Faculty

Marya Gwadz headshot

Marya Gwadz

PhD

Senior Research Scientist

1 212 992 7147

433 First Avenue
Room 748
New York, NY 10010
United States

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Professional overview

Dr. Gwadz is a licensed clinical psychologist, a Senior Research Scientist, and the Director of the Transdisciplinary Research Methods Core in the Center for Drug Use and HIV Research (CDUHR, P30 DA011041; Sherry Deren, PhD, and Holly Hagan, PhD, Co-PIs). Her research focuses mainly on identifying approaches to increase health equity among African American/Black and Hispanic populations. Dr. Gwadz has been leading intervention trials for over two decades, with an emphasis on studies to address HIV- and drug use-related health disparities in urban populations of color, and among women. She has a particular interest in creating culturally appropriate, cost-effective, scalable, and reproducible intervention programs, including studies using adaptive designs and the Multiphase Optimization STrategy (MOST). She also leads a program of research with vulnerable adolescent populations, including runaway and homeless youth.

Education

PhD in clinical psychology(1998) - NYU Graduate School of Arts and Sciences

Specialties

LGBTQ
Infectious disease
Women's health
HIV/AIDS
Substance use

Professional membership

American Public Health Association

Publications

Publications

Doing battle with "the monster: " How high-risk heterosexuals experience and successfully manage HIV stigma as a barrier to HIV testing

Gwadz, M., Leonard, N. R., Honig, S., Freeman, R., Kutnick, A., & Ritchie, A. S. (2018). International Journal for Equity in Health, 17(1). 10.1186/s12939-018-0761-9
Abstract
Background: Annual HIV testing is recommended for populations at-risk for HIV in the United States, including heterosexuals geographically connected to urban high-risk areas (HRA) with elevated rates of HIV prevalence and poverty, who are primarily African American/Black or Hispanic. Yet this subpopulation of "individuals residing in HRA" (IR-HRA) evidence low rates of regular HIV testing. HIV stigma is a recognized primary barrier to testing, in part due to its interaction with other stigmatized social identities. Guided by social-cognitive and intersectionality theories, this qualitative descriptive study explored stigma as a barrier to HIV testing and identified ways IR-HRA manage stigma. Methods: In 2012-2014, we conducted in-depth qualitative interviews with 31 adult IR-HRA (74% male, 84% African American/Black) with unknown or negative HIV status, purposively sampled from a larger study for maximum variation on HIV testing experiences. Interviews were audio-recorded and professionally transcribed verbatim. Data were analyzed using a systematic content analysis approach that was both theory-driven and inductive. Results: Stigma was a primary barrier to HIV testing among IR-HRA. In the context of an under-resourced community, HIV stigma was experienced as emerging from, and being perpetuated by, health care organizations and educational institutions, as well as community members. Participants noted it was "better not to know" one's HIV status, to avoid experiencing HIV-related stigma, which could interact with other stigmatized social identities and threaten vital social relationships, life chances, and resources. Yet most had tested for HIV previously. Factors facilitating testing included health education to boost knowledge of effective treatments for HIV; understanding HIV does not necessitate ending social relationships; and tapping into altruism. Conclusions: In the context of economic and social inequality, HIV stigma operates on multiple, intersecting layers. IR-HRA struggle with an aversion to HIV testing, because adopting another stigmatized status is dangerous. They also find ways to manage stigma to engage in testing, even if not at recommended levels. Findings highlight strategies to reduce HIV stigma at the levels of communities, institutions, and individuals to improve rates of annual HIV testing necessary to eliminate HIV transmission and reduce HIV-related racial and ethnic health disparities among IR-HRA.

Perceived access and barriers to care among illicit drug users and hazardous drinkers: Findings from the Seek, Test, Treat, and Retain data harmonization initiative (STTR)

Matsuzaki, M., Vu, Q. M., Gwadz, M., Delaney, J. A., Kuo, I., Trejo, M. E., Cunningham, W. E., Cunningham, C. O., & Christopoulos, K. (2018). BMC Public Health, 18(1). 10.1186/s12889-018-5291-2
Abstract
Background: Illicit drug use (DU) and hazardous drinking (HD) among marginalized populations may be associated with greater barriers to care. Methods: We used baseline data on the participants of the Seek, Test, Treat, and Retain data harmonization initiative. DU includes use of any illicit drugs within the past 6 months. HD was defined as scores ≥8 for men and ≥ 7 for women on Alcohol Use Disorders Identification Test within the past 12 months. Social support scores were assigned by summing scores from individual questions related to social support. Two outcomes for multivariable regression models and mediation analysis were perceived access to care and perceived barriers to care scores, calculated from summated points from individual questions within each domain. All models were adjusted for age, gender, race/ethnicity, and social support and stratified by HIV status. Results: Among 1403 illicit drug users and 4984 non-drug users, the mean age was 39.6 ± 12.2 years old, 71% were male, 57% African Americans, and 39% Hispanic/Latinos. Over 25% reported difficulties in covering medical costs and finding transportation to health care facilities and greater proportions of drug users and hazardous drinkers reported these issues than non-DU/non-HD. In multivariable models, DU and HD were both independently associated with having greater barriers to care (β: 0.49 (95% confidence interval: 0.19 to 0.79) p < 0.01; 0.31 (0.18 to 0.45) < 0.01) in HIV-negative participants. Neither DU nor HD was strongly associated with barriers to care for HIV-positive participants. Social support was associated with better perceived access to care and fewer barriers to care in the HIV-negative participants. Conclusion: The current study found that financial burdens of care, logistical difficulties in accessing care, and low social support were common challenges among individuals using illicit drugs and/or drinking hazardously. Addressing structural barriers and strengthening social support may be important strategies to improve health care among marginalized populations, regardless of HIV status.

Critical race theory as a tool for understanding poor engagement along the HIV care continuum among African American/Black and Hispanic persons living with HIV in the United States: A qualitative exploration

Freeman, R., Gwadz, M. V., Silverman, E., Kutnick, A., Leonard, N. R., Ritchie, A. S., Reed, J., & Martinez, B. Y. (2017). International Journal for Equity in Health, 16(1). 10.1186/s12939-017-0549-3
Abstract
Background: African American/Black and Hispanic persons living with HIV (AABH-PLWH) in the U.S. evidence insufficient engagement in HIV care and low uptake of HIV antiretroviral therapy, leading to suboptimal clinical outcomes. The present qualitative study used critical race theory, and incorporated intersectionality theory, to understand AABH-PLWH's perspectives on the mechanisms by which structural racism; that is, the macro-level systems that reinforce inequities among racial/ethnic groups, influence health decisions and behaviors. Methods: Participants were adult AABH-PLWH in New York City who were not taking antiretroviral therapy nor well engaged in HIV care (N = 37). Participants were purposively sampled for maximum variation from a larger study, and engaged in semi-structured in-depth interviews that were audio-recorded and professionally transcribed verbatim. Data were analyzed using a systematic content analysis approach. Results: We found AABH-PLWH experienced HIV care and medication decisions through a historical and cultural lens incorporating knowledge of past and present structural racism. This contextual knowledge included awareness of past maltreatment of people of color in medical research. Further, these understandings were linked to the history of HIV antiretroviral therapy itself, including awareness of the first HIV antiretroviral regimen; namely, AZT (zidovudine) mono-therapy, which was initially prescribed in unacceptably high doses, causing serious side effects, but with only modest efficacy. In this historical/cultural context, aspects of structural racism negatively influenced health care decisions and behavior in four main ways: 1) via the extent to which healthcare settings were experienced as overly institutionalized and, therefore, dehumanizing; 2) distrust of medical institutions and healthcare providers, which led AABH-PLWH to feel pressured to take HIV antiretroviral therapy when it was offered; 3) perceptions that patients are excluded from the health decision-making process; and 4) an over-emphasis on antiretroviral therapy compared to other non-HIV related priorities. We found that although participants were located at the intersection of multiple social categories (e.g., gender, social class, AABH race/ethnicity), race/ethnicity and social class were described as primary factors. Conclusions: Critical race theory proved useful in uncovering how macro-level structural racism affects individual-level health decisions and behaviors. HIV clinical settings can counter-balance the effects of structural racism by building "structural competency," and interventions fostering core self-determination needs including autonomy may prove culturally appropriate and beneficial for AABH-PLWH.

Health Technology-Enabled Interventions for Adherence Support and Retention in Care Among US HIV-Infected Adolescents and Young Adults: An Integrative Review

Margaret-Navarra, A., Gwadz, M. V., Whittemore, R., Bakken, S. R., Cleland, C. M., Burleson, W., Jacobs, S. K., & Melkus, G. D. (2017). AIDS and Behavior, 1-18. 10.1007/s10461-017-1867-6
Abstract
The objective of this integrative review was to describe current US trends for health technology-enabled adherence interventions among behaviorally HIV-infected youth (ages 13–29 years), and present the feasibility and efficacy of identified interventions. A comprehensive search was executed across five electronic databases (January 2005–March 2016). Of the 1911 identified studies, nine met the inclusion criteria of quantitative or mixed methods design, technology-enabled adherence and or retention intervention for US HIV-infected youth. The majority were small pilots. Intervention dose varied between studies applying similar technology platforms with more than half not informed by a theoretical framework. Retention in care was not a reported outcome, and operationalization of adherence was heterogeneous across studies. Despite these limitations, synthesized findings from this review demonstrate feasibility of computer-based interventions, and initial efficacy of SMS texting for adherence support among HIV-infected youth. Moving forward, there is a pressing need for the expansion of this evidence base.

Public health benefit of peer-referral strategies for detecting undiagnosed HIV infection among high-risk heterosexuals in New York City

Gwadz, M., Cleland, C. M., Perlman, D. C., Hagan, H., Jenness, S. M., Leonard, N. R., Ritchie, A. S., & Kutnick, A. (2017). Journal of Acquired Immune Deficiency Syndromes, 74(5), 499-507. 10.1097/QAI.0000000000001257
Abstract
Identifying undiagnosed HIV infection is necessary for the elimination of HIV transmission in the United States. The present study evaluated the efficacy of 3 community-based approaches for uncovering undiagnosed HIV among heterosexuals at high-risk (HHR), who are mainly African American/Black and Hispanic. Heterosexuals comprise 24% of newly reported HIV infections in the United States, but experience complex multilevel barriers to HIV testing. We recruited African American/Black and Hispanic HHR in a discrete urban area with both elevated HIV prevalence and poverty rates. Approaches tested were (1) respondent-driven sampling (RDS) and confidential HIV testing in 2 sessions (n = 3116); (2) RDS and anonymous HIV testing in one session (n = 498); and (3) venuebased sampling (VBS) and HIV testing in a single session (n = 403). The main outcome was newly diagnosed HIV infection. RDS with anonymous testing and one session reached HHR with less HIV testing experience and more risk factors than the other approaches. Furthermore, RDS with anonymous (4.0%) and confidential (1.0%) testing yielded significantly higher rates of newly diagnosed HIV than VBS (0.3%). Thus peer-referral approaches were more efficacious than VBS for uncovering HHR with undiagnosed HIV, particularly a single-session/anonymous strategy, and have a vital role to play in efforts to eliminate HIV transmission.

Understanding organizations for runaway and homeless youth: A multi-setting quantitative study of their characteristics and effects

Gwadz, M. V., Cleland, C. M., Leonard, N. R., Bolas, J., Ritchie, A. S., Tabac, L., Freeman, R., Silverman, E., Kutnick, A., Dickson, V. V., Hirsh, M., & Powlovich, J. (2017). Children and Youth Services Review, 73, 398-410. 10.1016/j.childyouth.2017.01.016

Using the multiphase optimization strategy (MOST) to optimize an HIV care continuum intervention for vulnerable populations: A study protocol

Gwadz, M. V., Collins, L. M., Cleland, C. M., Leonard, N. R., Wilton, L., Gandhi, M., Scott Braithwaite, R., Perlman, D. C., Kutnick, A., & Ritchie, A. S. (2017). BMC Public Health, 17(1). 10.1186/s12889-017-4279-7
Abstract
Background: More than half of persons living with HIV (PLWH) in the United States are insufficiently engaged in HIV primary care and not taking antiretroviral therapy (ART), mainly African Americans/Blacks and Hispanics. In the proposed project, a potent and innovative research methodology, the multiphase optimization strategy (MOST), will be employed to develop a highly efficacious, efficient, scalable, and cost-effective intervention to increase engagement along the HIV care continuum. Whereas randomized controlled trials are valuable for evaluating the efficacy of multi-component interventions as a package, they are not designed to evaluate which specific components contribute to efficacy. MOST, a pioneering, engineering-inspired framework, addresses this problem through highly efficient randomized experimentation to assess the performance of individual intervention components and their interactions. We propose to use MOST to engineer an intervention to increase engagement along the HIV care continuum for African American/Black and Hispanic PLWH not well engaged in care and not taking ART. Further, the intervention will be optimized for cost-effectiveness. A similar set of multi-level factors impede both HIV care and ART initiation for African American/Black and Hispanic PLWH, primary among them individual- (e.g., substance use, distrust, fear), social- (e.g., stigma), and structural-level barriers (e.g., difficulties accessing ancillary services). Guided by a multi-level social cognitive theory, and using the motivational interviewing approach, the study will evaluate five distinct culturally based intervention components (i.e., counseling sessions, pre-adherence preparation, support groups, peer mentorship, and patient navigation), each designed to address a specific barrier to HIV care and ART initiation. These components are well-grounded in the empirical literature and were found acceptable, feasible, and promising with respect to efficacy in a preliminary study. Methods/design: Study aims are: 1) using a highly efficient fractional factorial experimental design, identify which of five intervention components contribute meaningfully to improvement in HIV viral suppression, and secondary outcomes of ART adherence and engagement in HIV primary care; 2) identify mediators and moderators of intervention component efficacy; and 3) using a mathematical modeling approach, build the most cost-effective and efficient intervention package from the efficacious components. A heterogeneous sample of African American/Black and Hispanic PLWH (with respect to age, substance use, and sexual minority status) will be recruited with a proven hybrid sampling method using targeted sampling in community settings and peer recruitment (N = 512). Discussion: This is the first study to apply the MOST framework in the field of HIV prevention and treatment. This innovative study will produce a culturally based HIV care continuum intervention for the nation's most vulnerable PLWH, optimized for cost-effectiveness, and with exceptional levels of efficacy, efficiency, and scalability. Trial registration: ClinicalTrials.gov, NCT02801747, Registered June 8, 2016.

“Coming From the Place of Walking with the Youth—that Feeds Everything”: A Mixed Methods Case Study of a Runaway and Homeless Youth Organization

Leonard, N. R., Freeman, R., Ritchie, A. S., Gwadz, M. V., Tabac, L., Dickson, V. V., Cleland, C. M., Bolas, J., & Hirsh, M. (2017). Child and Adolescent Social Work Journal, 1-17. 10.1007/s10560-016-0483-z
Abstract
Organizations for runaway and homeless youth (RHY) provide essential services to highly vulnerable youth who have a wide variety of basic needs and complex psychosocial challenges. We present a mixed-methods case study of an RHY organization to identify the specific mechanisms and processes by the organization successfully promotes engagement and positive development of the youth they serve. We analyzed qualitative and quantitative data separately and then integrated these two strands of data. Our findings indicate a consistent convergence of responses across the data sources, in both the qualitative and quantitative strands, that consistently reflect the organization’s youth-centered approach. Primary among these policies and practices is the emphasis on building and maintaining empathetic relationships with youth, the promotion of youths’ autonomy, and an institutional culture of continuous evaluation of how the organization is meeting their mission to provide services that reflect best practices.

Optimization of Multicomponent Behavioral and Biobehavioral Interventions for the Prevention and Treatment of HIV/AIDS

Collins, L. M., Kugler, K. C., & Gwadz, M. V. (2016). AIDS and Behavior, 20, 197-214. 10.1007/s10461-015-1145-4
Abstract
To move society toward an AIDS-free generation, behavioral interventions for prevention and treatment of HIV/AIDS must be not only effective, but also cost-effective, efficient, and readily scalable. The purpose of this article is to introduce to the HIV/AIDS research community the multiphase optimization strategy (MOST), a new methodological framework inspired by engineering principles and designed to develop behavioral interventions that have these important characteristics. Many behavioral interventions comprise multiple components. In MOST, randomized experimentation is conducted to assess the individual performance of each intervention component, and whether its presence/absence/setting has an impact on the performance of other components. This information is used to engineer an intervention that meets a specific optimization criterion, defined a priori in terms of effectiveness, cost, cost-effectiveness, and/or scalability. MOST will enable intervention science to develop a coherent knowledge base about what works and does not work. Ultimately this will improve behavioral interventions systematically and incrementally.

Assertive communication in condom negotiation: Insights from late adolescent couples' subjective ratings of self and partner

Schmid, A., Leonard, N. R., Ritchie, A. S., & Gwadz, M. V. (2015). Journal of Adolescent Health, 57(1), 94-99. 10.1016/j.jadohealth.2015.03.005
Abstract
Purpose Assertive communication has been associated with higher levels of condom use among youth using self-report survey methodology. The purpose of this study was to examine the subjective ratings of assertiveness among young, romantically involved couples in the context of a condom negotiation task. Methods Using an innovative video-recall procedure, 32 couples (64 youth) engaged in a videotaped condom negotiation task and then rated self and partners' level of assertiveness. Both individual ratings of assertiveness and couple-level assertiveness were assessed using dyadic hierarchical linear modeling. Results Individuals' assertiveness was positively associated with condom use. Unexpectedly, the overall level of assertiveness in couples showed a curvilinear association with condom use. Very high and very low assertiveness was associated with lower condom use, whereas moderate levels of assertiveness were associated with higher condom use. Conclusions Moderate levels of assertiveness during condom negotiation may facilitate condom use in young couples. Increasing condom use among romantic partners may require developing interventions that strengthen youths' ability to engage in assertive communication strategies that balance emotional intimacy with self-advocacy.