Understanding Longitudinal Clinical Outcomes and Post-release Retention in Care among HIV-infected Prisoners in Lusaka, Zambia

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ABSTRACT This is an application for a Fogarty International Center International Research Scientist Development Award for Dr. Michael Herce, an infectious disease physician and experienced global health program implementer at the University of North Carolina at Chapel Hill (UNC). Dr. Herce is in the formative stage of his research career and aims to establish himself as an independent global health investigator in the areas of applied health behavior theory and HIV-related corrections research in sub-Saharan Africa (SSA). This award will provide Dr. Herce with the support necessary to achieve the following career development goals: (1) to advance his training in the responsible conduct of human subjects research, with a special focus on the ethical issues related to research involving prisoners; (2) to learn to apply health behavior theory and the qualitative evaluation of health behaviors in patient-oriented research and behavioral intervention design; (3) to obtain formal training in assessing and addressing alcohol use disorders (AUDs) and other psychosocial issues among HIV-infected prison populations in SSA; (4) to acquire advanced analytical skills in epidemiology and biostatistics; and (5) to develop expertise in the design, implementation, and oversight of large multi- disciplinary research projects in SSA. To realize these goals, Dr. Herce has assembled a highly accomplished and experienced core mentorship team comprised of: his U.S. primary mentor, Dr. David Wohl, UNC Associate Professor of Medicine and a recognized leader in clinical research involving HIV-infected prisoners; his Zambia primary mentor, Dr. Stewart Reid, UNC Associate Professor of Medicine, Senior Faculty Advisor to the Centre for Infectious Disease Research in Zambia (CIDRZ), and an expert in HIV and tuberculosis research and service delivery in Zambian prison populations; and Dr. Carol Golin, UNC Associate Professor of Medicine and Health Behavior, and an expert in HIV behavioral research and prevention efforts involving incarcerated people. Supporting Dr. Herce and his core mentors are two committed resource mentors: Dr. William Miller, an expert in advanced epidemiological methods and mentoring young global health investigators to career independence, and Dr. Seth Kalichman, a Professor of Psychology at the University of Connecticut and an expert in AUDs as they relate to HIV-risk behaviors for persons living with HIV in SSA. Globally, 10 million people are currently incarcerated, including 1 million prisoners in SSA. SSA prisons concentrate large numbers of people with, and at risk for, HIV infection. We and others have extended the regional scale-up of anti-retroviral therapy to include SSA prisons, and have shown that SSA inmates can start ART while detained and achieve excellent clinical outcomes in prison. However, the individual and public health benefits afforded by ART in prisons are often lost for prisoners after release (“releasees”) due to poor retention in HIV care. The factors driving this problem in SSA are unexplored, but AUDs are thought to play an important role due to their high prevalence in this population. To inform the design of a future transitional HIV care intervention, Dr. Herce proposes mentored research to prospectively assess clinical outcomes for HIV- infected prisoners after release (Aim 1); explore factors from health behavior theory that are associated with post-release retention in care, with a special focus on alcohol use disorders (Aims 2 & 2a); and conduct formative research to determine releasee and stakeholder knowledge, attitudes, and preferences surrounding transitional care interventions (Aim 3). To conduct his proposed research, Dr. Herce will leverage a national unique identifier system and HIV clinical database and an ongoing Gates Foundation-funded CIDRZ study. Understanding how AUDs and other factors influence the care continuum for HIV-infected prisoners after release is critical to developing future programs to keep this population retained in care, reduce prisoner morbidity and mortality, and prevent onward HIV transmission in communities to which prisoners return. The research and training activities outlined here will generate currently unavailable data to inform the design of such a transitional care program, and will form the basis of a R01 application to be completed before the end of the award period to evaluate this intervention among HIV-infected releasees in SSA.