Principal Investigator: April D. Kimmel, Ph.D.

Funding Source: Centers for Disease Control and Prevention (CDC), Department of Health and Human Services (HHS)

Project Summary: This project will leverage administrative claims data to identify people living with HIV who are receiving medical care but not antiretroviral therapy, and will deliver both provider- and patient-level interventions that support prescription of, and adherence to, antiretroviral therapy. This work will develop and evaluate the clinical and cost effectiveness of a real-time intervention that can be scaled and implemented in other jurisdictions. Increasing the appropriate prescription of antiretroviral therapy and supporting medication adherence are critical for improving the health of people living with HIV, ultimately extending life expectancy and preventing onward HIV transmission.

Site Principal Investigator: April D. Kimmel, Ph.D.

Funding Source: National Institutes of Health (NIH), National Cancer Institute (NCI), National Institute of Allergy and Infectious Diseases (NIAID), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), and National Institute on Drug Abuse (NIDA)

Project Summary: Elimination of HIV infection as a cause of human illness and death and achieving "zero HIV transmission" have been embraced by the AIDS research and treatment communities as achievable. As HIV care and treatment programs are implemented throughout Africa, critical advances in research and policy are needed so that care and treatment resources can be deployed to optimal benefit: decreasing both new HIV transmissions and HIV-related morbidity and mortality.

Among the most important challenges to maximizing the public health benefits of HIV care and treatment programs are late diagnosis of HIV infection, low rates of linkage to care and high rates of late ART initiation which in turn are associated with high rates of mortality, more costly clinical management and continued HIV transmission. In addition there remain unanswered clinical questions for persons living with HIV (PLWH) even with optimal ART. For PLWH in Sub-Saharan Africa (SSA), ART has been highly effective in decreasing HIV-related morbidity (and mortality), but the association of HIV with metabolic diseases and other conditions of aging (e.g. cancers), and the impact of under- or over-nutrition are not well defined.

Newly funded as CA-IeDEA four years ago, we have built a new Central Africa IeDEA (CA- IeDEA), and have:

• Compiled and managed secondary source patient-level data on ~52,000 patients through both extraction from existing electronic data and new on-the-ground systems for efficient capture of clinical data in low-resource clinical settings
• Been highly productive scientifically with >20 publications even while data collection was in development
• Continued to foster African leadership and build local research capacity.

We propose now to increase the database modestly (to ~80,000 patients) to increase the representativeness of HIV in the region geographically and in service delivery strategies and success and to expand our implementation science approaches to optimize short- and long-term HIV care outcomes both in Central Africa and globally, continue to investigate epidemiologic questions with clinical impact, with a focus on the comorbidities of aging and women's reproductive health.

Principal Investigator: April D. Kimmel, Ph.D.

Funding Source: National Institute on Minority Health and Health Disparities

Project Summary: While clinical care for HIV has made tremendous advances, many persons living with HIV in the U.S. do not receive the evidence-based care that will allow them to fully extend life and improve health. Lack of effective HIV care is particularly problematic in the Southern region, the epicenter of the U.S. HIV epidemic and where poverty, uninsurance, rurality and a constrained health workforce further threaten effective care. Research suggests that system-level factors, or the structural and policy-related aspects of health care delivery, have the potential to improve quality of care and health outcomes. But little is known about their role in the context of HIV care delivery, quality of care and health outcomes.

The proposed research will study how two modifiable system-level factors — geographic accessibility to care and physician payment policies — affect quality of HIV care and population outcomes, including new HIV infections, along the HIV care continuum in the U.S. South. Because racial and ethnic minorities face increased barriers to HIV care, we pay special attention to how these system-level factors may contribute to disparities in quality of HIV care and population outcomes along the HIV care continuum.

The research involves developing a novel database that combines multiple data sources, including Medicaid administrative claims files, HIV surveillance data, and county and state characteristics from national datasets. Our approach will rely on state-of-the-art spatial network analysis and data visualization (mapping), statistical tests using econometric methods, and systems science forecasting techniques that have been used to study quality of care and population health outcomes. The work moves beyond examination of core quality of HIV care measures to include HIV-related preventive care measures that collectively are critical to reducing HIV morbidity and mortality.

In investigating these factors, the study will answer important questions, such as:

• How do geographic accessibility, measured in travel time to receive care, and physician payment for services affect quality of HIV care in the South?
• Are these effects different among racial and ethnic minorities?
• Do improvements in geographic accessibility or increased physician payments reduce new HIV infections and racial and ethnic disparities along the HIV care continuum?

By quantifying the role of system-level factors in quality of HIV care and population health along the HIV care continuum, as well as understanding disparities in these effects, the research will provide valuable information to state and federal policy makers who seek to address systemic challenges to effective HIV care, efficiently allocate scarce resources, and improve public health.