Using Telehealth to Address Alcohol Misuse in HIV Care

项目摘要 在艾滋病毒携带者(PLWH)中，酗酒与减少对 抗逆转录病毒治疗和降低艾滋病毒病毒抑制的几率以及肝脏和神经认知 功能障碍、心血管疾病、癌症、全身性炎症和存活率下降。行为 干预可以显著减少PLWH的饮酒，增加避孕套的使用，增加ART 坚持，并降低艾滋病毒病毒载量。我们最近发现，有助推器的激励面试(MI) 经过6个月的治疗，与通常的艾滋病毒护理相比，饮酒的减少尤其明显 在12个月的随访中得到了很好的维护，并得到了生化验证。然而， 提供MI需要训练有素的工作人员进行反复的咨询，而这一资源不太可能 在大多数照顾PLWH的社区卫生中心提供。在我们最近的工作中，我们发现 可以通过视频会议和电话以高保真的方式提供MI，使用资源高效型 辅导员的集中核心。我们进一步发现，两者通过视频延长咨询的组合 或者电话和交互式短信显示出进一步减少饮酒和增加 抑制艾滋病毒病毒的几率。拟议的研究的目的是测试现实世界中 REACH(在艾滋病毒护理中减少酒精使用和相关并发症)远程健康咨询方案 实用型混合型有效性--实施随机试验。我们将招募600名酗酒者 来自美国不同地理区域的四个联邦合格医疗中心的PLWH，这 为超过14,000名公众健康中心提供服务。完成注册后，参与者将被随机分配到 通过电话进行单次短暂干预(BI)，并在适当时转介到当地治疗，或者BI加 转诊至远程健康咨询(TC)。参与者将在24个月后完成随访 评估饮酒和健康结果的长期变化的基线。我们将检验TC的假设 与BI相比，将导致(A)每周饮酒量和重度饮酒频率的减少 以及(B)在12个月和24个月的随访中，病毒载量无法检测到的几率增加。次要的 结果包括自我报告的ART依从性，与非排他性伴侣进行无公寓性行为， 其他物质使用频率、磷脂酰乙醇水平(最近饮酒的生物标记物)，以及 退伍军人老龄化队列研究指数得分。我们还将检查TC有效性的潜在主持人。AS 次要目标是，我们将评估与动态方面相对应的执行措施 可持续发展框架，并检查可接受性、适当性和 在普罗科特实施成果框架指导下的可行性。因此，这一务实的混合类型1试验 将有助于建立REACH TC干预的真实有效性，同时也提供关键 与执行相关的措施和成果，将为未来实现技术合作、扩大规模和可持续性提供信息。

Project Summary Among people living with HIV (PLWH), alcohol misuse has been associated with reduced adherence to antiretroviral therapy and decreased odds of HIV viral suppression, as well as liver and neurocognitive dysfunction, cardiovascular disease, cancer, systemic inflammation, and decreased survival. Behavioral interventions can significantly reduce drinking in PLWH as well as increase condom use, increase ART adherence, and decrease HIV viral load. We recently found that motivational interviewing (MI) with booster sessions through 6 months, compared to HIV care as usual, results in particularly large reductions in drinking that are well-maintained over a 12-month follow-up and have been validated biochemically. However, delivering MI requires trained staff to conduct repeated sessions of counseling, a resource that is unlikely to be available at most community health centers caring for PLWH. In our recent work, we have found that it is feasible to deliver MI by videoconferencing and telephone with high fidelity using a resource-efficient centralized core of counselors. We further have found that a combination of both extended counseling by video or telephone and interactive text messaging shows promise in further reducing drinking and in increasing the odds of HIV viral suppression. The purpose of the proposed study is to test the real-world effectiveness of the ReACH (Reducing Alcohol use and related Comorbidities in HIV care) telehealth counseling protocol in a pragmatic Hybrid Type 1 effectiveness-implementation randomized trial. We will recruit 600 heavy-drinking PLWH from four federally-qualified health centers in geographically distinct regions across the U.S, which provide services to over 14,000 PLWH. Upon completing enrollment, participants will be randomized to receive either single-session brief intervention (BI) by phone with referral to local treatment when appropriate or BI plus referral to ReACH telehealth counseling (TC). Participants will complete follow-ups through 24 months after baseline to assess longer-term changes in drinking and health outcomes. We will test the hypothesis that TC compared to BI will result in (a) reduced number of drinks consumed per week and frequency of heavy drinking and (b) increased odds of having an undetectable viral load at 12- and 24-month follow-ups. Secondary outcomes include self-reported ART adherence, engagement in condomless sex with non-exclusive partners, frequency of other substance use, phosphatidylethanol levels (a biomarker of recent alcohol use), and Veterans Aging Cohort Study index scores. We also will examine potential moderators of TC effectiveness. As a secondary aim, we will assess implementation measures corresponding to aspects of the Dynamic Sustainability Framework and examine implementation outcomes of acceptability, appropriateness, and feasibility guided by Proctor’s Implementation Outcomes Framework. Thus, this pragmatic Hybrid Type 1 trial will help establish the real-world effectiveness of the ReACH TC intervention while also providing key implementation-related measures and outcomes that will inform future ReACH TC scale up and sustainability.