Addressing Barriers to Retention in HIV Care for Hispanic Immigrants

解决西班牙裔移民艾滋病毒护理中的保留障碍

• 批准号: 9205542
• 负责人: Julie Levison
• 金额: $ 20.09万
• 依托单位: MASSACHUSETTS GENERAL HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2014
• 资助国家: 美国
• 起止时间: 2014-02-01 至 2019-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9205542
• 关键词: Acculturation; Acquired Immunodeficiency Syndrome; Acute; Address; Adherence; Affect; Appointment; Area; Attention; Award; Behavior; Behavioral; Behavioral Sciences; Caring; Case Manager; Centers for Disease Control and Prevention (U.S.); Chronic Disease; Clinic; Clinical; Communicable Diseases; Communities; Community Health Aides; Complement; Consensus; Coupled; Data; Decision Making; Development; Diffusion; Disease Management; Disease model; Early treatment; Economic Conditions; English Language; Epidemic; Event; Feedback; General Hospitals; Goals; HIV; HIV Infections; HIV diagnosis; Health; Health behavior; Healthcare; Healthcare Systems; Hispanics; Immigrant; Individual; International; Interruption; Intervention; Interview; K-Series Research Career Programs; Knowledge; Lead; Massachusetts; Measures; Mediating; Medical; Mentors; Mentorship; Methodology; Methods; Modeling; National Institute of Mental Health; Not Hispanic or Latino; Nurses; Outcome; Outcomes Research; Outpatients; Participant; Patients; Physicians; Politics; Population; Positioning Attribute; Preparation; Prevention; Procedures; Process; Provider; Public Health; Qualitative Research; Randomized; Research; Research Peer Review; Research Personnel; Resources; Risk; Risk Factors; Risk-Taking; Role; Sampling; Self Efficacy; Site; Social Workers; Standardization; Structure; Supervision; System; Testing; Theoretical model; Training; Universities; Viral Load result; Vulnerable Populations; Work; antiretroviral therapy; base; care delivery; career; clinical care; clinical risk; community based participatory research; community partnership; community setting; contextual factors; effective intervention; experience; family influence; health care availability; health care model; health disparity; health seeking behavior; health service use; improved; improved outcome; innovation; insight; literacy; multidisciplinary; novel; personalized approach; pilot trial; power analysis; preference; primary outcome; public health relevance; public health research; social; study population; success; theories; therapy development; transmission process; treatment as usual; uptake; virology

DESCRIPTION (provided by applicant): Patient engagement in HIV care encompasses a cascade of events from HIV diagnosis to retention in care. Each step is vital in achieving the goal of virologic suppression and improved health outcomes. Compromising this clinical imperative is the nearly 50% of HIV-infected individuals in the US who are not in continuous HIV care. The HIV epidemic poses a particularly severe problem in Hispanic populations. While Hispanics comprise 16% of the US population, they comprise 20% of new HIV infections. Immigrants make up 42% of new HIV diagnoses in Hispanics. Emerging interventions to improve retention in HIV care in the general HIV-infected population have not been adequately studied in Hispanic immigrants, a growing segment of the population where risk for poor outcomes is a precarious reality. Factors specific both to Hispanic cultures and to immigrant status are essential to highlight for effective intervention development. A better understanding of these factors could lead to improved, tailored approaches to retention in HIV care for Hispanic immigrants, improvement in health outcomes, and a reduction in ongoing HIV transmission. CANDIDATE: My specialized training in clinical infectious disease, public health, and Hispanic studies, coupled with extensive resources at Harvard University and Massachusetts General Hospital (MGH), uniquely position me to accomplish these aims. I have five peer-reviewed research articles directly related to HIV outcomes and the consequences of adherence to care in resource-limited settings, and extensive clinical experience caring for HIV-infected individuals as well as immigrants. RESEARCH: I will conduct formative qualitative research with Hispanic immigrants infected with HIV and their medical providers to understand factors (e.g. individual preferences, structural barriers) and agents (e.g. role of the family) that influence decision-making around retention in primary HIV care. I will give specific attention to generating novel intervention ideas to improve retention in HIV care through these in-depth interviews with patients and the multi-disciplinary providers within an HIV provider team including physicians, nurses, social workers, case managers, and community health workers (Aim 1). I will expand the Andersen Model of Health Services Use to include conceptual models of health disparities in order to evaluate societal, clinic/system- level, and individual determinants of HIV care utilization. Guided by this conceptual model, formative research, and community stakeholder feedback, we will identify the most significant and modifiable factors that determine retention in HIV care for the study population in order to inform the development of an intervention. We will develop and pilot test a culturally-tailored intervention (Aim 2). The intervention will target Hispanic immigrants who are not retained in HIV care, and for whom there are limited culturally relevant interventions. We will intervene at a particularly vulnerable period in the HIV care cascade, retention in care, where care interruption poses substantial consequences for both the individual, due to risk of clinical decline and risk-taking behaviors, and for public health, due threat of resulting HIV transmission. Standardization of the intervention will occur through iterative refinements based on participant and community advisory board feedback. Through a focused randomized pilot trial (Aim 3), we will further refine study procedures and perform preliminary power analyses in preparation for a larger, more definitive test of the intervention directed through submission of an R01 proposal at the end of the award. TRAINING/MENTORING: My long-term career goal is to become an independent investigator with expertise in developing culturally-tailored community-based interventions to improve outcomes in HIV and other chronic diseases for vulnerable populations. I will need rigorous training in methodologies that will enable me to fully capture factors, such as culture and context, and processes, such as acculturation, that influence use of HIV care for Hispanic immigrants. Training in community-engaged methods will facilitate effective development and deployment of novel interventions in the community setting. To complement my prior training in clinical care and HIV outcomes research, I have outlined a plan for intensive training in community-based participatory research, qualitative research, behavioral theory, and intervention development. This training will occur through graduate-level coursework as well as through intensive supervision with my mentors, who are internationally- recognized leaders in areas of research directly related to the proposal. My mentorship team also has a strong foothold in community-based partnerships for research and HIV care delivery in Massachusetts and nationally. Furthermore, this project advances the institutional strategic priorities of the CDC, NIMH and the Office of AIDS Research, notably, to reduce HIV health disparities and to improve medical care for people living with HIV. The successful completion of this research will position me as an expert in retention in care for HIV-infected Hispanic immigrants, and more generally will enable me to address challenges in vulnerable populations burdened with chronic illnesses that require innovative models for disease management.

描述（由申请人提供）：患者参与艾滋病毒护理包括从艾滋病毒诊断到继续护理的一连串事件。每一步对于实现病毒学抑制和改善健康结果的目标都至关重要。在美国，近50%的艾滋病毒感染者没有接受持续的艾滋病毒护理，这一临床需求受到了影响。艾滋病毒流行在西班牙裔人口中构成了特别严重的问题。虽然西班牙裔占美国人口的16%，但他们占新艾滋病毒感染者的20%。移民占西班牙裔艾滋病毒新诊断的42%。新出现的干预措施，以改善保留在艾滋病毒护理在一般艾滋病毒感染者的人口还没有得到充分的研究，在西班牙裔移民，越来越多的部分人口的风险，为穷人的结果是一个不稳定的现实。西班牙裔文化和移民身份的特定因素对于突出有效的干预措施发展至关重要。更好地了解 这些因素可能会导致改进，量身定制的方法，以保留在艾滋病毒护理的西班牙裔移民，改善健康结果，并减少正在进行的艾滋病毒传播。候选人：我在临床传染病、公共卫生和西班牙裔研究方面的专业训练，加上哈佛大学和马萨诸塞州总医院（MGH）的广泛资源，使我能够实现这些目标。我有五篇同行评议的研究文章直接涉及艾滋病毒的结果和在资源有限的环境中坚持护理的后果，以及护理艾滋病毒感染者的丰富临床经验 以及移民。研究人员：我将与感染艾滋病毒的西班牙裔移民及其医疗服务提供者进行形成性定性研究，以了解影响初级艾滋病毒护理决策的因素（例如个人偏好，结构性障碍）和代理人（例如家庭的作用）。我将特别关注产生新的干预思想，以提高保留在艾滋病毒护理通过这些深入的采访与患者和多学科的艾滋病毒提供者团队，包括医生，护士，社会工作者，个案管理员，和社区卫生工作者（目标1）。我将扩大卫生服务使用的安德森模型，包括健康差距的概念模型，以评估社会，诊所/系统级，和艾滋病毒护理利用的个人决定因素。在此概念模型、形成性研究和社区利益相关者反馈的指导下，我们将确定决定研究人群保留HIV护理的最重要和可修改的因素，以便为干预措施的制定提供信息。我们将开发和试点测试一个文化定制的干预（目标2）。这项干预措施将针对那些没有接受艾滋病毒护理的西班牙裔移民，对他们来说，与文化相关的干预措施有限。我们将在艾滋病毒护理级联中特别脆弱的时期进行干预，保持护理，其中护理中断对个人造成重大后果，由于临床下降和冒险行为的风险，以及对公共卫生造成的艾滋病毒传播的威胁。干预的标准化将通过基于参与者和社区咨询委员会反馈的迭代改进来实现。通过一项集中的随机试点试验（目标3），我们将进一步完善研究程序，并进行初步的功效分析，为在奖励结束时提交R 01提案指导的更大，更明确的干预测试做准备。培训/指导：我的长期职业目标是成为一名独立的调查员，拥有开发文化定制的社区干预措施的专业知识，以改善弱势群体的艾滋病毒和其他慢性疾病的结果。我将需要严格的培训方法，使我能够充分捕捉因素，如文化和背景，以及过程，如文化适应，影响使用艾滋病毒护理的西班牙裔移民。社区参与方法的培训将有助于在社区环境中有效地制定和部署新的干预措施。为了补充我之前在临床护理和艾滋病毒结果研究方面的培训，我概述了一项计划，在社区参与性研究、定性研究、行为理论和干预措施开发方面进行强化培训。这种培训将通过研究生水平的课程以及通过与我的导师，谁是国际公认的领导人在直接相关的研究领域的建议密集的监督发生。我的导师团队还在马萨诸塞州和全国以社区为基础的研究和艾滋病毒护理提供伙伴关系中站稳了脚跟。此外，该项目还推进了疾病预防控制中心、国家卫生研究所和艾滋病研究办公室的机构战略优先事项，特别是减少艾滋病毒健康差距和改善艾滋病毒感染者的医疗保健。这项研究的成功完成将使我成为艾滋病毒感染的西班牙裔移民的保留护理专家，更广泛地说，将使我能够解决患有慢性疾病的弱势群体面临的挑战，这些疾病需要创新的疾病管理模式。