The HIV Care Continuum and Health Policy: Changes through Context and Geography

项目总结（摘要）。 艾滋病毒护理连续体是一个令人信服的流行病学框架，描述了 通过护理，包括诊断、联系和 保持护理，使用抗逆转录病毒疗法（ART），并最终抑制病毒。健康 政策可能会深刻影响沿着护理连续体的结果，这些影响可能 在不同区域和不同背景下进行修改。 在观察性队列中，临床护理保留、ART使用和病毒抑制 比例因现有数据和所研究的人口而异。美国 《国家艾滋病毒/艾滋病战略》（更新至2020年）和2013年世界卫生组织修订版 ART指南还参考了护理连续体中的里程碑。因为患者 保护和负担得起的医疗法案（ACA）和其他国家的健康政策在北部和拉丁美洲 美洲国家旨在改善医疗保健的可及性，减少健康差距， 在这些环境中，政策和环境因素对护理连续性结果的影响是 流行病学家、临床医生和政策制定者的极大兴趣。 这项研究旨在量化卫生政策，社会人口，背景， 艾滋病毒感染者中艾滋病毒护理连续性结果的地理模式和相关因素 美国（US），加拿大和墨西哥的人。背景因素包括精神因素 疾病、区域贫困、居住城市化以及其他个人和环境因素 特色北美艾滋病队列研究与设计合作组织（NA-AIDS Cohort Collaboration on Research and Design） 和加勒比、中美洲和南美洲艾滋病毒流行病学网络 （CCASAnet）提供了丰富的数据来源，可供开展这项工作。 目标1将量化北美和拉丁美洲连续护理结果的差异， 评估卫生系统、人口统计学、风险、背景和地理差异。因为 研究背景因素和卫生系统特征对护理的影响 具有临床护理数据的纵向队列的连续结局很少， 由于地理位置有限，这种分析将是新颖的，而且具有重要意义。 目标2和3将提供有关ACA对改善医疗保健的影响的推论 在美国接受治疗的HIV感染者中。国家主导的医疗补助覆盖范围的扩大 将被用作准实验，以评估对护理连续体的影响， 其他艾滋病毒疾病的结果，比较前ACA（2014年前）ACA实施期间。

PROJECT SUMMARY (ABSTRACT). The HIV Care Continuum is a compelling epidemiologic framework describing the movement of people living with HIV/AIDS through care, including diagnosis, linkage and retention in care, use of antiretroviral therapy (ART), and ultimately, viral suppression. Health policies may profoundly influence outcomes along the Care Continuum, and these effects may be modified across regions and through individual contexts. In observational cohorts, retention in clinical care, ART use, and viral suppression proportions have varied depending on available data and the population under study. The US National HIV/AIDS Strategy (updated to 2020) and the revised 2013 World Health Organization ART guidelines also reference milestones in the Care Continuum. Because the Patient Protection and Affordable Care Act (ACA) and other national health policies in North and Latin American countries aim to improve healthcare access and reduce health disparities, describing the effect of policy and contextual factors on Care Continuum outcomes in these settings is of great interest to epidemiologists, clinicians, and policy makers. This research seeks to quantify health policy, sociodemographic, contextual, and geographic patterns and correlates of HIV Care Continuum outcomes among HIV-infected persons in the United States (US), Canada, and Mexico. Contextual factors include psychiatric illness, regional poverty, residential urbanicity, and other individual and environmental characteristics. The North American AIDS Cohort Collaboration on Research and Design (NA- ACCORD) and Caribbean, Central and South America network for HIV epidemiology (CCASAnet) provide rich data sources in which to conduct this work. Aim 1 will quantify disparities in Care Continuum outcomes in North and Latin America, assessing health system, demographic, risk, contextual, and geographic differences. Because research into the influence of contextual factors and health system characteristics on Care Continuum outcomes in longitudinal cohorts with clinical care data have been sparse or geographically limited, this analysis will be novel and of significant importance. Aims 2 and 3 will provide inferences about the ACA's effects on improving healthcare among HIV-infected individuals in care in the US. The state-led expansion of Medicaid coverage under the ACA will be used as a quasi-experiment to assess effects on Care Continuum and other HIV disease outcomes, comparing pre-ACA (pre-2014) to ACA implementation periods.