Future HIV Mentoring Programs to Enhance Diversity.

This paper proposes a general template to guide future mentoring program development addressing: (i) considerations to ensure an adequate research workforce; (ii) key guidelines and principles of mentoring; and (iii) use of a logic model to develop program milestones, outcomes and evaluation. We focus on these areas to guide and inform the most effective mentoring program components, which we find to be more helpful than identifying specific features and ingredients. Although the focus is on the development of a new generation of investigators from diverse backgrounds, this template may also apply to mentoring programs for other investigators and for disciplines beyond HIV.

Building a More Diverse Workforce in HIV/AIDS Research: The Time has Come.

UNLABELLED: Investigators from diverse racial and ethnic backgrounds are grossly underrepresented in the nation's biomedical research enterprise. Projections of current demographic trends suggest that population growth rates of minority populations will outpace that of the Caucasian population by 2060. Thus, this workforce will remain a poor reflection of the U.S. POPULATION: As a result of this underrepresentation of all sectors of the U.S. populace, the majority of the HIV research involving minority populations-those disproportionately impacted by HIV infection-will be conducted by investigators who do not resemble them. Although this does not necessarily preclude scientifically valid and important research, it produces research without the important cultural and contextual issues that can enhance the utility and generalizability of specific findings or interventions. The goal of this review is to not only raise awareness of the small numbers of minority investigators engaged in biomedical research, but also to identify the challenges to recruiting and retaining these investigators. In this article, while we discuss issues of diversity in general, the focus will be upon the mental health aspects of the HIV epidemic for illustrative purposes: to demonstrate the issues associated with enhancing investigator diversity as a strategy for remediating the chronic shortage of historically underrepresented investigators in scientific research. After presenting the magnitude of the problem and a rationale for enhancing diversity of the biomedical research workforce, we identify a number of potential reasons and challenges for the shortage of minority investigators. Aspects of the mentoring process, together with ten key suggestions, are discussed as the backdrop for the supplement papers that follow (dealing with mentoring principles, challenges, and mentoring-related issues on mentee, mentor, mentee-mentor relationship, and programs). By identifying these realities we hope to: (1) promote greater discussions of these challenges in academic institutions and settings; (2) suggest meaningful strategies to address these challenges; and (3) foster a national discussion about the long-term investment necessary for permanent change, as there are no easy 'fixes' for these challenges.

Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel.

DESCRIPTION: After HIV diagnosis, timely entry into HIV medical care and retention in that care are essential to the provision of effective antiretroviral therapy (ART). Adherence to ART is among the key determinants of successful HIV treatment outcome and is essential to minimize the emergence of drug resistance. The International Association of Physicians in AIDS Care convened a panel to develop evidence-based recommendations to optimize entry into and retention in care and ART adherence for people with HIV. METHODS: A systematic literature search was conducted to produce an evidence base restricted to randomized, controlled trials and observational studies with comparators that had at least 1 measured biological or behavioral end point. A total of 325 studies met the criteria. Two reviewers independently extracted and coded data from each study using a standardized data extraction form. Panel members drafted recommendations based on the body of evidence for each method or intervention and then graded the overall quality of the body of evidence and the strength for each recommendation. RECOMMENDATIONS: Recommendations are provided for monitoring entry into and retention in care, interventions to improve entry and retention, and monitoring of and interventions to improve ART adherence. Recommendations cover ART strategies, adherence tools, education and counseling, and health system and service delivery interventions. In addition, they cover specific issues pertaining to pregnant women, incarcerated individuals, homeless and marginally housed individuals, and children and adolescents, as well as substance use and mental health disorders. Recommendations for future research in all areas are also provided.

Valuing the Vulnerable - The Important Role of Transgender Communities in Biomedical Research.

Every cell has a genetic sex that is determined at the time of fertilization. However, the natal sex of cells may not match the hormonal environment in which they reside in transgender individuals. This discordance provides a unique opportunity to study the short- and long-term effects across a range of cellular functions, health conditions, physiologic processes and psychosocial outcomes to the benefit of transgender and cisgender communities. While there is a growing body of knowledge as the literature on sex differences in virtually every organ system accumulates, there remains a paucity of data on the effect of cross hormonal therapy on cellular function in transgender individuals. Beyond cellular function, the effect of cross hormonal therapy on neuroanatomy, the interpretation of neuropsychological assessments or even the effect of daily stressors of stigma and discrimination on long-term neurocognitive function remain unclear. In 2011 the Institute of Medicine indicated that transgender adults were an understudied population and in critical need of more biomedical and population health research, yet the experience of stigma, discrimination, microaggressions, limited access to culturally competent care continue to make this an unfulfilled mandate. In addition to using a life course perspective, it is essential to identify research gaps and formulate a responsive research agenda while maintaining scientific rigor and respectful involvement of the population under study. None of this, however, will enhance the participation of transgender communities in biomedical research until the transgender and biomedical research communities can engage in open, respectful and bidirectional dialogue. From respectful, sensitive and appropriate health care to culturally competent research engagement from study inception to data dissemination, transgender communities can make an important and valuable contribution to biomedical research. Inclusion of their voices at all levels, including investigators from transgender communities, are essential to advance this much overdue scientific agenda. Transgender, cisgender and the biomedical research communities will all benefit from a more inclusive and expansive research agenda.

Enrollment of racial/ethnic minorities and women with HIV in clinical research studies of HIV medicines.

PURPOSE: Inclusion of women and racial/ethnic minorities is a requirement for federally supported clinical research, but data on clinical research participation from women and racial/ethnic minorities with HIV are few. To describe participation in clinical research of HIV medicines among women and racial/ethnic minorities, and associated factors, we used data from a cross-sectional behavioral surveillance interview project conducted in 15 U.S. states. METHODS: Data were from 6,892 persons living with HIV infection, recruited in facilities in seven U.S. states and using population-based methods in eight other states, between 2000-2004. We calculated self-reported participation in a clinical research study of HIV medicines, factors associated with self-reported study participation among men and women, and reasons for not participating in a study among nonparticipants. MAIN FINDINGS: Overall, 17% of respondents had ever participated in a clinical research study. For men, the odds of participation were lower for black or Hispanic men (versus white men) and were higher for men whose risk for HIV infection was male-male sex (versus men with male-female sex risk) and for men with AIDS. For men who had not participated in a study, black men were more likely than white men to report not participating in a study because they were unaware of available studies or were not offered enrollment (75% vs. 69%), and because they did not want to be a "guinea pig" (11% vs. 8%). Among women, participation was not associated with race/ethnicity or risk for HIV infection but was associated with living in an area with an NIH- or CDC- supported clinical research network. HIV-infected women were more likely than HIV-infected men with comparable modes of HIV acquisition to have participated in a study. CONCLUSIONS: Among persons with HIV interviewed in these 15 states, self-reported participation in clinical research studies was higher among women than men, but racial/ethnic minority men were less likely to report study participation. Our data suggest that clinicians and researchers should make increased efforts to offer study participation to racial and ethnic minority men.

Integrating care for hepatitis C virus (HCV) and primary care for HIV for injection drug users coinfected with HIV and HCV.

Injection drug use accounts for most of the incident infections with hepatitis C virus (HCV) and for at least one-third of new human immunodeficiency virus (HIV) infections. Coinfection with HCV and HIV presents complex and challenging medical conditions. Ensuring access to and maintaining care for HIV and HCV for drug users presents special challenges to the health care team that require a nonjudgmental attitude, experience, and patience. Care for HCV infection, however, can be used as an instrument to engage drug-using persons in ongoing primary care relationships. Common elements to both care for HCV infection and primary care for HIV infection are testing for and counseling about HCV and HIV, substance abuse and mental health services, social support, and subspecialty referral. These elements, in particular treatment for substance abuse, can be focal points for model care systems that provide integrative care for both HCV and HIV infections.

Overcoming barriers to prevention, care, and treatment of hepatitis C in illicit drug users.

Injection drug use accounts for most of the incident infections with hepatitis C virus (HCV) in the United States and other developed countries. HCV infection is a complex and challenging medical condition in injection drug users (IDUs). Elements of care for hepatitis C in illicit drug users include prevention counseling and education; screening for transmission risk behavior; testing for HCV and human immunodeficiency virus infection; vaccination against hepatitis A and B viruses; evaluation for comorbidities; coordination of substance-abuse treatment services, psychiatric care, and social support; evaluation of liver disease; and interferon-based treatment for HCV infection. Caring for patients who use illicit drugs presents challenges to the health-care team that require patience, experience, and an understanding of the dynamics of substance use and addiction. Nonetheless, programs are successfully integrating hepatitis C care for IDUs into health-care settings, including primary care, methadone treatment and other substance-abuse treatment programs, infectious disease clinics, and clinics in correctional facilities.

HIV/AIDS: a minority health issue.

HIV infection among racial and ethnic minorities is an ongoing health crisis. The disproportionate impact of HIV infection on racial and ethnic minorities has affected communities already struggling with many social and economic challenges, such as poverty, substance abuse, homelessness,unequal access to health care, and unequal treatment once in the health care system. Superimposed on these challenges is HIV infection, the transmission of which is facilitated by many of these factors. Although the epidemic is disproportionately affecting all racial and ethnic minorities, within these minority populations women are particularly affected. The care and management of racial and ethnic minorities who have HIV infection has been complicated by the unequal access to health care and the unequal treatment once enrolled in health care. Health insurance status, lack of concordance between the race of the patient and the provider, and satisfaction with the quality of their care all impact on treatment outcomes in this population. In addition, the provider must be aware of the many comorbid conditions that may affect the delivery of care to minority patients living with HIV infection: depression, substance and alcohol abuse, and posttraumatic stress disorders. The impact of these comorbid conditions on the therapeutic relationship, including treatment and adherence, warrants screening for these disorders and treating them when identified. Because the patient provider relationship has been repeatedly identified as a predictor of higher adherence, developing and maintaining a strong therapeutic alliance is critical. Participation of racial and ethnic minorities in HIV clinical trials, as in other disease states, has been very poor. Racial and ethnic minorities have been chronically underrepresented in HIV clinical trials, despite their overrepresentation in the HIV epidemiology. This underrepresentation seems to be the result of a combination of factors including (1) provider bias in referring to clinical trials, (2) mistrust of clinical research, (3) past poor experience with the health care system, and (4) the conspiracy theories of HIV disease. The paucity of minority health care professionals and minority investigators in HIV research further affects minority participation in clinical research. To improve racial and ethnic minority participation in clinical trials a sustained effort is necessary at multiple levels. Increased recruitment and retention is an ongoing need, and one that will not be satisfactorily addressed until there are better community-academic and research partner-ships, and the research questions posed also address issues of concern and significance to the affected community. Reduction in barriers to participation in clinical trials, especially given the many competing needs of racial and ethnic minority patients, is also needed. Multidisciplinary HIV care teams and research staff with training in cultural competency and cultural sensitivity may also be helpful. Prevention of HIV infection remains essential, especially among those seeking care for HIV infection. Despite several published recommendations for the inclusion of HIV prevention in the clinical care setting, studies have documented how few providers actually achieve this goal, especially those who care for disadvantaged patients. Although there are many barriers to discussing HIV risk behaviors and prevention strategies in an office visit,including time constraints and potential provider discomfort in discussing these matters, clinical visits represent an important opportunity to reinforce HIV prevention and possibly decrease further HIV transmission.

Linkage, engagement, and retention in HIV care among vulnerable populations: "I"m sick and tired of being sick and tired".

There are disparities in engagement and retention in HIV care and outcomes of care across segments of society. For example, HIV mortality rates remain markedly elevated among black women and men compared with their white counterparts. These differences reflect broader disparities across social, economic, and cultural lines. Improvement in engagement and retention in HIV care requires interventions that account for forces present in the socioecologic framework of health behaviors. Improvement in linkage to care at HIV testing is crucial to overall engagement and retention in care. Strategies for linkage to care at testing can help overcome many of the forces that result in failure to engage and remain in care by starting the patient on a solid path to clinical care. This article summarizes a presentation by Victoria A. Cargill, MD, MSCE, at the IAS-USA continuing education program held in New York, New York, in May 2013.