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 通过加强接触前预防（PrEP）的获得来预防艾滋病毒传播，特别是在 艾滋病毒感染率不成比例的边缘化人群（例如，在种族/族裔和性别方面属于少数群体的人 艾滋病毒/艾滋病（艾滋病毒/艾滋病）是结束艾滋病毒流行的关键一步。尽管不健康的饮酒是一种 艾滋病毒发病率的主要可改变风险因素，在边缘化人口中比例过高， 预防干预措施存在，协同解决不健康的酒精使用和PrEP。 需要了解不健康酒精使用者的PrEP摄取情况，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。退伍军人健康 美国退伍军人管理局（VA）是为不健康饮酒提供循证护理的领导者，但数量巨大 我们的初步研究表明，对使用不健康酒精的退伍军人实施PrEP存在差距 PrEP知识，使用和覆盖面的主要差距，以及使用不健康酒精的退伍军人。循证 对于不健康的酒精使用，可以采取干预措施/治疗，但酒精使用在历史上是针对性的， 艾滋病毒预防干预措施。我们的跨学科专家团队在艾滋病毒和成瘾医学，交叉 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 将使用社会生态学理论指导下的顺序混合方法， 实施科学和发现/设计/构建/测试（DDBT）流程，以了解 在PrEP护理连续体中使用不健康的酒精，然后改进现有的决策辅助工具，以增加PrEP 在VA中与酒精相关的护理点开始初级护理。量化工作将包括~ 190万 个人，包括足够数量的少数群体患者（例如，约115，000名少数族裔 性取向和约11，000名具有少数性别身份的人），并将评估模式的变化 在VA机构和患者亚组中，PrEP的启动和持续性（目标1）。调查结果将用于 为定性工作提供有目的的抽样，以进行改进（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的支持下开发的（目标3）。我们的研究是以患者为中心的，在表征方面具有创新性 PrEP护理总体上以及在有和没有不健康的酒精使用的患者的不同亚组中， 一种新颖的自然语言处理（NLP）驱动的算法，用于识别性少数群体， 一个现有的决策辅助工具，以促进共同决策，共同预防艾滋病毒和酒精使用。 研究活动将在社区咨询委员会的反复投入下进行。这项研究高度 响应NIAAA的优先事项，并具有潜在的高影响力，因为它将为整合患者奠定基础- 在常规的初级保健环境中，为艾滋病毒预防提供以中心和多目标的新型决策辅助， 提高护理公平性的潜力。

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.