New York University College of Nursing (NYUCN) received a five-year, $7.56 million grant from the National Institute on Drug Abuse (NIDA) at the National Institutes of Health (NIH) to evaluate the efficacy and cost-effectiveness of a peer-driven intervention to seek out heterosexuals at high risk for HIV in their communities, test them for HIV, and link them to care in a timely fashion if they are found to be HIV infected.
An estimated 25% of individuals currently living with HIV in the United States do not know they are infected. This undiagnosed HIV infection is particularly prevalent among populations that experience barriers to testing and care and that are therefore difficult to reach and engage. It is well documented that heterosexuals at high risk for HIV ("HHR") are significantly less likely to test for HIV and more likely to be diagnosed with HIV late in the course of their HIV disease compared to their peers with traditional risk factors for HIV such as men who have sex with men and those who inject drugs. HHR also tend to experience serious delays in accessing care, placing them at grave risk for illness, loss of quality of life, and early mortality. People of color, particularly African Americans and Latinos, are vastly over-represented among the population of HHR.
The overall goal of this study is to develop a user-friendly, fairly brief, potent, and cost-effective method for reaching the population of HHR, and bringing those found to be infected with HIV into care in a timely fashion.
The problem of testing, treatment, and retention into care for HHR is challenging, because the population experiences a range of barriers to needed services. Among these are structural barriers, such as poor access to or difficulty accessing high-quality HIV testing and care; social barriers including social norms that do not encourage frequent use of health care generally, including of HIV testing; and numerous individual-level barriers such as mistrust of medical settings, fear of HIV testing, and not feeling at particularly high risk for HIV.
In fact, the prevalence of HIV infection among HHR in New York City has been found to be very high. Our research team, in collaboration with the New York City Department of Health and Mental Hygiene, has conducted surveillance with this population as part of the National HIV Behavioral Surveillance (NHBS) studies, led by Dr. Holly Hagan, a Professor at the College of Nursing. In the 2006-2007 study the NHBS found that over 7% of HHR in high-risk areas in New York City were infected with HIV, and only about 5% were aware of their diagnoses.
"Even more striking, the NHBS study found that 11% of those in central Brooklyn were HIV-infected but did not know their status," said Dr. Marya Gwadz, a Senior Research Scientist at the College of Nursing, and the peer-driven intervention study's Principal Investigator. "These findings inspired us to focus our efforts on this vulnerable population, and to concentrate on central Brooklyn, an area considered 'high risk' because of its elevated rates of poverty and a high HIV prevalence."
Gwadz and her research team, which includes Dr. Charles Cleland, Dr. Holly Hagan, Dr. Ann Kurth, and Dr. Noelle Leonard of the College of Nursing, and Dr. David Perlman of Beth Israel Medical Center, will build on the NHBS methodology, which uses a peer referral method called "respondent driven sampling," to seek out and test HHR for HIV. Further, it will combine this recruitment method with peer education activities that can be conducted during the course of peer recruitment. These peer education activities are designed to increase an individual's motivation to join the study, be tested for HIV, and receive care in a timely fashion if HIV-infected. This is followed by patient navigation, an approach to support access to care, for those found to be HIV infected.
The peer-driven intervention is tailored specifically for African American and Latino HHR. "We also designed it to be easy to use in the future in health departments and community-based organizations, by making use of computerized interactive components that don't require staff time to facilitate, peer-delivered components, which participants deliver independently, and patient navigation, a flexible and individualized approach to managing a complex health care system," said Dr. Gwadz. The project will enroll 3400 HHR in central Brooklyn over the course of five years.
"The Department of Health has taken an active role in making sure all New Yorkers are offered HIV testing during medical encounters and then linked to care if they are found to be infected. Yet despite these efforts, the NHBS found that only a third of HHR had been tested in the past year. This suggests to us that in addition to the Department of Health initiatives we need active recruitment approaches to reach and engage people in their communities. Peer-driven interventions are powerful because they can simultaneously address both individual and social barriers," said Gwadz. "Participants also like peer-driven interventions, because it provides them with a chance to give back to the community and help others access needed services."
The NHBS studies are the main surveillance efforts funded by the Centers for Disease Control and Prevention. These studies use both the peer referral method (respondent driven sampling), as well as individual recruitment of participants in select social venues at select times, called "venue based sampling." While both of these recruitment methods have been effective in reaching vulnerable populations, no one has yet directly compared their effectiveness and relative costs for identifying undiagnosed HIV infection in HHR. One aim of this study is to answer this important research question and therefore provide guidance to the public health community on the costs and relative merits of each recruitment approach.
"The study is designed to complement the vital local and national HIV prevention initiatives currently in place. We plan to contribute an efficient, innovative, and sustainable multi-level intervention to the HIV prevention portfolio at the end of the study," said Gwadz, "as well as guidance on optimal approaches to reach HHR. Because the vast majority of HHR are African-American or Latino, we hope the study will ultimately play an important role in reducing racial/ethnic disparities in HIV/AIDS."
|Contact: Christopher James|
New York University