Prof. Marya Gwadz awarded $5.8M NIH HIV care continuum intervention grant for at-risk African American/Black and Hispanic persons living with HIV

New York University Rory Meyers College of Nursing Senior Research Scientist Marya Gwadz, PhD, along with Distinguished Professor Linda M. Collins, PhD, Penn State’s College of Health and Human Development, have received a five-year, $5.8M grant from the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health (NIH).

The NIDA funding will support a study which utilizes a pioneering engineering-inspired framework - the Multiphase Optimization STrategy (MOST) - developed by Dr. Collins, to design an intervention to increase engagement along the HIV care continuum for African American/Black and Hispanic People Living with HIV (PLWH) who are neither taking antiretroviral therapy (ART) nor well engaged in HIV primary care.

“At least half of PLWH in the U.S. are neither sufficiently engaged in HIV primary care nor taking antiretroviral therapy (ART),” said Dr. Gwadz.  “In particular, African American/Black and Hispanic PLWH are less likely to be well engaged along the HIV care continuum than their White peers, and as a result, have lower rates of HIV viral suppression, greater morbidity, and earlier mortality from HIV.” 

“Traditional ART adherence interventions are not appropriate for these individuals,” notes Dr. Gwadz, “because they experience serious emotional, attitudinal, social, and structural barriers to initiating ART, and as a result, can be described as ‘not ready’ for ART. Further, those who have delayed, declined, or discontinued ART also avoid HIV care, and therefore are rarely seen in HIV clinics. These multi-level barriers must be addressed to increase their emotional and practical readiness to both initiate ART and engage in HIV care. Yet there are almost no behavioral interventions focusing on patients who have delayed, declined, or discontinued ART.”

The study also includes co-investigators Charles M. Cleland, PhD and Noelle R. Leonard, PhD at NYU Meyers, Leo Wilton, PhD at Binghamton University, and Scott Braithwaite, MD at the NYU Langone School of Medicine.

The MOST framework is a means of assessing the performance of individual intervention componentsand their interactions, in contrast to the “classical” approach of testing a packaged multi-component intervention against a control.

This is the first study to apply the MOST framework in the field of adult HIV treatment and prevention, and also the first study to include a cost-effectiveness analyses as one aspect of the optimization process.

To this end, the goals of the proposed intervention are threefold:

1. Identify which of five intervention components contribute meaningfully to improvement in the primary outcome, viral suppression, and secondary outcomes, absolute viral load, ART adherence, and engagement in HIV primary care, all assessed via objective biomarkers or through the medical record.
2. Identify mediators and moderators of the efficacy of each intervention component (e.g., substance use history, sexual minority status), and also of interaction effects between components.
3. Using a mathematical modeling approach led by Dr. Braithwaite, build the most cost-effective and efficient intervention package from the components found to be efficacious in the first goal.

The necessity of potent interventions for this cohort has become increasingly apparent to public health researchers and other stakeholders over the last several decades, particularly for PLWH of color who suffer a unique set of barriers to engagement in the current HIV care continuum. 

“The reasons that PLWH of color are less likely to be well engaged along the HIV care continuum stem from a variety of factors--alcohol or drug use problems, distrust of medical settings and medications, fear of side effects, stigma associated with HIV, and others--both historical and cultural,” said Dr. Gwadz. “Further, these barriers are grounded in and complicated by low socio-economic status.” 

“These gaps in the HIV care continuum signal the need for culturally targeted interventions to reduce racial/ethnic health disparities, eliminate forward transmission of HIV, and decrease healthcare costs, consistent with the high-priority research areas recently designated by the NIH Office of AIDS Research,” said Dr. Collins.  “But we need new methodological approaches to these serious problems.”

“The intervention components we will test are grounded in our past research with this population and the larger research literature on care continuum interventions. Importantly, they are culturally appropriate for African American/Black and Hispanic PLWH, including those with substance use problems, and sexual minorities,” said Dr. Cleland. “The components include Motivational Interviewing intervention sessions with individual PLWH, peer mentorship, focused support groups, pre-adherence skill building, and patient navigation to ancillary services.”

“These groups desire and deserve good health as much as any other, but the impediments to their achieving that goal are multi-faceted and complex,” said Dr. Leonard. “For the past ten years our research team at NYU has focused on understanding these barriers from the perspectives of African American/Black and Hispanic PLWH, as well as how to reduce or circumvent them.”

“We are appreciative that interventions to improve engagement along the HIV care continuum for our nation’s most vulnerable populations ranks among NIDA’s highest research priorities,” said Dr. Wilton.

Drs. Gwadz, Cleland, and Leonard are affiliated with NYU Meyers’ NIDA-funded Center for Drug Use and HIV Research (CDUHR; P30DA011041). Dr. Gwadz serves as director for CDUHR’s Transdisciplinary Research Methods Core, and Drs. Cleland and Leonard are associate directors in the core.

Dr. Collins is Distinguished Professor in the Department of Human Development and Family Studies and director of The Methodology Center, an externally funded research center at the Pennsylvania State University supported by NIDA, NIAAA, NCI, and NIDDK.

Dr. Wilton is Professor in the Department of Human Development, Binghamton University. 

Dr. Braithwaite, MD, MSc is Tenured Professor of Population Health and Medicine, Director of the Division of Comparative Effectiveness and Decision Science at New York University School of Medicine and President of the Society of Medical Decision Making.