From the start of the HIV epidemic, scientists in San Francisco have been at the forefront of HIV prevention science. As the HIV epidemic and national needs evolve, CAPS alters its research emphasis to stay on the cutting edge of HIV prevention science.
Early History: 1986–2000
In 1981, the first cases of AIDS were identified in San Francisco as well as in New York and Los Angeles. Even before HIV was discovered, it was recognized that AIDS was likely a blood-borne, sexually transmitted disease and that behavioral factors were probably associated with its spread. Behavioral scientists in San Francisco investigated behaviors among at-risk populations in San Francisco and the consequences of HIV in the community. The Center for AIDS Prevention Studies (CAPS) was established in 1986 and focused on the prevalence of HIV disease and risk behaviors. A grant from the National Institute of Mental Health (NIMH) allowed us to attract a group of scientists and to establish a center of excellence for training medical, social, and behavioral scientists.
By the early 1990s, the modes of HIV transmission and the epidemiology of risk behaviors were well understood, and some early evidence about the determinants of high-risk behavior were emerging. Hence, CAPS began to focus more explicitly on descriptive studies of the negative consequences of HIV disease and on developing prevention interventions and rigorously evaluating them. For example, CAPS scientists demonstrated the effectiveness of HIV testing and counseling as a prevention strategy. We knew that our research was for naught if it did not get to those who needed it most: prevention service providers. And so we created the Technology and Information Exchange (TIE) Core to provide a feedback loop between CAPS and the community.
The HAART Era
In 1996, with the beginning of the era of highly active antiretroviral therapy (HAART), we added a new dimension: integration across disciplines. We integrated social, psychological, and biomedical perspectives to understand the impact of HAART on risk behavior and seroincidence. We worked on cross-disciplinary studies of HIV and other diseases or behaviors (e.g., stress and coping studies) and began to develop a portfolio of studies on policy and ethics issues in HIV/AIDS research and care. In keeping with the demographics of the epidemic, we greatly expanded our research portfolio on HIV prevention in ethnic minority communities. In addition, we increased our commitment to training scientists to conduct research in minority communities by focusing our Traineeships in AIDS Prevention Studies (TAPS, begun in 1989) fellowship program on recruitment of ethnic minority scientists and by establishing the Training Program for Scientists Conducting Research to Reduce HIV/STI Health Disparities.
Recent History: 2001–present
Recognizing the growing importance and availability of a wide variety of biostatistical, qualitative, and electronic data recording methods in HIV research, we created a Methods Core to meet CAPS investigators’ increasing demand for expertise in these areas. Our major training activities—TAPS and the Collaborative HIV Prevention Research in Minority Communities Program, both formerly funded by CAPS, as well as the International Traineeships in AIDS Prevention Studies—successfully competed for separate training grants. During this period, we focused more extensively on the dissemination of science and translation of research to practice. With the addition of the Pacific AIDS Education and Training Center as a CAPS partner, our portfolio of research studies on HIV policy expanded beyond prevention to treatment and health services issues.
In 2006, CAPS successfully applied for renewed NIMH funding and took on new leadership with Dr. Steve Morin as director. During this time CAPS developed a more extensive focus on HIV policy research and work with local, state, federal, and global agencies We recruited Dr. Marguerita Lightfoot to CAPS in 2008 to serve as co-director and to lead efforts on adolescent HIV prevention and reducing disparities. We also saw a steady expansion of international studies into 45 countries. Our international efforts have been aided by co-locating and joining forces with the UCSF program in Global Health Sciences, one of the few university-based degree programs preparing students for careers in implementation of global health programs, where about two-thirds of studies are focused on HIV/AIDS.
Scientific Accomplishments: 2006–present
Over a recent three-year period, CAPS investigators produced 472 publications in medical, public health, economic, and social science journals on issues relating to domestic and international HIV/AIDS prevention. Below we provide a brief summary of some CAPS research accomplishments, highlighting the innovative research programs of our early-career faculty.
Preventing New HIV Infections
We are proud of having produced a number of important social and behavioral interventions to reduce the number of new infections:
- Mpowerment. This community-level intervention was found to be safe and effective in reducing behavioral HIV risk with young gay and bisexual men in a randomized, controlled trial. It is now one of the evidence-based interventions promoted by the Centers for Disease Control and Prevention. To date, more than 150 domestic organizations (and a number of international groups) have implemented Mpowerment.
- NIMH Healthy Living. This multisite randomized, controlled trial established the safety and efficacy of a cognitive-behavioral intervention designed to reduce transmission risk behavior among HIV-positive persons. A CAPS team led by Drs. Morin, Johnson, and Lightfoot published the final trial outcomes which established a significant reduction in transmission risk acts for the intervention group compared to a control group.
- Enhancing positive prevention. The Health Resources and Services Administration (HRSA) worked with a team of CAPS scientists led by Dr. Myers to assess the extent to which HIV prevention opportunities were being missed in Ryan White–funded clinics. HRSA launched an initiative to implement and evaluate HIV prevention interventions with HIV-positive patients in 15 primary health care settings across the country.
- NIMH Acute HIV Infection Study. A team of investigators at CAPS led by Dr. Steward, an early-career researcher working with Dr. Morin, coordinated a multisite study to understand better the role of acute infection in HIV transmission. Five sites conducted in-depth qualitative interviews and longitudinal quantitative assessments of HIV transmission risk behavior among individuals diagnosed with acute or very recent HIV infection.
Optimizing HIV-Related Health Outcomes
A team of investigators at CAPS led by Dr. Johnson has developed a program of research to improve health outcomes through linkage to care, treatment engagement, retention in care, and improved adherence to AIDS-related medications:
- Improving adherence. A team led by Drs. Johnson and Charlebois analyzed data from the Healthy Living Project to assess the effect of the intervention model promoting treatment engagement on antiretroviral therapy adherence.
- Reducing substance abuse. Other studies conducted using baseline data from Healthy Living indicate that regular use of stimulants (e.g., cocaine, crack, methamphetamine) is independently associated with HIV disease markers.
In light of the epidemiology of HIV in the US, CAPS investigators are focused on reducing HIV-related health disparities:
- Race, socioeconomic status, and AIDS. Dr. Michael Arnold, as a fellow working with Dr. Rutherford at CAPS, collaborated with researchers at the San Francisco Department of Public Health to examine the role of socioeconomic context and race in AIDS treatment and survival among 4211 people with AIDS living in the City between 1996 and 2001.
- Responding to the needs of African Americans. In collaboration with the Cochrane HIV/AIDS Group, Dr. Darbes and her team completed and published a meta-analysis examining the efficacy of HIV prevention interventions with heterosexual African Americans.
- Marginalized adolescents. Dr. Lightfoot and her team are pursuing a program of research to develop innovative HIV prevention interventions for marginalized, underserved adolescent populations at elevated risk for HIV infection.
- The Bruthas Project. This community-collaborative intervention seeks to prevent HIV risk behavior among African American men who have sex with men and with women but who do not form an identity around their same-sex behavior.
Because global equity is also a priority for research at CAPS, a number of investigators are responding to the international pandemic:
- Cochrane Collaborative HIV/AIDS Review Group on HIV Infection and AIDS. The HIV/AIDS group is one of 52 Cochrane Collaborative Review Groups and the only one located in the US.
- NIMH Project Accept. A team of investigators led by Dr. Morin and Ms. Khumalo-Sakutukwa developed and implemented a community-level, multisite intervention as part of the HIV Prevention Trials Network.
- International men who have sex with men (MSM). Investigators at CAPS have continued to focus on MSM as a most-at-risk population for HIV infection in international settings. Dr. Lane and his team conducted one of the first studies to estimate HIV prevalence among MSM in South Africa townships. Work in China conducted by Dr. Choi and her team observed an HIV prevalence rate of 1.5% and a syphilis rate of 13.5% among MSM.