It is our pleasure to announce that ODP’s 2020 Early-Stage Investigator Lecture awardee is Dr. Julia Marcus. The award recognizes early-career prevention scientists who have not successfully competed for a substantial NIH-supported research project, but who have already made outstanding research contributions to their respective fields and are poised to become future leaders in prevention research.
Dr. Marcus is an infectious disease epidemiologist and Associate Professor at Harvard Medical School and Harvard Pilgrim Health Care Institute. Her research focuses on improving the implementation of pre-exposure prophylaxis (PrEP) for HIV prevention.
Dr. Marcus has led studies that are cited by the Centers for Disease Control and Prevention as key evidence of the real-world effectiveness of PrEP, and by the Infectious Diseases Society of America and the American Association for the Study of Liver Diseases in support of hepatitis C virus screening for PrEP users. Dr. Marcus has pioneered the use of machine learning with electronic health record data to identify potential PrEP candidates in health care settings—an approach that is now the basis for multiple implementation projects across the country.
She is also a science communicator and her writing about the public health response to the coronavirus pandemic has been featured in “The Atlantic.”
We spoke to Dr. Marcus to learn more about her work, her perspective on the challenges facing HIV prevention research, and her approach to public health.
Tell us a little bit more about the focus of your research.
My research is focused on improving the implementation of pre-exposure prophylaxis, which is also called PrEP. It’s the use of antiretroviral medications to prevent people from contracting HIV, almost like birth control does [for pregnancy]. PrEP has been approved by the Food and Drug Administration since 2012 and we know that it’s very safe and highly effective—even up to 99% effective—at preventing HIV. But despite that, fewer than one in five people who have indications for PrEP are taking it. We also see striking inequities in who is taking PrEP, including racial and ethnic inequities. My research focuses on how we can better implement PrEP to improve population impact and reduce the disparities we see in access.
I’m also working toward interventions that would address provider-level barriers to PrEP prescribing, including stigma and the challenges of identifying patients who could benefit from PrEP. Those interventions are being evaluated in public health clinics and community health centers that serve safety net populations, including marginalized communities who lack access to health insurance. The goal is to increase PrEP uptake in the people who are most likely to benefit and least likely to access it otherwise.
From your perspective and experience, what role does methods development play in prevention research?
The interventions that we’re developing to improve PrEP prescribing are based on prediction models, which use electronic health record data and machine learning algorithms to try to identify patients who are most likely to contract HIV and would therefore be most likely to benefit from PrEP. I think this approach has utility across many areas of prevention research.
Did you always know you wanted to work in HIV prevention research?
I have always been passionate about sexual health but hadn’t expected to become an HIV researcher. After graduating from college, I was in a training course to become a sex educator in San Francisco and a researcher came to speak about a study he was helping lead on HIV superinfection, or reinfection in someone who was already living with HIV. That research question was driven by people in the community who wanted to understand the potential risks associated with condomless sex between two people who already had HIV.
I was so struck by the idea that I could help generate knowledge that would allow people to make more informed decisions about their lives, including their sexual health. I actually went and asked that researcher if I could work for him and ended up working in that lab, which is the same lab that eventually conducted the iPrEx study, which was the first study to show that PrEP was efficacious.
You mentioned that you’re interested in informed decision-making and risk. Can you talk a little about what it means to use the harm reduction framework and why it’s important?
It’s clear from many areas of disease prevention that an abstinence-only approach to behavior that might increase risk is not effective or sustainable. An alternative approach is one that’s more akin to harm reduction—a movement by and for people who use drugs to reduce the harms of not just drug use but also laws, stigma, and structural violence related to drug use. Harm reduction allows for abstinence but does not require or expect it. That model has also been applied to sexual transmission of HIV, where we’ve learned that expecting people to abstain from sex entirely or even use condoms every time is not always pragmatic and can actually drive people away from public health efforts, particularly when it perpetuates stigma associated with those behaviors and ignores the structural inequities that often drive people’s decision making and risk.
A harm reduction framework assumes that some risk will happen and tries to mitigate harms in those situations through both individual-level empowerment and structural interventions. The harm reduction framework is particularly important because it acknowledges the contextual factors that drive risk, which are often out of people’s control. Those contextual factors are particularly relevant in HIV prevention, including the effects of structural racism on access to PrEP and other effective interventions.
What are some of the challenges facing HIV prevention research?
When I first started working in the PrEP field, the main questions were about safety and efficacy and how well this intervention would translate to real-world settings. I initially set out to help answer some of those questions about safety and effectiveness in clinical practice but now, many years later, those questions have mostly been answered.
Now the questions are about implementation and what is getting in the way of this highly effective intervention having a real population-level impact. My research has evolved along with the field from pure clinical epidemiology to implementation science. Now I’m asking questions that are much more about health care access, stigma, structural racism, and all of the other barriers that we see to having PrEP reach its full potential. Those questions are in some ways harder to address than developing a highly effective medication, which is really just the first step.
Although you already know from your work in HIV prevention how challenging it can be to implement harm reduction messages and practices, is there anything you’ve learned that’s surprised you during the coronavirus pandemic about the dissemination and implementation of harm reduction strategies?
I’ve been watching the coronavirus pandemic unfold through the eyes of an HIV prevention researcher. While they are two very different viruses, there is a lot we’ve learned during the HIV response that can be applied now. I think we have not seen harm reduction embraced in the coronavirus pandemic, which doesn’t surprise me because the United States has historically resisted harm reduction for substance use and HIV, largely because of stigma. I’ve been trying to draw attention to what we can learn from harm reduction that can be applied to coronavirus prevention. I think we’d have a more effective response to the coronavirus pandemic if messaging and policies about how to reduce risk were more cognizant of structural factors that drive people’s risk, and better designed to identify and meet people’s reasons for resisting suggested safety guidelines.
What is one thing that you hope people learn from your work?
What underlies my work is a strong belief that all people are entitled to the information and health care services that they need to have a healthy life, including a healthy sex life. As researchers and clinicians who work to prevent HIV, we sometimes forget that sexual health includes a lot more than disease prevention. I hope that my work conveys the importance of expanding our perspective beyond disease prevention toward a more positive approach to health overall and specifically to sexual health.
Do you have any advice for future trainees interested in prevention research?
Mentors are hugely important in research. But I think it’s equally critical to invest in a peer support network. Honestly, my peer support network is the main thing that is keeping me sane right now. Research can be an emotional rollercoaster. It helps so much to have supportive and affirming colleagues who can commiserate about all the inevitable rejections, celebrate milestones, and make us laugh.
I get to think, talk, and create with brilliant collaborators who expand my mind and improve my science. It’s been gratifying to see my work incorporated into clinical guidelines and practice but it’s even more rewarding to hear about the ways my work has resonated for people on an individual level. Most days I can’t believe I get paid to do this.