Between 2006 and 2009, the incidence of human immunodeficiency virus (HIV) infections increased significantly among adolescents and young adults. Although new biomedical primary prevention agents such as microbicides and pre-exposure prophylaxis (PrEP) decrease rates of HIV acquisition in trials, their effective-ness in practice will depend largely on clinician recommendations. However, despite the recent FDA approval of the first oral PrEP agent, data are not available regarding physician knowledge and attitudes about these methods with regard to use in youth. Physician intention to recommend these agents to adolescents, which is likely to be a powerful predictor of actual recommendations, is also unknown. This lack of data is a significant problem because the information will be critical to the design of interventions to improve the rate at which physicians recommend these agents to adolescents, an age group disproportionately affected by HIV infection. Dr. Mullins's long-term goal is to decrease HIV acquisition among adolescents through an independent research career focusing on the successful dissemination and uptake of new biomedical prevention agents. The candidate has demonstrated strong potential to conduct research. She has been the first-author for 5 pri- mary research manuscripts published in high-impact pediatric journals and presented her findings at national and international research meetings. She developed basic research skills through coursework culminating in a Master of Science in Epidemiology/Clinical Research. The overall objective of this K23 application, which is the next step toward attainment of the candidate's long-term goal, is to define the factors that influence physician intention to recommend microbicides and PrEP to adolescents. The central hypothesis is that physicians will have low intention to recommend microbicides and PrEP to adolescents, and factors such as knowledge, cur- rent HIV prevention practices, attitudes, subjective norm, and structural/policy factors will influence these inten- tions. The rationale underlying the proposed research is that, once the factors that influence intention to rec- ommend new agents are understood, such information can be used to design interventions that accelerate recommendations for new HIV prevention agents among clinicians who care for adolescents, which in turn will decrease adolescent HIV acquisition. The proposed research involves primary data collection using a mixed methods approach to explore and quantify physician attitudes toward and intentions to recommend new bio- medical HIV prevention agents to youth and to identify factors associated with these intentions. In the first phase, individual interviews will be conducted with 40 physicians who provide primary care to adolescents in order to explore and define the salient attitudes. The findings from this phase will inform the development of a new, validated survey designed to quantify physician attitudes and intentions with regard to recommending and prescribing microbicides and PrEP to adolescents for HIV prevention. In the final phase, the new survey will be administered to a national sample of 2500 physicians who provide primary care to adolescents to assess inten- tions to recommend and prescribe microbicides and PrEP and define predictors of these intentions. The pro- posed research will contribute novel information regarding the factors that influence physician intention to rec- ommend new prevention agents. The results will inform tailored interventions to educate physicians about these agents in order to maximize adolescent HIV prevention efforts and also will be applicable in the devel- opment of interventions to improve dissemination of other HIV prevention measures in development. In order to achieve her long-term career goal and the objectives of this application, the candidate will require training in mixed methods research (including qualitative and survey methods), health disparities, eth- ics of sexual health research, use of antiretroviral medications, and design/implementation of intervention stud- ies. These needs will be met through a combination of strong mentorship, didactics, and clinical experience. The mentorship team includes researchers with expertise in relevant content areas and mentoring junior facul- ty. Dr. Jessica Kahn, the primary mentor, provides expertise in prevention of sexually transmitted infections in adolescents and methodologic expertise in (1) the assessment of physician intentions to recommend STI pre- vention agents and (2) qualitative and survey research methods. She holds current R01 funding and is an ac- tive investigator and leader in the Adolescent Medicine Trials Network for HIV/AIDS Interventions. Dr. Kahn has successfully mentored many trainees and junior faculty. Her expertise will be complemented by that of the co-mentors and advisory committee members. The scientific environment at Cincinnati Children's Hospital Medical Center (CCHMC) provides an ideal setting for Dr. Mullins to achieve research independence. CCHMC has supported numerous junior investiga- tors, and 36 faculty hold NIH career development awards. The Division of Adolescent Medicine, which has seven NIH-funded faculty members and a focus on adolescent reproductive health research, had $1.7 million in grant support in 2011. The Division provides infrastructure and a wealth of intellectual resources for the de- velopment of the candidate. In summary, the candidate's demonstrated potential for research, novel research plan, relevant career development plan, excellent mentorship team, and outstanding research environment contribute to her ability to achieve research independence with the essential support provided by a K23 career development award.
The proposed research and training are relevant to public health because improved understanding of primary care physician attitudes and intentions toward the use of new biomedical HIV prevention agents is necessary in order to design interventions to enhance the dissemination of new, efficacious methods of prevention to adolescents. Because new HIV infections disproportionately affect adolescents and young adults in the United States, such interventions will play an important role in decreasing the rates of HIV infection in this vulnerable age group, which would meet goals set by the 2011 Trans-NIH HIV/AIDS plan, the National HIV/AIDS Strategy, and Healthy People 2020. The combination of the proposed research, didactics, and career development activities will provide the candidate with the skills needed to become a successful, independent clinical investigator in the field of adolescent HIV prevention.