Poverty, Mental Bandwidth, and an Unconditional Cash Transfer Intervention to Enable Health Behaviors for Pregnant People with HIV

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PROJECT SUMMARY Candidate: I am a Fellow in Infectious Diseases at the University of Pennsylvania and a physician-scientist with a Master of Public Health degree and 5 years of experience working in rural Haiti. While I have a strong track record of published research at the intersection of poverty, food security, and infectious diseases, my experiences have motivated me to shift my research in two ways. First, I have developed an interest in poverty's effects on decision-making, including the theory of poverty's psychological impacts, the empirical measures of these impacts, and the scientific approaches used to examine the effects of poverty alleviation on health behaviors and outcomes. Second, I plan to move from observational work towards the design and execution of hybrid effectiveness-implementation clinical trials of innovative economic interventions to improve HIV outcomes. Background: Poverty is an important contributor to poor short- and long-term HIV outcomes for pregnant people with HIV (PrPWH). This problem is particularly salient in Haiti, where 25% of people live in extreme poverty and only half of PrPWH are retained in care 12 months after starting ART. Recent research in behavioral economics has shown that poverty can result in worse health outcomes by taxing mental bandwidth, resulting in a heightened focus on immediate needs and less attention to future-oriented decisions. Mental bandwidth is likely further taxed by the added burdens of HIV and the perinatal period. Consequently, anti-poverty interventions targeting PrPWH may be particularly effective at improving health outcomes. Training: To achieve research independence, I require additional training in 1) behavioral economics and the decision-making processes underlying health behaviors; 2) the conduct and analysis of qualitative studies; and 3) hybrid effectiveness-implementation clinical trials. Mentors: My training and research plans will be overseen by Dr. Harsha Thirumurthy, who has extensive mentoring experience and expertise in developing and testing economic interventions to improve HIV outcomes. Drs. Louise Ivers (research in rural Haiti, qualitative design), Florence Momplaisir (implementation science, qualitative design, PrPWH), and Heather Schofield (mental bandwidth measures in poverty) will be additional co-mentors, and Drs. Christophe Millien (PrPWH in Haiti) and Alisa Stephens-Shield (biostatistics) will be advisors. Research: I will use 3 aims to accomplish my objective of assessing a key pathway — mental bandwidth — by which poverty (and cash transfers to combat poverty) can affect health behaviors among PrPWH in rural Haiti: 1) Characterize the relationship between mental bandwidth, HIV, and the perinatal period; 2) Identify key characteristics of an unconditional cash transfer intervention for PrPWH; and 3) Conduct a Hybrid Type 2 effectiveness-implementation trial of an unconditional cash transfer intervention for PrPWH. This research will be conducted at St. Boniface Hospital in Fond-des-Blancs, Haiti. I will use the findings from this K23 as the basis for an R01 proposal to conduct a larger trial of an unconditional cash transfer powered for clinical outcomes (e.g., postpartum viral suppression).