"We're Here to Take Care of Our Community": Lessons Learned From the U.S. Federal Health Center Covid-19 Vaccine Program.

Equitable access to vaccination is crucial to mitigating the disproportionate impact of Covid-19 on low-income communities and people of color in the United States. As primary care clinics for medically underserved patients, Federally Qualified Health Centers (FQHCs) emerged as a success story in the national effort to vaccinate the U.S. public against Covid-19. In February 2021, the Federal Health Center Covid-19 Vaccine Program began allocating vaccine supply directly to FQHCs in an effort to improve vaccine equity. This qualitative study documents how FQHCs in two states successfully mitigated barriers to vaccine access, responded to patient concerns about vaccination, and worked to maintain and grow community trust in a climate of uncertainty and fear during early vaccine roll-out to the general population. Using a socio-ecological model, we show how FQHCs intervened at multiple levels to advance vaccine equity, revealing valuable lessons for health promotion practice in primary care settings or underserved communities. Our findings provide descriptive context for existing quantitative evidence showing FQHCs' greater success in vaccinating people of color, and foreground valuable and innovative strategies for trustworthy health communication practices and equitable resource allocation to medically underserved patients and populations.

All of Us and the Promise of Precision Medicine: Achieving Equitable Access for Federally Qualified Health Center Patients.

The United States National Institutes of Health's (NIH) All of Us (AoU) initiative recruits participants from diverse backgrounds to improve the makeup of biobanks, considering nearly all biospecimens used in research come from people of European ancestry. Participants who join AoU consent to provide samples of blood, urine, and/or saliva and to submit their electronic health record to the program. In addition to diversifying precision medicine research studies, AoU will return genetic results back to many participants, which may require further follow-up care (i.e., more frequent cancer screening or mastectomy after a BRCA result). To help achieve its goals, AoU has partnered with Federally Qualified Health Centers (FQHCs), which is a type of community health center whose patient base is comprised largely of people who are uninsured, underinsured, or on Medicaid. Our NIH-funded study convened FQHC providers involved in AoU to better understand precision medicine in community health settings. Drawing from our findings, we present barriers community health patients and their providers face when accessing diagnostics and specialty care after genetic results necessitate medical follow-up care. We also propose several policy and financial recommendations to help overcome the challenges discussed, stemming from a commitment to equitable access to precision medicine advances.

The 'indirect costs' of underfunding foreign partners in global health research: A case study.

This study of a global health research partnership assesses how U.S. fiscal administrative policies impact capacity building at foreign partner institutions. We conducted a case study of a research collaboration between Mbarara University of Science and Technology (MUST) in Mbarara, Uganda, and originally the University of California San Francisco (UCSF), but now Massachusetts General Hospital (MGH). Our case study is based on three of the authors' experiences directing and working with this partnership from its inception in 2003 through 2015. The collaboration established an independent Ugandan non-profit to act as a local fiscal agent and grants administrator and to assure compliance with the Ugandan labour and tax law. This structure, combined with low indirect cost reimbursements from U.S. federal grants, failed to strengthen institutional capacity at MUST. In response to problems with this model, the collaboration established a contracts and grants office at MUST. This office has built administrative capacity at MUST but has also generated new risks and expenses for MGH. We argue that U.S. fiscal administrative practices may drain rather than build capacity at African universities by underfunding the administrative costs of global health research, circumventing host country institutions, and externalising legal and financial risks associated with international work. ABBREVIATIONS: MGH: Massachusetts General Hospital; MUST: Mbarara University of Science and Technology; NIH: National Institutes of Health; UCSF: University of California San Francisco; URI: Uganda Research Institute.

Inequality and ethics in paediatric HIV remission research: From Mississippi to South Africa and back.

In 2013, physician-researchers announced that a baby in Mississippi had been 'functionally cured' of HIV [Persaud, D., Gay, H., Ziemniak, C. F., Chen, Y. H., Piatak, M., Chun, T.-W., … Luzuriaga, K. (2013b, March). Functional HIV cure after very early ART of an infected infant. Paper presented at the 20th conference on retroviruses and opportunistic infections, Atlanta, GA]. Though the child later developed a detectable viral load, the case remains unprecedented, and trials to build on the findings are planned [National Institute of Allergy and Infectious Diseases. (2014). 'Mississippi baby' now has detectable HIV, researchers find. Retrieved from http://www.niaid.nih.gov/news/newsreleases/2014/pages/mississippibabyhiv.aspx ]. Whether addressing HIV 'cure' or 'remission', scrutiny of this case has focused largely on scientific questions, with only introductory attention to ethics. The social inequalities and gaps in care that made the discovery possible - and their ethical implications for paediatric HIV remission - have gone largely unexamined. This paper describes structural inequalities surrounding the 'Mississippi baby' case and a parallel case in South Africa, where proof-of-concept studies are in the early stages. We argue that an ethical programme of research into infant HIV remission ought to be 'structurally competent', and recommend that paediatric remission studies consider including a research component focused on social protection and barriers to care.

"Come back when you're dying:" the commodification of AIDS among California's urban poor.

As with any other long-term illness, the decline in health that accompanies symptomatic HIV infection often has a profound negative impact on employment and personal finances. However, research to date on the financial consequences of AIDS has focused largely on middle-class working individuals, and cannot account for the experiences of those who are already poor and unemployed at the time of their infection. We conducted in-depth qualitative interviews with 33 Californian heterosexual couples in which one partner was infected with HIV and the other was HIV-negative. Most couples interviewed were low-income, marginally housed, and either former or active substance users. Unlike their middle-class counterparts, it became clear through the course of our study that many participating couples were living in a world in which a positive HIV antibody test or an AIDS diagnosis could result in an improved quality of life by allowing for increased access to Supplemental Security Income, subsidized housing, food and services. This situation is in part a consequence of recent policy decisions related to the "War on Drugs" and welfare reform. These policies have contributed to the creation of an economy of poverty in which the sick, needy, and addicted must compete against each other for scarce resources. Within such an economy, an HIV or AIDS diagnosis may actually operate as a commodity.