Ask Away! Series featuring Dr. Cachay

Welcome to our new Ask Away! blog series where you’ll get an opportunity to ask any burning questions to a member of the UCSD ACTRI team and get expert insights.

This month, we are featuring Dr. Edward Cachay, who is a board-certified infectious disease physician who specializes in caring for individuals with HIV. He is a part of UC San Diego Health's Owen Clinic, one of the nation's outstanding primary care centers for HIV positive men and women. He is also ACTRI’s Community Research Partnerships Director. 

Some of the topics discussed below include Dr. Cachay’s background, culturally sensitive research strategies, challenges in community research partnerships, HIV care challenges, teaching key lessons to medical students, ongoing clinical programs, personal inspiration, recent advancements in HIV research, improvements in HIV management, and holistic patient care.

Let’s dive right into it!

Tell us about your background as an Infectious Disease Specialist and as ACTRI's Community Research Partnerships Director.
Growing up, I frequently relocated because of my father's job and lived in the coast, Andes, and Amazons cities of Peru during my childhood. Traveling throughout the territory of Peru, I have seen firsthand the challenges that people living in disadvantaged communities face and learned the value of education as a way to advance the lives of people. As a medical student in Lima, I quickly realize how social disparities influence outcomes in healthcare. Furthermore, when caring for AIDS patients in Medical School, I learned how stigma and human perceptions influence how we practice medicine. Hence, I pursued a career in ID/HIV because I wanted to serve and be a voice for those at the margins of society. Having the privilege to serve as a facilitator for our community's participation in research endeavors felt compelled to me, and one of the reasons I accepted the privilege to serve as Directors of ACTRI Community Research partnerships.

What strategies or approaches do you use to ensure that research projects are conducted in a culturally sensitive and inclusive manner, considering the diverse perspectives and needs of the community?
A. Transparency
B. Acknowledge lessons of the past
C. Empathy, compassion, self-awareness of cultural differences
D. Be involved and present
E. Aim to build a shared-decision making process

How do you measure the impact and success of community research partnerships? What metrics or indicators do you use to evaluate the outcomes and sustainability of these collaborations?
This is an area where there is little consensus, and much innovation is needed for granular details. In principle, the perspective of both community and research collaborators might differ, but in principle, the goal is the same "The research need to generate answers for questions that are applicable for most in our community and not to just an individual group:

A. From investigators' perspective: We want research to include a diverse group of people for results to be valid to most communities in need in our country.
B. From the Community perspective, we want research endeavors to migrate from community-place to community-research-based to eventually become a shared-making process.
C. Sustainability: From outreach to collaborations and shared leadership addressing pressing questions/needs problems community

Can you provide an example of a successful community research partnership that you have been involved in? What made it successful, and what were the outcomes or impacts?
Title: ACTRI's Crucial Role in Overcoming Stigma and Driving Engagement During COVID-19
In the midst of the COVID-19 pandemic, the UCSD Altman Clinical and Translational Research Institute (ACTRI) embarked on a groundbreaking national clinical trial aimed at evaluating the potential of convalescent plasma as an outpatient preventive or therapeutic solution. This initiative not only showcased the institution's dedication to cutting-edge research but also underscored the importance of community engagement and breaking down barriers that hinder research participation.
A notable challenge that emerged during this endeavor was the existing stigma and mistrust surrounding the concept of plasma transfusion, particularly within various communities of color. To address this, ACTRI embraced a strategic approach that would not only drive research engagement but also build trust among these communities. The lesson learned was invaluable: establishing programs perceived as beneficial services accessible to the community can significantly bolster research involvement.
For instance, at a time when COVID-19 testing resources were scarce, ACTRI took a proactive step by setting up free testing tents outside Jacobs Medical Center. This not only provided a vital service to the community but also offered individuals the option to participate in research, provided they met the necessary criteria. By aligning research with immediate community needs, the institution made research participation more attractive and accessible.
The outcome of these efforts was nothing short of impressive. The UCSD ACTRI emerged as the most successful recruitment site among the 31 institutions nationwide participating in the clinical trial. This achievement not only speaks volumes about UCSD's commitment to research but also highlights the significance of community-focused engagement strategies.
Perhaps most importantly, the results of the study yielded critical insights that informed professional treatment guidelines. By actively involving a diverse range of participants, including those who might have been hesitant due to stigma, the study was able to provide a more comprehensive and accurate understanding of convalescent plasma's efficacy and potential benefits.
The UCSD ACTRI's involvement in the national clinical trial during the COVID-19 pandemic serves as a remarkable example of how bridging the gap between research and community needs can yield exceptional results. By offering tangible benefits to the community while emphasizing research's potential impact, the institution not only overcame barriers but also contributed significantly to scientific knowledge and treatment guidelines. This experience serves as a reminder of the transformative power of research engagement grounded in community-centric principles.

What are some of the challenges faced in the care and treatment of individuals with HIV, and how do you address those challenges in your practice?
This complex topic reflects our the intricacies of our country's deeply rooted social disparities. There are various intersecting challenges. There is a disproportionate impact on communities of color, the barriers to testing accessibility, the stigma associated with HIV, and the intricate connections between mental health, poverty, substance use, and unstable housing crises that disproportionately affect many of these populations.
The accessibility of testing, an essential tool in disease prevention and management, poses an additional obstacle for many individuals, further accentuating the existing disparities. Limited availability of testing centers, compounded by financial constraints and geographical barriers, can deprive vulnerable communities of timely diagnoses and essential care. This underscores the unfortunate truth that those most in need of medical attention are systematically denied equitable access to crucial services.
Navigating the landscape of HIV is further complicated by the stigma attached to the disease. The fear of discrimination and societal judgment often discourages individuals from pursuing testing, diagnosis, and necessary care. Consequently, a troubling cycle emerges wherein the very stigma hindering engagement also perpetuates the spread of the disease.

Could you tell us more about the HIV primary care-based model for the treatment of hepatitis C that you established at UC San Diego Health? How has it impacted the care of patients living with HIV?
At the end of 2006, in an era with few effective treatment options for Hep C, I noted that people living with HIV coinfected with Hep C died disproportionally at increased rates than those people with HIV without Hep C. However, I realized that they were dying not due to liver complications but AIDS-related opportunistic infection, substance overdose, suicide and accidents. It hit me hard to realize that the root was that most people with HIV and Hep C were not engaged in care, taking their HIV medications and had many competing personal barriers to care.
Hence, in 2007, we created a new model of care with one simple principle: decentralize their treatment in an era where patients waited for 6-months to see a sub-specialist. We also change the conventional approach "Give me a reason why we need to treat your Hep C" for "give me a reason why we can't treat you." Looking backwards it was the most inclusive and equitable concept we can have in medicine.
We use simple behavioral concepts that aim to build trust and provide people in need something to look freard to. From 75% of people with Hep C active in 2007 in our system, currently, we have only 2.5% of active HCV viremia among our HIV Hep C population, among the lowest in our country. This reminds me of one major lesson from the Famous Dr. Osler in the 1800’s which taught that Medicine is about not only science and skill, but also about empathy and having a good, caring, and tender heart with each of our patients.

As an educator, what are some of the key messages or lessons you emphasize when teaching medical students, residents, and fellows about HIV and infectious diseases?
A: Focus on the patient first, then on the disease
B. Clinical judgment must prevail
C. Listen to your patients, examine them thoroughly, and then look at the computer
D. Think critically and reassess
E. Don't be afraid of failure and retrying as otherwise, you will never be able to serve well

Can you discuss any ongoing clinical programs or trials that you're currently involved in to enhance the care of patients living with HIV?
A. I am participating in studies that help better understand the natural history of anal dsyplasia to anal cancer progression - a major burden among patients with HIV.
B. I am the UCSD PI for the ANCHOR trial, a strategy to mitigate alcohol consumption among patients living with HIV.
C. Styuding impact new HeC medication on efforts to eliminate HCV
D. I am the director of the UCSD-USA Navy Military international HIV training program that aims to train medical providers in countries of need in Africa, Eastern Europe and Latin America to provide service to their people in need.

What inspired you to specialize in infectious diseases and focus on HIV care? How has your experience shaped your perspective as a physician?
As noted in the introduction, my childhood experiences and I will summarize it all with “making the diagnosis is just the beginning”.

Are there any recent advancements or breakthroughs in the field of HIV research or treatment that you find particularly exciting or promising?
Among the most important ones is the availability of long-acting injectable intramuscular medications to treat HIV. They provide an important alternative for many people who struggle to take daily medications.

In your experience, what are some of the most significant changes or improvements you've witnessed in the management of HIV over the course of your career?
A. Availability of antiretroviral therapy that changes it from an illness to be a manageable chronic condition
B. Simplification of one pill a day
C. Availability of new injections every two months

How do you ensure the physical health and well-being of your patients with HIV while also addressing their emotional and mental health needs?
Listening and individualizing their needs. No judgment, no opinions. I endeavor to make everyone feel included, respected and served. More importantly, being there whenever they need me.

Don't forget to email us at: researchcomm@health.ucsd.edu or v3chavez@health.ucsd.edu if you have any additional questions for him. 

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Lastly, this Ask Away! Series will be posted on a bi-monthly basis, so feel free to send any questions you might have about research and science our way!

Until next time,

UC San Diego ACTRI