Community Vulnerability and Responses to Drug-User-Related HIV/AIDS

描述（由申请人提供）：这是社区脆弱性和对吸毒者相关艾滋病毒/艾滋病的反应研究的竞争性延续申请，该研究旨在研究为什么美国大都市地区吸毒者对艾滋病毒/艾滋病的脆弱性及其反应随时间而变化。在可能影响疫情的政策和项目中。药物使用和艾滋病毒流行随着时间的推移而变化。在最后一个资助期内，我们发现1992年至2002年，美国96个最大的大都市地区注射吸毒者（IDUs）的艾滋病毒患病率下降，1992年至2000年，这些地区的IDUs人口患病率下降，但随后又开始上升。我们还表明，大都市地区在这些轨迹上存在差异，各种社会和政策力量影响了IDU流行率、IDU流行率的种族差异、IDU流行率中的艾滋病毒流行率、IDU流行率中的艾滋病流行率的种族差异、药物滥用治疗覆盖率、注射器交换获取和覆盖率。不幸的是，我们最近的分析表明，青少年（15 - 29岁）的IDUs患病率已经开始上升。此外，正如其他人所表明的那样，艾滋病毒在一些大都市地区的非注射吸毒者（海洛因、可卡因、快克、安非他明或甲基苯丙胺的非注射使用者）中广泛传播。这些变化是在最近经济从缓慢下降转向迅速下降的背景下发生的，这种转变将导致在维持，更不用说扩大为吸毒者提供的服务方面出现很大困难。因此，这一拟议延续的具体目标是：为了描述1992年至2012年美国96个最大大都市地区的趋势，(a)关键流行病学结果(注射吸毒者和非注射吸毒者的人口患病率，特别是年轻人的患病率；以及在注射吸毒者中，艾滋病毒流行率、晚期诊断艾滋病毒病例和艾滋病发病率和死亡率)，以及(b)实施循证药物相关干预措施（药物滥用治疗、注射器交换、艾滋病毒咨询和检测）和(c)非循证药物相关干预措施（监禁和逮捕吸毒者）。2. 了解宏观社会背景（如经济变化、社会融合、种族居住隔离）和流行病学需求如何影响干预措施；干预措施和宏观社会背景如何共同影响流行病学背景；一些干预措施（如逮捕、监禁）如何影响其他干预措施（如注射器交换覆盖范围）；以及一些流行病学结果（例如，年轻注射吸毒者的流行）如何影响其他结果（例如，艾滋病毒流行）。3. 开发一个综合理论，使用基于主体的建模，这些过程如何相互作用，从而在给定的社会背景下，各种干预组合可能产生的影响。4. 向公共卫生机构传播估计、结果和理论认识，并继续就如何应对提供咨询意见。

DESCRIPTION (provided by applicant): This is a competing continuation application for the Community Vulnerability and Responses to Drug-User- Related HIV/AIDS study of why large US metropolitan areas vary over time in their vulnerability to HIV/AIDS among drug users and in their responses-i.e., in policies and programs that may affect the epidemic. Drug use and HIV epidemics change over time. In the last funding period, we showed that HIV prevalence in the 96 largest US metropolitan areas declined among injection drug users (IDUs) from 1992 to 2002, and that the population prevalence of IDUs declined in these areas from 1992 to 2000, but then began to rise again. We also showed that metropolitan areas varied in these trajectories, and that a variety of social and policy forces shaped IDU prevalence, racial disparities in IDU prevalence, HIV prevalence among IDUs, racial disparities in AIDS prevalence among IDUs, drug abuse treatment coverage, and syringe exchange access and coverage. Ominously, our recent analyses indicate that the prevalence of IDUs among youth (aged 15 - 29) has begun to rise. Further, as others have shown, HIV has spread widely among NIDUs (non-injecting users of heroin, cocaine, crack, amphetamines or methamphetamine) in some metropolitan areas. These changes are occurring against the backdrop of an economy that has recently shifted from slow to rapid decline, a shift that will lead to great difficulty in maintaining, let alone expanding, services for drug users. Therefore, the Specific Aims of this proposed continuation are: 1. To describe trends, in the 96 largest US metropolitan areas from 1992 - 2012, in (a) critical epidemiologic outcomes (population prevalence of IDUs and NIDUs, and particularly their prevalence among youth; and, among IDUs, HIV prevalence, late-diagnosis HIV cases, and AIDS incidence and mortality) as well as in (b) the implementation of evidence-based drug- related interventions (drug abuse treatment, syringe exchange, HIV counseling and testing) and (c) non- evidence-based drug-related interventions (incarceration and arrests of drug users). 2. To understand how macro-social contexts (e.g., economic changes, social integration, racial residential segregation) and epidemiologic need affect interventions; how interventions and macro-social contexts together affect epidemiologic contexts; how some interventions (e.g., arrests, incarceration) affect others (e.g., syringe exchange coverage); and how some epidemiologic outcomes (e.g., prevalence of young IDUs) affect others (e.g., HIV prevalence). 3. To develop an integrated theory, using agent based modeling, of how these processes interact and thus what the impacts of various intervention mixes are likely to be in given social contexts. 4. To disseminate estimates, results and theoretical understandings to public health agencies and continue to advise them on how they might respond. PUBLIC HEALTH RELEVANCE: This project will estimate changes in injection and non-injection drug use, in HIV, AIDS and AIDS mortality rates among injection drug users, and in drug- and HIV-related interventions among drug users, in 96 large metropolitan areas over a 21-year period (1992 - 2012). We will investigate how these epidemics and interventions affect one another, and how macro-contextual factors like economic and social conditions shape them both. We will identify metropolitan areas in which serious drug use, HIV or AIDS epidemics are emerging, and offer state and local health departments and drug agencies the best information available on policies and programs that might reduce these epidemics. Our findings will also help national public health agencies, including the CDC and SAMHSA, and other researchers, plan a mixture of evidence-based programs and policies to reduce the forces that lead to high-risk drug use and the associated HIV and AIDS epidemics.