理人员、初级保健提供者和MSM患者， 男男性接触者健康方面存在不同程度差异的州。 这项拟议的研究建立在雷夫曼博士之前关于结构性污名对健康影响的研究基础上 影响到性少数群体，艾滋病毒预防和预防方案的实施，以及艾滋病毒的治疗和护理。她 将进行以下K01培训，为拟议的研究和她的职业目标做好准备： (1)在美国接受卫生和社会政策制定方面的培训；(2)获得统计方面的高级培训 因果性中介分析方法评估不同程度的耻辱；(3)接受发展培训 和评估多成分的临床干预措施；以及(4)获得卫生信息学方面的培训，以便 将干预措施整合到电子病历中。为了实现这些培训目标，雷夫曼博士 组建了一个由卫生法律、政策和管理主席Michael Stein博士领导的指导团队， 波士顿大学公共卫生学院(BUSPH)；芬威卫生医学主任Kenneth Mayer博士； 科琳·巴里博士，朱莉和弗雷德·索珀教授，约翰斯大学卫生政策和管理主席 和北卡罗来纳大学生物统计学教授黛比·程博士。雷夫曼博士的训练将使她做好准备 实现她成为独立调查员的长期职业目标，减少不成比例的 艾滋病毒造成的负担和性少数群体之间的其他健康差距。

PROJECT SUMMARY Dr. Raifman’s long-term career development goal is to become an independent researcher working to reduce sexual minority health disparities with a focus on reducing the burden of HIV among men who have sex with men (MSM). MSM in the United States have a lifetime risk of human immunodeficiency virus (HIV) nearly 80 times that of men who have sex with women, but just 4% reported using pre-exposure prophylaxis (PrEP) to prevent HIV in 2014. Structural stigma based on sexual orientation may contribute to slow PrEP uptake. Dr. Raifman will evaluate the role of structural stigma in MSM PrEP awareness and uptake and will develop and refine a clinic-level intervention to reduce structural stigma and improve PrEP uptake. She has the following research aims: (1) Assess state-level structural stigma and PrEP awareness and uptake among MSM through a difference-in-differences analysis; (2) Assess the relationship between sexual minority stigma in healthcare settings and PrEP awareness and uptake, and whether stigma in healthcare setting mediates any relationship between state-level stigma and PrEP awareness and uptake; and (3) Develop and refine a PrEP and structural stigma intervention for primary care settings. Dr. Raifman will use Centers for Disease Control and Prevention repeated cross-sectional National HIV Behavioral Surveillance Data collected from MSM in 21 cities and national Internet survey data from MSM collected by Fenway Health in 2013. She will also conduct qualitative interviews with clinic administrators, primary care providers, and MSM patients in Massachusetts and Georgia, states with differing levels of disparities in MSM health. The proposed research builds upon Dr. Raifman’s prior research on the health effects of structural stigma affecting sexual minorities, on HIV prevention and PrEP implementation, and on HIV treatment and care. She will pursue the following K01 training aims to prepare her for the proposed research and for her career goals: (1) Acquire training on health and social policymaking in the US; (2) Acquire high-level training in statistical methods for causal mediation analysis to evaluate different levels of stigma; (3) Acquire training on developing and evaluating multi-component, clinical interventions; and (4) Acquire training in health informatics in order to integrate interventions into electronic medical records. To achieve these training goals, Dr. Raifman has assembled a mentorship team lead by Dr. Michael Stein, the chair of Health Law, Policy, and Management at Boston University School of Public Health (BUSPH); Dr. Kenneth Mayer, Medical Director of Fenway Health; Dr. Colleen Barry, the Julie and Fred Soper Professor and Chair of Health Policy and Management at Johns Hopkins; and Dr. Debbie Cheng, BUSPH Professor of Biostatistics. Dr. Raifman’s training will prepare her to achieve her long-term career goal of becoming an independent investigator reducing the disproportionate burden of HIV and other health disparities among sexual minorities.