Informing and promoting Shared decision making for HIV Prevention and Alcohol Reduction: Engaging Diverse Veterans to Refine and Pilot a Decision Aid (SHARE Study)

摘要 通过加强暴露前预防(PrEP)预防艾滋病毒传播，特别是在 艾滋病毒发病率不成比例的边缘化人群(例如，种族/族裔和性别化 这是结束艾滋病毒流行的关键一步。尽管饮酒不健康是一种 艾滋病毒发病率的中心可改变风险因素，在边缘人群中比例过高，很少有艾滋病毒 现有的预防干预措施可以协同解决不健康的酒精使用和PrEP。研究是 需要了解不健康饮酒个人对PrEP的吸收情况，并开发可扩展的 以患者为中心的干预措施，协同解决不健康的酒精使用和艾滋病毒问题。退伍军人健康 美国退伍军人管理局(VA)在为不健康的酒精使用提供循证护理方面处于领先地位，但规模很大 对于不健康饮酒的退伍军人，在实施PrEP方面存在差距-我们的初步研究表明 在PrEP知识、使用和覆盖方面的主要差距，以及使用不健康酒精的退伍军人。循证的 对于不健康的酒精使用，可以进行干预/治疗，但在#年，酒精使用历来没有针对性。 艾滋病毒预防干预措施。我们的艾滋病毒和成瘾医学跨学科专家团队，交集 酒精使用和艾滋病毒、实施科学、健康差异研究和社区合作研究 将在社会生态学理论的指导下使用顺序混合方法，综合框架 实施科学和发现/设计/构建/测试(DDBT)流程，以了解 在PrEP护理过程中使用不健康的酒精，然后完善现有的决策辅助以增加PrEP 在退伍军人事务部进行与酒精相关的护理时开始初级保健。量化工作将包括约190万 个人，包括足够数量的小规模患者(例如，约115,000名小规模患者 性取向和约11,000人的性别认同)，并将评估模式的变化 跨退伍军人管理局设施和患者亚组的PrEP启动和持久性(目标1)。调查结果将用于 通知有目的的抽样以改进定性工作(目标2)，然后对现有的决策辅助工具进行试点测试 以前在NIAAA支持下开发的(目标3)。我们的研究是以患者为中心的，在特征上是创新的 在不健康饮酒和不健康饮酒患者的不同亚群中进行整体和不同亚组的准备护理，利用 一种新的自然语言处理(NLP)驱动的性别少数群体识别和定制算法 现有的决策辅助工具，以促进共同制定预防艾滋病毒和饮酒的共同决策。 研究活动将在社区咨询委员会的反复投入下进行。这项研究是高度 响应NIAAA的优先事项，并有可能产生重大影响，因为它将为整合患者- 以中心和多目标为中心的新型决策援助，用于常规初级保健环境中的艾滋病毒预防 有可能增加医疗服务的公平性。

ABSTRACT Preventing HIV transmission with enhanced Pre-exposure Prophylaxis (PrEP) access, particularly among marginalized populations with disproportionate HIV incidence (e.g., minoritized racial/ethnic and sexual orientation and gender groups), is a crucial step in ending the HIV epidemic. Though unhealthy alcohol use is a central modifiable risk factor for HIV incidence and over-represented among marginalized populations, few HIV prevention interventions exist that synergistically address both unhealthy alcohol use and PrEP. Research is needed to understand PrEP uptake among individuals with unhealthy alcohol use and to develop scalable patient-centered interventions that synergistically address unhealthy alcohol use and HIV. The Veterans Health administration (VA) is a leader in provision of evidence-based care for unhealthy alcohol use, yet substantial gaps in PrEP implementation for Veterans with unhealthy alcohol use exist—our preliminary research suggests major gaps in PrEP knowledge, use, and reach, and Veterans with unhealthy alcohol use. Evidence-based interventions/treatments are available for unhealthy alcohol use, but alcohol use is historically under targeted in HIV prevention interventions. Our team of interdisciplinary experts in HIV and addiction medicine, the intersection of alcohol use and HIV, implementation science, health disparities research, and community-partnered research will use sequential mixed methods guided by socioecological theory, the Consolidated Framework for Implementation Science, and the Discover/Design/Build/Test (DDBT) process to understand the impact of unhealthy alcohol use on the PrEP care continuum and then refine an existing decision aid to increase PrEP initiation in primary care at the point of alcohol-related care in the VA. Quantitative work will include ~1.9 million individuals, including adequate numbers of minoritized patients (e.g., ~115,000 individuals with minoritized sexual orientation and ~11,000 individuals with minoritized gender identity) and will assess variation in patterns of PrEP initiation and persistence across VA facilities and patient subgroups (Aim 1). Findings will be used to inform purposive sampling for qualitative work to refine (Aim 2) and then pilot test an existing decision aid for developed previously with NIAAA support (Aim 3). Our study is patient-centered and innovative in characterizing PrEP care overall and within diverse subgroups of patients with and without unhealthy alcohol use, leveraging a novel natural language processing (NLP)--driven algorithm for identifying sexual minority groups, and tailoring an existing decision aid to facilitate shared decision-making for co-occurring HIV prevention and alcohol use. Study activities will be conducted with iterative input from a community advisory board. The study is highly responsive to NIAAA priorities and has potential for high impact as it will lay foundation for integrating a patient- centered and multi-targeted novel decision aid for HIV prevention in routine primary care settings that may have potential to increase equity in care.