Research

Last year, Grant Lindsey visited Oakland’s Downtown Youth Clinic for the first time, accompanying his partner who was being treated there for HIV. Lindsey is not HIV-positive, but this was a new relationship, and he was there to offer help and encouragement.

“I really wanted to support my partner, and I wanted to get educated for myself,” he said. “I wanted to get up to date as far as HIV and safe sex were concerned.”

While at the clinic, Lindsey was tested for HIV. He also talked with the clinic director and medical staff about his new relationship, and he got answers to questions that had been worrying him.

Soon, he was volunteering for a new study to test an HIV prevention pill (Truvada), which has been found to protect uninfected persons against the virus. This prevention pill is part of a new strategy called PrEP (pre-exposure prophylaxis) that includes taking the daily antiretroviral medication, Truvada, which was approved last year by the FDA. Truvada is provided for the study by its maker, Gilead Sciences, Inc. 

This bold research, which is funded by UC’s California HIV/AIDS Research Program (CHRP), engages people at high risk for HIV infection in an innovative new biomedical prevention effort in their communities. The study in Oakland and other East Bay cities is one of three PrEP research projects funded by CHRP to help curb HIV in California. The combined effort is the largest PrEP demonstration project in the U.S. (See "Combining a prevention pill with community treatment programs")

“I didn’t know anything about this,” said Lindsey. “It’s amazing. HIV is still rampant, and not enough people are talking about it.” 

Lindsey is a young African American, and he’s right about the soaring rate of HIV infection in some communities. Despite great overall success against HIV infection, the disease still takes an enormous toll in some parts of the population. Infection rates are on the rise among young African-American men who have sex with men (MSM), and among other young gay men of color in Oakland, Richmond and other cities throughout California and the U.S.

From 2008 to 2010, the estimated number of new HIV infections among MSM jumped 12 percent, and the highest number of new infections occurred in young African-American men aged 13–24, according to the Centers for Disease Control and Prevention.

“Sexual health services for these young men are scarce,” says Kimberly Koester, director of qualitative research at UCSF’s AIDS Policy Research Center. “Community clinics treat HIV-positive men, but few reach high-risk, HIV-negative young men.”

Teens in particular, she says, need help learning about sexual health and staying focused on safe behavior. “If they can get the support and education, we hope many of them can avoid infection.”

Oakland's Downtown Youth Clinic is about to become ground zero for an ambitious effort to study the effectiveness of both PrEP and another strategy called TLC+ (testing and linkage to care plus treatment) among high-risk uninfected and HIV-infected youth. The project will seek the best ways to identify at-risk youth, determine their HIV status, help them manage their sexual health, and develop innovative ways to keep them engaged in either treatment (if HIV-positive) or in PrEP and other preventive services (if uninfected).

Many sexual health experts believe that education and the kind of environment in which it is offered are crucial to reach young people.

“Our aim is to bring down the barriers that prevent young people from seeking help, so they will educate themselves and stick with treatment,” says Michael D’Arata, director of clinical services for the new PrEP/TLC+ project.

“I am a huge supporter of PrEP, but clinical strategies alone will not succeed. They must be part of a broader effort to help the at-risk teens. We will be developing a complete sexual health clinic for these young people.”

The Downtown Youth Clinic is partnering with researchers from the Center for AIDS Prevention Studies at UCSF on the new project. Its services are open to all HIV-positive adolescents in the Bay Area. The center is recognized for its innovative strategies, such as its informal, non-institutional feel, its youth-friendly model of care and its use of social networks to reach youth in need — all designed to reach out to young patients, get them in treatment and help them focus on their sexual health.

The project aims to determine if similar approaches will engage high-risk, uninfected young men, and help them stay connected to sexual health services. When he visited the clinic with his partner, Grant Lindsey noticed that couches replace chairs in the waiting room, and he saw how they were arranged to encourage interaction instead of isolation. “It was very warm and inviting, and the staff were very easy to talk to,” he said. “I felt very comfortable there.”

In their work with young HIV-positive patients, D’Arata and his staff have sought to bring their message to young clients in ways and in settings that are most likely to succeed: by encouraging patients to recruit their friends and peers; and by reaching them at concerts and clubs, through Facebook and other social media, and offering small “rewards” for being tested or getting others to seek treatment.

D’Arata wants to try many of these strategies to reach HIV-negative youth as well. To hone in on best practices, Koester and the UCSF research team are interviewing potential PrEP candidates about their experiences and feelings about the program and gauging their interest in accessing PrEP and sexual health services in general.

The DYC-UC project got its initial start last year. The UC California HIV/AIDS Research Program (CHRP) supported a pilot program in which Koester and her colleagues carried out in-depth interviews with partners of HIV-positive patients at DYC and with sexual health providers. They also conducted focus groups with potential PrEP candidates to inform the new effort.

The preliminary studies found some evidence that many young adults felt saturated with messages and information that only come to them online, or through other electronic means.

“Many of the young people we interviewed said they preferred to receive support in-person, through a personal mentor and/or social support group that meets once a week and is led by a sexual health staffer,” says Xavier Erguera, an analyst working with UCSF’s Koester.

At the same time, he says, they supported incorporating online communication into the mix — some even offering their own strategies for combining personal mentorship, peer social support groups and online support structures in one program.

Erguera, a young gay Latino, currently is finishing up an Americorps internship as a health educator.

“I am very interested in HIV prevention. I feel there’s a challenge facing biomedical and behavioral interventions. I’m hopeful that this new clinic will be able to model a way of harmonizing the two, and energizing them both to help young people.”

D’Arata’s focus is on attracting potential PrEP/TLC+ candidates, and holding their interest in their overall sexual health.

“We want to create a ‘sexual health club.’ Youth will actually have a clinic card that will give them access to the DYC. Not only will they have access to full sexual health services, but also to events and activities that are very popular but sometimes expensive for teens — tickets to concerts and to gay night at Great America. We want them to think of the clinic as a part of their lives, besides its sexual health role.”

An advisory board made up of peers of potential clients will determine how the center looks and the music played in the waiting room, he says. “The main thing is to break down the barriers to seeking help.”

The DYC-UC effort supports the government’s National HIV/AIDS Strategy, released by the Obama administration in 2010. The strategy goals are to reduce the number of people who become infected by HIV, increase access and care to people with HIV and to reduce HIV-related health disparities.

“We are particularly in line with the national goal of reducing health disparities, since we are working with minority populations,” said UCSF’s Koester.  “But we are opening new doors — supporting people who are HIV-negative and finding the best ways to help them stay HIV-negative. We’re thrilled to be developing this road map that’s a natural part of the national AIDS strategy — the goal of an AIDS-free generation.”