Implementation Science in HIV Prevention: Health Equity and a Path Forward

Steven A. John, PhD, MPH, is the director of research at the Eli Coleman Institute for Sexual and Gender Health and an associate professor in the Department of Family Medicine and Community Health. Dr. John is a public health scholar and implementation scientist. Much of his research focuses on supporting the rollout of evidence-based practices to support HIV and STI prevention. He leverages principles from implementation science about how to speed up that pipeline from when something is developed to when it makes a clinical impact on patients. Much of his work related to HIV prevention has aligned with the development of new biomedical tools to support HIV prevention as the pipeline keeps developing new modalities to both prevent and treat HIV.

Can you tell us about your current research on HIV and STI treatment and prevention?

A lot of my research over my career and continuing today is about how to better leverage the tools that we have available for HIV and STI prevention and make them more accessible and available to patients who could use them. One of my biggest areas of research is related to increasing the availability of HIV pre-exposure prophylaxis (known as PrEP). That has been around for almost a decade and a half.

PrEP started as a once-daily pill that people can take to prevent HIV, and that was FDA-approved in 2012. Since then, we've found different ways to leverage the dosing of that medication so people can take it every day. People can take it on demand or around sexual activities in particular, so they don't have to take it every day. We've also had additional research showing that different levels of adequate adherence support protection against HIV, and we've found that it's pretty robust at preventing HIV, even when missing some doses here and there.

Much of the biomedical advancement of HIV prevention has really followed the lines of contraception. So there has been the development of injections that folks can get so they don't have to take a daily pill. What became available as Cabotegravir (CAB-LA) is an injection that people take every eight weeks, and that provides protection for a two-month window. But just recently, there's been a new, twice-yearly injection that has been approved by the FDA, Lenacapavir, which has been found to provide superior protection against HIV compared to some of the other PrEP tools that we have available, and that's mostly because it helps prevent any challenges with missed doses.

Can you explain a little more about the dosing and how that is managed?

Folks have different options. They can take a pill every day if they want. But some people don't like to take pills, and some people worry about missing a pill here and there. Some people are worried about others finding their medications. When they see a prescription for something like PrEP, some folks might think it's HIV treatment medication. There's a lot of stigma related to HIV. There's also a lot of stigma sometimes related to PrEP, even in that folks sometimes make assumptions of promiscuity and whatnot when folks are taking it. Some confidentiality is provided by some of these injections because pill bottles aren't nearby.

A lot of my research has looked at several things such as preferences for the types of PrEP that folks would like, even before they become available, getting an idea of how many folks might switch to a new modality based on their life circumstances, and what might work best for them.

Then our research has also looked at getting prepared for the availability of a potential vaccine to prevent HIV, which does not exist yet. But we had some renewed optimism related to the mRNA vaccines. And within this line of PrEP research, a lot of our effort is trying to reach folks who could benefit most from it. And so we often look at it from a health disparities lens and a health equity lens of who could benefit most from a vaccine.

In what ways are various communities affected differently?

We know from epidemiology data that certain communities are more highly affected by HIV. For instance, some of the work that I've done is focused on young, gay, bisexual, queer, and other men who have sex with men and understanding the challenges that some of these folks have trying to get access to culturally competent healthcare and competent sexual health education.

Some of our work has been on developing an mHealth app to support sharing accurate, reliable, and evidence-informed sexual health information. That has been particularly important today because what were previously considered reliable sources of information from web pages funded by the federal government have undergone changes in accuracy regarding some of that information.

The development of that work takes a long time. We spent five years doing the formative work and developing that app, and now we're really trying to pursue additional funding to test it in a much larger population of patients while also understanding that mHealth apps are not a magic bullet to ending the HIV epidemic. Although we can give great information and help share that information, there are still challenges within our healthcare system in navigating access. So our goals are really trying to leverage the mHealth app as one of several tools to try to help folks get better access to these medications to prevent HIV.

In addition to PrEP research, I collaborate in some work focused on the treatment side. We've had some great advancements in HIV medications, helping people live long, healthy lives while on these HIV medications.

But we also have a lot of work to do to help continue helping folks get access to care and stay engaged in care. Now, with the success of our new medications, a lot of our research is also moving to a life course perspective. Some of our projects are looking at supporting older adults living with HIV and how to keep them engaged in care. One of the projects that I collaborate on is focused on older adults living with HIV in rural areas. Our outcomes are not just HIV-related; they also address things like isolation, loneliness, and quality of life. We often find that if we address some of the larger contextual issues, then the HIV and health outcomes fall in line as well.

How has your work in this area progressed over time, and what recent findings or developments stand out to you?

The most pivotal thing that our field has identified is this new twice-yearly injection form of pre-exposure prophylaxis or PrEP. We think about it from a paradigm-shifting perspective. We think that it can really overcome a lot of barriers that folks have experienced with being on oral PrEP and even on some of the earlier formulations of injectables that required dosing more frequently.

Some of our challenges fall within a sociopolitical landscape. We still have major social issues that make accessing care challenging. From a social standpoint, those are related to bias in healthcare, discrimination, and stigma. And now we have threats from an institutional level and a health insurance and healthcare system standpoint of impeding access to care, related to changes that could potentially happen to Medicaid and Medicare.

Another challenge is trying to continue our work in the face of these obstacles. We've seen the direct threats as some NIH grants were terminated, either directly or administratively canceled. We've also seen a lot of our direct-to-service type of grants get cut, like funding through the CDC and other areas. A lot of our community-based organizations rely on those types of funding to keep the programs going.

We are at a point where we know how to treat HIV really well and we know how to prevent HIV really well. But from a psychosocial standpoint, we still have a lot of these larger contextual issues to navigate in order to end the HIV epidemic.

Are there any emerging scientific advances or new approaches that you find especially promising for HIV or STI prevention and treatment?

This is not necessarily new from a scientific aspect, but it's much newer from a scientific communication standpoint, and it's what we refer to as treatment as prevention (TasP).

What we know is that HIV medications work so well that they reduce the amount of viral load in the body. The amount of HIV in the body gets down to levels that our tests can't detect, and at that point we call it “undetectable.”

So there's been a new push for messaging related to undetectable equals untransmittable. Getting people on HIV medication and keeping them engaged in care not only keeps them healthy, but it prevents onward transmission to their sexual partners. This “U equals U” — undetectable equals untransmittable — messaging has several benefits. It’s not only about sharing scientific findings but also about trying to reduce some of the stigma related to HIV because we know that there's a long history of that in our country and worldwide.

Which populations are more at risk, and what factors contribute to these disparities?

There are populations that have heightened vulnerability to HIV, and our epidemiology data show that transgender women in particular are particularly vulnerable to HIV. We've also seen that gay, bisexual, queer, and other men who have sex with men are at heightened vulnerability as well. We see higher rates of HIV incidence in those populations.

Within all of this, though, it's important to look at it from an intersectionality lens. Even within these groups that are disproportionately affected, there are subgroups that are even more highly affected. We frequently see that by race and ethnicity. In particular, Black trans women are particularly vulnerable to HIV. We see that among men who have sex with men, too: Black and Latino men who have sex with men are at heightened vulnerability, too.

We've tried to move away from some of this higher-risk type of language in order to move away from the individual-centric prevention modality. Our understanding is that these disparities are caused by larger macro-level factors. And so it's analogous to what we formerly often referred to as sexual and gender minorities. We like to now use “sexual and gender minoritized.”

It’s about understanding that the onus of that inequity is caused by other systems. We see various forms of discrimination contributing to that. We see how employment and income can impact one’s ability to get insurance and to afford co-pays for prevention and treatment. And we can see how having access to transportation can get you access to clinical appointments and things.

So we have these large barriers that we are competing with. And then we also have to think about it from a discrimination standpoint. Within our healthcare system, we know that there's bias in the delivery of healthcare. We're actively trying to train clinicians and our future generations of providers, but we still have racism, homophobia, transphobia, and those types of things in healthcare and our healthcare systems.

What do you hope to achieve in the next few years through your research or clinical work?

Our goals are to end the HIV epidemic, and some of those initial goals were to try to end the HIV epidemic by the year 2030. That seems a little bit unrealistic now, given the current cuts and infrastructure changes. But from a moving-the-needle standpoint, we want to continue to try to increase access to these evidence-based forms of treatment and prevention.

When we look at areas of PrEP among young gay, bisexual, queer, and other men who have sex with men, the rate of PrEP use is about one in four among folks who could benefit from it. But our epidemiology modeling studies indicate that our level of PrEP should be closer to 50% of those who would benefit to really move the needle. Some of our goals of ending the HIV epidemic revolve around increasing access to PrEP.

But none of this is in isolation. It's the coupling effect of increasing access to treatment and keeping people engaged in care, and then also increasing access to the number of people engaging in HIV prevention as well.

So a lot of our field is really pushing forward concepts of implementation science, realizing that we have innovations available to end the HIV epidemic. We just need to figure out how to get them within our clinical systems, in our communities, and into the hands of the individuals who could benefit most from them.

A lot of our work is focused on how to better roll out what we already have, as opposed to developing something brand new.

For people outside the research or medical communities, why does this work matter? Why should the average person care about advances in HIV and STI prevention?

Folks should care about the HIV epidemic because it is affecting a lot of people in the United States and worldwide. In the US, we still have about 30,000 people newly diagnosed with HIV each year, despite the ability of known prevention and treatment mechanisms to prevent onward transmission of HIV. Approximately 1.2 million people in the U.S. have HIV.

When we think about that in the context of our healthcare systems, those systems spend over $16 billion in treatment costs related to preventable sexually transmitted infections–both bacterial and viral. HIV prevention can be really cost-efficient as opposed to the lifetime treatment costs for somebody who would be diagnosed with HIV today, which is estimated at over $400,000.

The amount that we might spend on prevention goes a long way in saving money for our healthcare systems, which trickles down to all aspects of our healthcare. And that's just from the dollar-pragmatic perspective. I share that first because it's something that might reach across different political divides: the significant cost-benefit of this type of work.

It is also from an equity-centered approach in that HIV does not affect all communities the same. So there's a moral obligation that we have as a society to look after one another. We should pay attention to these things even if they are not affecting our communities as much because there might be other things that affect our community more. We should be taking care of our neighbors.