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Project Director/Lead Investigator: Ma Somsouk (UCSF PI); Susan L. Ivey (UCB Project Director/Co-PI); Scarlett Lin Gomez (CPIC Project Director/Co-PI); Marguerita Lightfoot, PhD (UCSF PRC PI) Specific Aim 1: We will conduct a community-based participatory research (CBPR) study to better understand specific patient attitudes and knowledge about cancer; knowledge about colorectal cancer prevention and detection; acceptability of different modalities of colorectal screening (stool-based testing versus endoscopic testing); barriers and facilitators to screening; access and use of health services; and health information seeking behavior. Building upon existing community-academic partnerships, we will:

• Sub-Aim 1: Convene a CAB of patients, family members, and providers from local South Asian communities to provide input and guidance during all phases of the study. All focus group and interview domains and questions will be reviewed by community advisors prior to use.
• Sub-Aim 2: Conduct 8 focus groups (FGs) among South Asian men and women (e.g., Asian Indian, Pakistani, and Bangladeshi groups in the San Francisco Bay area) to understand patient perceptions of cancer, cancer risks, and colorectal screening modalities.
• Sub-Aim 3: Conduct a series of 10 interviews with local community providers and cancer experts to understand contextual and system-level factors in cancer prevention strategies and how they may affect low adherence to CRC screening in South Asian men and women, and to assess relevant interventions, strategies, and messages for improving uptake of colorectal cancer screening among South Asian men and women.

Specific Aim 2: We will apply novel classification techniques to analysis of existing population based data to identify subgroups of South Asians at highest risk of low adherence to CRC screening and late stage diagnosis, for informing targeted community interventions, communication strategies, and messaging to reach South Asian populations. We will:

• Sub-Aim 1: Incorporate guidance from the CAB on key factors to consider in CRC screening. CAB input will inform the design of the analysis of existing population-based data and the interpretation of the results.
• Sub-Aim 2: Use population-based California Cancer Registry data from 1988-2012 to assess prevalence of advanced CRC among South Asian ethnic groups and apply recursive partitioning to identify high-risk populations with high proportions of advanced disease.
• Sub-Aim 3: Use contemporary state-level data (California Health Interview Survey data 2001–2009) to assess trends in CRC screening among South Asians and identify highrisk populations with low adherence to CRC screening guidelines, focusing on insurance coverage, use of other types of preventive services, length of US residence, limited English proficiency, and health literacy measures.

Specific Aim 3: Exploratory: Using findings from Aims 1-2, targeted literature review, and with guidance from the community advisory board, we will identify relevant, ethnic-specific community interventions and communication strategies, including key health messages about CRC screening, tailored to South Asian American target audiences, accounting for differing preferences for type of screening test, primary care versus specialty care access, health literacy levels, and differing language, gender, and cultural needs. We will also assess the feasibility of the interventions and strategies identified, in preparation for next steps of designing tailored interventions, strategies, and messages to better engage South Asian patients in the uptake of colorectal screening modalities.

HIV rates are at catastrophic levels Among young Black Men who have sex with Men (YBMSM). A study in 21 US cities found that 21% of YBMSM aged 18-29 were HIV+, compared to 9% of Latino and 7% of white young MSM (YMSM), and these disparities are worsening. YBMSM are more likely to be HIV-infected, less likely to be aware of their HIV-infection, and less likely to disclose that they are HIV-infected, relative to Men of other ethnic/racial groups. HIV+ YBMSM are also less likely than white MSM to be in treatment for HIV and to have undetectable viral loads (VLs). When HIV+ individuals achieve an undetectable VL, their own health improves, and they are also less infectious to others. Getting to that point, however, requires that HIV+ individuals: (1) know their HIV status; (2) link to HIV Care; (3) stay in Care over time; (4) begin appropriate treatment; and (5) adhere to antiretroviral therapy (ART). We refer to these steps as engagement in the HIV Care Continuum (CC). While these approaches have great potential to reduce HIV incidence, it is estimated that only 25% of HIV+ people in the US have engaged in the CC to the point of having undetectable VLs. Research suggests that HIV+ YBMSM engage in the CC far less than others. A community-level intervention (CLI) to build and mobilize communities of YBMSM to support HIV+ Men to engage in the CC, decrease psychosocial barriers and increase psychosocial facilitators to engage in the CC within those communities may be an efficacious approach to prevent HIV transmission and Improve health outcomes for YBMSM. This proposal will test the efficacy of such a CLI model, called United Black Element+ (UBE+). UBE+ will be an adaptation of a current CLI, called UBE. UBE has already engaged hundreds of YBMSM in Dallas TX, and it diffuses support for HIV Prevention and creates positive social norms around reducing rates of unprotected sex and increasing regular HIV testing by building an empowered, mobilized YBMSM Community. UBE+ will be an adaptation and extension of UBE designed to increase YBMSM's engagement in the CC. the aims of this project are: (1) to adapt and expand UBE into UBE+, a multilevel intervention that includes a new focus on increasing engagement in the CC Among HIV+YBMSM, including targeting psychosocial barriers and facilitators to engaging in the CC that are experienced in this Community (e.g., HIV stigma and social support); (2) to implement UBE+ in Dallas for 3 years in collaboration with a local AIDS Service Organization currently implementing UBE, the Dallas County Health Department, and the Texas Department of State Health Services' (TDSHS) HIV-STD Program; and (3) to evaluate the efficacy of UBE+ in increasing engagement in the CC in Dallas (utilizing Houston as a control Community) using 2 independent methods: (a) a longitudinal cohort of HIV+ YBMSM providing data on engagement in Care, and experiences of psychosocial and logistic barriers and facilitators to engagement in Care; and (b) public health data that the TDSHS independently collects on HIV+ YBMSM's engagement in the CC.

Less than half of individuals living with HIV in the United States are receiving ongoing Care, and only one- quarter have an undetectable Viral Load. The National HIV/AIDS Strategy prioritizes Care and treatment of HIV- infected individuals, yet improvement in Care retention rates is clearly needed. Research on HIV Care has used attendance at primary Care appointments to assess whether Patients are in Care. While Medical visits are necessary, they are not sufficient and do not necessarily reflect a patient's level of Engagement. Engagement in Care is about the patient experience and interactions with providers and the Care site. We propose to create a patient-centered Index of Engagement in HIV Care that will be framed within a model of Health Care Empowerment, which refers to participation in Care in a way that is engaged, informed, collaborative, committed, and tolerant of uncertainty. We will create the Index through a collaborative process of consensus- building with Patients, providers, and Research experts using iterative online Delphi Surveys and in-person focus groups. We will then translate these narrative findings into scale items and develop them further through cognitive interviewing with Patients. We will validate the Index by administering i to a sample of Patients undergoing the Patient Reported Outcomes within the CFAR Network of Integrated Clinical Systems (CNICS) and examining retrospective, cross-sectional, and prospective Appointment and Viral Load Data. The resulting Index of Engagement in HIV Care will have implications for both Clinical Care and Research, identifying Patients who are at risk fo poor Clinical outcomes and providing a metric by which to develop and evaluate interventions aiming to improve Engagement in Care.

Compared to other racial/ethnic groups in the US, black men who have sex with men (MSM), once diagnosed, are less likely to be optimally engaged in HIV care and treatment. This undermines the promise of recent prevention approaches for reducing the disproportionate effects of HIV/AIDS on Black communities, emphasizing the urgency for increased Research focus and Intervention Development. Understanding HIV care engagement in the context of the dyad may be part of a comprehensive effort to addressing multilevel influences on HIV care engagement outcomes that are unique to HIV+ black MSM towards achieving the maximum public Health benefit of treatment-as-prevention. However, the scarcity of dyad-level Research limits our understanding of couple dynamics involved in HIV care engagement to inform Intervention Development targeting the couple, underscoring the need for Couple-Based studies of relational dynamics important to the HIV care engagement of the HIV+ partner(s). Mobile technology-based strategies (mHealth) offer tremendous potential as an acceptable, feasible, and effective Intervention platform for enhancing HIV care engagement among HIV+ black MSM in couples by facilitating couple dynamics optimal to HIV care engagement. Further, mHealth offers potential in addressing limitations in previous Intervention Research with couples, one of which is the dissipation of Intervention effects over time due to absence of booster sessions. Therefore, the aims of the study are to: elucidate the effects of couple dynamics on HIV care engagement among partnered synthesize the quantitative and qualitative (mixed methods) outcomes from Aim 1 to identify the issues the Intervention will target, and to iteratively determine core components of a couple-based Intervention for HIV+ black MSM (Aim 2); and develop a novel, technology-based Intervention prototype for enhancing HIV care engagement among HIV+ black MSM in couples (Aim 3). HIV+ black MSM (Aim 1); The overall objective of this application is to achieve a better understanding of the couple dynamics involved in HIV care engagement among HIV+ Black men in same-sex relationships. The end goal is the Development of an mHealth tool that targets couple dynamics important to enhancing HIV care engagement. Through these aims, I will acquire additional Training necessary for my career Development in (a) theory and mixed methods for conducting Couple-Based Research, (b) formative Research in Intervention Development, and (c) prototype design. These Research and career Development activities will build the foundation to my becoming an independent, NIH-funded investigator with skills to conduct Couple-Based Intervention Research that is part of a comprehensive effort in HIV prevention integrating advances in technology and Behavioral Medicine to reduce racial/ethnic disparities in HIV.