reprinted from Issue 9, Fall 2009 of Frontiers of Medicine (PDF)
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Through its combined expertise in the biomedical, behavioral and social sciences, UCSF's Department of Medicine continues to be a global leader in preventing and treating HIV/AIDS, and working towards a cure. The Department is home to a number of programs of the AIDS Research Institute, an umbrella organization made up of more than 50 independent programs and laboratories throughout UCSF.
Since 1981, when the first case of what later became known as HIV and AIDS was reported, UCSF's clinicians and researchers have been at the forefront of investigating these diseases. San Francisco General Hospital is home to the world's first HIV clinic, Ward 86, which opened in 1983, as well as the first inpatient HIV/AIDS unit.
Center for AIDS Prevention Studies
In addition to its groundbreaking clinical care and medical research, UCSF is a pioneer in HIV/AIDS prevention and policy development. The Center for AIDS Prevention Studies (CAPS) is the largest and oldest university-based HIV prevention science center in the world. Founded in 1986, CAPS has 23 full-time faculty, including experts in anthropology, biostatistics, epidemiology, political science, psychology and sociology, as well as medical doctors. Its primary goals are reducing the number of new infections, testing and treating patients for HIV more effectively, and reducing disparities in health outcomes.
"Over the years, we've developed many successful prevention inter-ventions that have been documented in clinical trials," says Professor Steve Morin, PhD, director of CAPS and chief of the Division of Prevention Science. "Many of them have been adopted by the Centers for Disease Control (CDC) in their evidence-based programs." CAPS now has more than 60 research projects in 45 countries – ranging from an investigation of HIV risk among male parolees and their female partners in the U.S. to a study of medication adherence in Bangalore, India.
Morin, who holds a doctorate in psychology, is currently researching HIV prevention strategies in Zimbabwe and publicly funded clinics in the United States. In addition to his wide-ranging research background, Morin brings extraordinary policy experience to CAPS. From 1987 to 1997, he worked on Capitol Hill as a principal legislative assistant to Representative Nancy Pelosi and then for the Labor-Health and Human Services-Education Appropriations Subcommittee, which funds most of the federal response to AIDS. He still contributes to policy briefings with Speaker Pelosi's office, and frequently helps shape legislation.
"We actually have the ability here, with everything in our database on HIV disease progression and costs, to run analyses that the Congressional Budget Office can't do," Morin says. "Over the years, we've built a capacity for policy research unlike any other place in the country. As an HIV think tank, it's something that a university is better equipped to do than a government agency, which is often diverted to respond to whatever is in the morning paper."
Cultivating Research in Minority Communities
Communities of color experience a disproportionately high level of many health problems, including HIV. Conducting research in these communities is more challenging because the particular needs and cultures of communities of color need to be addressed. Minority researchers' first-hand cultural and linguistic knowledge often engenders more trust and gives them greater access within their own communities; however, they are greatly underrepresented in the scientific community.
To help address this need, CAPS established the Collaborative HIV Prevention Research in Minority Communities Program in 1996. Each year, three to five early career scientists who are conducting HIV-prevention research within ethnic minority communities are chosen to participate in this three-year visiting professor program. They spend six weeks each summer at UCSF learning how to shape and fund their research questions, receiving intensive feedback from UCSF faculty and their peers. They also receive seed money to conduct pilot studies to gather preliminary data, as well as stipends to cover their summer living expenses.
"The program is designed to help people who have promising career paths in social and behavioral HIV/AIDS prevention research take their research to the next level as independent investigators," says Associate Professor Tor Neilands, PhD, who directs the program along with Associate Professor Diane Binson, PhD. "At their home institutions, these early career faculty may be the only minority researchers in their departments, and the only social scientists studying HIV prevention issues in minority communities."
So far, 40 visiting professors have participated in the program. These scholars have published more than 430 articles and received more than $50 million in grant funds from competitive agencies, including the National Institutes of Health (NIH) and the CDC.
"This is a life-changing program," says Nelson Varas-Díaz, PhD, an associate professor in the social work department at the University of Puerto Rico, who recently completed the program. His home university is mainly a teaching institution, and is just beginning to incorporate research. He wanted to learn how to conduct large-scale research projects, and needed the expertise of mentors to guide him.
Varas-Díaz was interested in developing interventions to reduce HIV stigma among health professionals in Puerto Rico. His preliminary research demonstrated that many in the medical profession blamed people with HIV for their infection, believing patients deserved the consequences. "As you can imagine, that can do horrible things to doctor-patient relationships," says Varas-Díaz. "I understood the problem, but how do you go about contributing to solving it? I had never done an intervention in my life, so my first and second summers here were a crash course into what intervention research entails, and how you put that into a fundable grant."
With this support, Varas-Díaz applied for and received a prestigious R01 grant from the NIH to develop and test a 10½ hour curriculum for medical students. It educates them about the disease, teaching them specific skills for interacting with HIV patients and handling their own emotions. "When you talk to medical students, they are really scared about how to talk to patients in a way that is not insulting, and how to address certain issues around sexuality," he says.
Varas-Díaz, who is one of only four R01 investigators in Puerto Rico, hopes this intervention will help the next generation of the island's doctors provide better care for persons with HIV. "My grant is a direct product of the visiting professors program," he says. "It is not only impacting my career – it's also impacting the level and quality of HIV research in Puerto Rico."
New Challenges, New Tools
As the HIV epidemic evolves, CAPS is evolving as well, says Associate Professor Marguerita Lightfoot, PhD, who, along with Professor Susan Kegeles, PhD, co-directs CAPS. "Early on, much of the focus in prevention was with gay white men," says Lightfoot. "Now we recognize the growing HIV prevalence in other populations. Whether it's gay men of color, transgender women, homeless youth or couples in South Africa, we have a cadre of investigators who are out in the field, doing applied research in partnership with communities. You really have to figure out the culture of the population you are working with so you are able to target your messages appropriately, in a way that is acceptable, engaging and relevant."
Lightfoot serves as director of the Technology and Information Exchange Core at CAPS, and much of her own work focuses on using technology to reach homeless or incarcerated youth. "If you ask most adolescents, 'Why didn't you use a condom?' you're likely to hear, 'I don't know – it just happened,'" says Lightfoot. "We're trying to teach them that nothing 'just happens' – there are triggers that lead to risky behavior."
In collaboration with a computer programmer and young people who provided voiceovers, Lightfoot developed a computerized intervention. One game in the intervention shows a party filled with young people drinking and dancing, and asks participants to pick out triggers that could contribute to the characters having unprotected sex, such as substance use, people or feelings.
In a pilot study, Lightfoot found that adolescents who participated in this computerized intervention were significantly less likely to engage in sexual activity and reported significantly fewer sexual partners. The intervention was so successful that some youth viewed the videos multiple times on their own, and urged their friends to watch them as well.
"How do you get people to make the right decisions about their health, whether that's using a condom or taking your medication?" asks Lightfoot. "You need to have some understanding of how people operate within their social networks and families, what it means in terms of their culture and beliefs, and what would motivate them to change their behavior. Understanding the world in which people live, and how we can influence their behavior, is really important. The strength of UCSF is that we can utilize and leverage our expertise in both the behavioral and biomedical sciences."