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保留护理的一系列事件。每一步对于实现病毒抑制和改善健康结果的目标都至关重要。美国近 50% 的 HIV 感染者没有接受持续的 HIV 护理，这损害了这一临床必要性。艾滋病毒的流行给西班牙裔人口带来了特别严重的问题。虽然西班牙裔人口占美国人口的 16%，但他们占新增艾滋病毒感染者的 20%。西班牙裔新确诊艾滋病毒患者中，移民占 42%。旨在改善一般艾滋病毒感染人群中艾滋病毒护理保留率的新兴干预措施尚未在西班牙裔移民中得到充分研究，西班牙裔移民是人口中日益增长的一部分，其结果不佳的风险是一个不稳定的现实。西班牙文化和移民身份的具体因素对于强调有效干预措施的发展至关重要。更好地理解 这些因素可能会导致改进、量身定制的方法来保留西班牙裔移民的艾滋病毒护理、改善健康结果并减少持续的艾滋病毒传播。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培训，加上哈佛大学和马萨诸塞州总医院 (MGH) 的丰富资源，使我能够实现这些目标。我有五篇经过同行评审的研究文章，与艾滋病毒结果和在资源有限的环境中坚持护理的后果直接相关，以及护理艾滋病毒感染者的丰富临床经验 以及移民。研究：我将对感染艾滋病毒的西班牙裔移民及其医疗提供者进行形成性定性研究，以了解影响保留初级艾滋病毒护理决策的因素（例如个人偏好、结构性障碍）和因素（例如家庭的角色）。我将特别关注通过对患者和艾滋病毒提供者团队中的多学科提供者（包括医生、护士、社会工作者、病例管理者和社区卫生工作者）进行深入访谈，产生新颖的干预想法，以提高艾滋病毒护理的保留率（目标 1）。我将扩展安徒生卫生服务使用模型，将健康差异的概念模型纳入其中，以便评估艾滋病毒护理利用的社会、诊所/系统层面和个人决定因素。在这一概念模型、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艾滋病毒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。我们将开发并试点测试针对文化的干预措施（目标 2）。该干预措施将针对没有接受艾滋病毒护理且文化相关干预措施有限的西班牙裔移民。我们将在艾滋病毒护理级联中特别脆弱的时期（即保留护理）进行干预，在这种情况下，由于临床衰退和冒险行为的风险，护理中断会对个人和公共健康造成重大后果，从而对公共健康造成严重后果。艾滋病毒传播。干预措施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。通过重点随机试点试验（目标 3），我们将进一步完善研究程序并进行初步功效分析，为在获奖结束时提交 R01 提案所指导的干预措施进行更大规模、更明确的测试做准备。培训/指导：我的长期职业目标是成为一名独立调查员，拥有开发适合文化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治疗结果。我需要在方法方面接受严格的培训，使我能够充分掌握影响西班牙裔移民艾滋病毒护理使用的因素，例如文化和背景，以及过程，例如文化适应。社区参与方法的培训将有助于在社区环境中有效开发和部署新颖的干预措施。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，我概述了一项基于社区的参与性研究、定性研究、行为理论和干预开发方面的强化培训计划。这种培训将通过研究生水平的课程以及我的导师的密切监督来进行，他们是与该提案直接相关的研究领域的国际公认的领导者。我的导师团队在马萨诸塞州和全国范围内的研究和艾滋病毒护理服务社区合作伙伴关系中也拥有牢固的立足点。此外，该项目还推进了疾病预防控制中心、国家卫生研究院和艾滋病研究办公室的机构战略重点，特别是减少艾滋病毒健康差距并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护理感染艾滋病毒的西班牙裔移民的专家，更广泛地说，将使我能够应对患有慢性疾病的弱势群体所面临的挑战，这些群体需要创新的疾病管理模式。