Seeing the Big Picture

People with HIV face a very different future than they did in the early 1980s, when a diagnosis was a death sentence. With early and consistent antiretroviral therapy (ART), people with HIV now have a normal life expectancy. But less than half of those with HIV in the US are estimated to be on ART or achieve optimal levels of HIV viral suppression—and the number is even lower globally. Why are these outcomes so abysmal? And how can the treatment gap be narrowed? This is just one of the complex health challenges that collaborators in CUNY’s Institute for Implementation Science in Population Health (ISPH) have in their sights.

The Institute, which opened its doors in July 2016, is part of the new and growing field of implementation science, whose practitioners identify and address the social, behavioral, economic, and management barriers that stand in the way of effective implementation of public health and healthcare programs, including treatments.

While most centers and institutes devoted to implementation science are housed in medical schools, CUNY’s ISPH is a university-wide endeavor, allowing researchers—and students—to draw on expertise and collaborators from every corner of CUNY.

“Implementing large-scale programs and understanding their impact is inherently a multidisciplinary endeavor,” says ISPH Executive Director Denis Nash, PhD. “Through the ISPH we can leverage the breadth of CUNY’s diverse strengths in ways that many other centers and institutes across the country can’t.”

The Institute’s home base is in the Graduate School of Public Health and Health Policy, but faculty at Hunter, Queens, Lehman, and City colleges including behavioral scientists and psychologists are currently among the ISPH’s investigators, and Nash hopes to recruit other investigators to join the Institute in areas like social media, computer and data science, and criminal justice.

“In the era of big data, the information we’re gathering is not all necessarily coming from the health sector,” Nash says. “And with our CUNY-wide orientation we can draw on expertise, perspectives, and disciplines outside of the health sector, but that is nonetheless relevant to population health, for example data on tobacco sales or heroin purity.”
The ISPH is also unusual among implementation science programs in its focus on scaling and evaluating the effectiveness of interventions at the population health level, rather than primarily focusing on translating evidence-based strategies and interventions from research studies to health programs and policies, says Nash.
“Implementation science is often described as the process of translating or integrating evidence-based strategies from the research setting into real-world service programs and policies,” Nash says. “Our Institute is focused on assessing the impact of these strategies when they are implemented in the real world, especially as they are scaled-up. Our view is that major population health improvements can be realized through more effective and efficient implementation of strategies that we already know about—that have already proven efficacious in the research environment—and that just need to be more effectively implemented at a larger scale.”

Nash and ISPH Associate Director Sarah Kulkarni, MPH, have worked together since 2008 on both domestic and global HIV treatment programs, which have served as incubators for rapid evolution in the field of implementation science over the last few years, according to Kulkarni.

“The inspiration for the ISPH came from the HIV scale-up work that Denis has been involved in for a while,” she says. “He saw opportunities to take the lessons learned from HIV work to other population health priorities and problems, and to create new collaborations among the investigators we were already working with.”

Finding keys to the HIV epidemic

Among ISPH’s large-scale projects is its global HIV work, through the International Epidemiologic Databases to Evaluate AIDS (IeDEA). This global network of HIV care cohorts operates in 42 countries, and continuously reviews data gathered on over one and a half million people enrolled in HIV care globally. As part of IeDEA, Nash and colleagues are following large cohorts of people with HIV in five central African countries. He and other IeDEA researchers analyze the outcome data to identify and describe implementation problems, determine how common they are across various settings or whether they’re context specific, and then work to identify solutions, says Nash.

Ellen Brazier, a second-year epidemiology doctoral student, is a member of the IeDEA research team at ISPH, and is currently working with Nash on designing and implementing a survey of over 250 HIV care clinics across the global IeDEA network. The survey results will help IeDEA investigators explore the links between health facility capacity, service delivery strategies, and optimal patient and program outcomes such as retention in care, treatment initiation, and, ultimately, viral load suppression.

“Figuring out which health facility attributes and service delivery strategies are more or less effective in keeping patients in care and enabling them to achieve viral load suppression in a timely manner is key to ending the HIV epidemic,” she says. “It’s also an important implementation science question because simply knowing that lowering patients’ viral load will reduce transmission does not tell us what strategies are effective in achieving these ends across multiple health facilities and diverse contexts.”

ISPH collaborators and colleagues in Ethiopia, where nearly 900,000 people are living with HIV, recently completed and published the results of a five-year NIH-funded study there that probed into why people often start treatment at a very late stage in the development of their disease.

“Because 8-25% of people in sub-Saharan Africa who start HIV treatment die within a year—and have likely unwittingly transmitted HIV to others during the years prior to starting HIV treatment—the persistent problem of late HIV treatment initiation is among the most important remaining HIV implementation science challenges,” Nash says. Through six HIV clinics in Ethiopia that deliver services at a very large scale, Nash and his team enrolled and interviewed 1,180 people who were just starting treatment to understand more about what prevented some from getting diagnosed and on treatment earlier.

The results of that study provided a set of new leads, he says, “and even some very clear answers about what needs to be done next.” These answers include the need to expand and better target testing coverage with timely linkage to care, and clinic-based programmatic initiatives promoting patient-centered, stage-appropriate counseling, engagement in pre-ART care, and smoother integration of HIV and TB treatments. The Ethiopian national HIV program has changed their universal testing policy to be more targeted, in part because of the results of this study.

Testing a New Treatment Paradigm in New York State

ISPH is also involved in a large-scale NIH-funded HIV project in New York City focused on people enrolled in the Ryan White Program, the payer of last resort for HIV care. In partnership with the New York City Health Department, a CUNY research team is in the fourth year of a rigorous assessment of the effectiveness of a multi-pronged intervention called HIV Care Coordination, which has enrolled over 8,000 of the most vulnerable people with HIV citywide.

“People targeted by this program have a history of suboptimal HIV treatment outcomes, and have not been able to achieve sustained viral load suppression, which is needed to extend their life expectancy,” Nash explains. “Many of them contend with a number of major barriers to care such as homelessness, mental illness, and substance use.”

McKaylee Robertson, a fourth-year epidemiology doctoral student and member of the research team, is developing methods for and conducting an analysis of data gathered through the study. Patients in the city’s HIV Care Coordination Program not only get intensive medical care, she explains, but a care coordinator who helps ensure that all of their service providers are talking to each other, and a patient navigator who helps ensure that their practical needs like transportation to appointments and housing are met. Their medical and non-medical needs are routinely assessed, and care and services, including mental health and substance abuse treatment, are adjusted to meet their needs.

The research group has already published several papers planned under the grant.

“If, in the end, our research shows that the program is more effective and/or more cost effective than standard of care, or if it’s most effective with newly diagnosed patients or for people out of medical care, there could be a more efficient targeting of the program in New York City through Ryan White funding,” Robertson says. And those results would shape the care provided under Ryan White programs in dozens of other metropolitan areas around the country that have challenges similar to those of New York City, she adds.

Ending the AIDS Epidemic in New York State

With funding from the New York State AIDS Institute, the ISPH also developed an interactive, web-based, public facing dashboard system to help track the progress of Governor Andrew Cuomo’s Ending the Epidemic (ETE) Initiative, which seeks to reduce the annual number of new HIV infections in the state of New York to just 750 (down from an estimated 3,000 cases) by 2020.

The ETE Dashboard is an interactive platform facilitating data integration, data analysis and data visualization of HIV trends in the state of New York to address needs of diverse stakeholders for informed decision making.

The latest data posted on the ETE Dashboard indicate that the initiative is just about on-track to achieve its goal. There were an estimated 2,115 new HIV infections in New York in 2016, a 13% drop from the previous year, which almost hit the annual ETE target for the year set at 2,050. Other key metrics were nearly on target, or in the case of PrEP use among Medicaid recipients, surpassed the ETE goals, suggesting the initiative is making headway.

“While it is too soon to say definitively, taken together, these data may be an early indication that the ETE initiative is having an impact,” says Dr. Denis Nash, Professor of Epidemiology at CUNY SPH, and the Executive Director of ISPH.

The downward trend in incident infections is encouraging, but according to the ISPH, the trend needs to progress at a faster rate, at least a 23% decrease per year, in order to reach the ETE’s 2020 goal of reducing the number of new infections to 750.

Collaboration Leads to Solutions

Beyond HIV, an ISPH team are studying population health in slum communities in Haiti to try to understand more about the demographic and health priorities in those communities, and is assessing risk factors for non-communicable diseases such as hypertension. Another team is working on genetic markers for ovarian cancer risk to understand whether these markers might be useful at a larger scale to predict disease aggressiveness and risk. Others are researching implementation questions related to smoking and asthma. “If you look across this institute there are 15 investigators and more than a half dozen of Affiliated Investigators, all whom have research foci relating to questions of implementation and policy,” Nash says. The ISPH leadership team now also includes Dr. Renee Goodwin, a clinical psychologist and epidemiologist who joined as the Deputy Director of the Institute, whose research focuses on substance use, smoking, and depression. Goodwin’s research portfolio is also strategic for the ISPH. “These are significant determinants of population health, all amenable to substantial improvements through better implementation of policies, programs and services,” says Nash.

Through fieldwork and thesis projects CUNY doctoral and masters of public health students are working with the ISPH, giving them an opportunity to be involved in large-scale research projects related to real-world implementation—work that they might not otherwise be able to work on until after they graduated, Nash says. “Implementation science in population health, and the associated methodological approaches, haven’t really made it to a classroom or a curriculum yet, so to learn it you need to be part of it.”

Nash and Kulkarni hope to soon translate some of the training that’s taking place in the field into the classroom, says Nash. “The intersection of implementation science and population health is an emerging area, so the theories related to it are very much in development, and the methods we use are also very applied and not often formally taught in the public health curriculum. We are looking for way to infuse it into the curriculum at CUNY.” As a start, Nash envisions developing a seminar-style course that brings together people from different perspectives and disciplines, and then to identify and develop more detailed courses.

Implementation science attracts a certain kind of researcher, according to Nash. “People drawn to implementation science in the field of population health tend to like the idea of working on big, complicated, real-world problems. Once you wade into the details of why something is working or not working,” he says, “there’s never one answer, and there’s a lot of complexity and messiness to it—but there are solutions that can have substantial impact at the population level. And that’s, of course, why most of us get into public health.”