Impacts of universal access to HIV/AIDS care among HIV+ injection drug users

描述（由申请人提供）：本申请的目的是为长期使用注射药物（IDU）的HIV感染者的前瞻性队列寻求新的资金，该队列与全面的HIV临床监测相关，以检查个人，社会，政策，经济和身体暴露对HIV治疗结果的影响。我们试图分析这些背景的决定因素，包括监禁，无家可归，参与性交易，在个人和社区层面上的HIV RNA血浆病毒载量的影响。我们将加强我们正在进行的流行病学和临床研究活动与分子遗传学和地理信息系统（GIS）为基础的方法，以模拟这些暴露对社区水平的血浆病毒载量，艾滋病发病率和抗逆转录病毒药物耐药性的产生的影响。在认识到越来越多的国际关注艾滋病毒的“风险环境”，一个概念性的框架模型的影响，外源性和内源性的特征对艾滋病毒感染的风险，我们将采用这种结构整合数据从个人和社区层面的艾滋病毒治疗结果的分析。这项建议是在国际上广泛一致认为需要对注射吸毒者中与艾滋病毒有关的发病率和死亡率持续上升的情况作出紧急反应的时候提出的。来自数学建模、观察性队列和临床试验的新证据揭示了个体内和社区水平的HIV RNA病毒载量与个体间HIV传播风险之间的密切联系，导致高活性抗逆转录病毒治疗（HAART）覆盖率较高的人群感染率较低。这一观察结果导致重新开展艾滋病毒预防工作，寻找弱势群体成员，对他们进行艾滋病毒感染检测，并让他们参与医疗保健，包括艾滋病毒感染治疗，以减少与艾滋病毒有关的发病率和死亡率，并降低艾滋病毒血清转化的发生率。我们提议的研究将在全省范围的“寻找、测试和治疗”活动中进行。考虑到迄今为止建立的研究基础设施和我们评估HAART获得和依从性障碍的跟踪记录，我们处于独特的有利地位，可以前瞻性地评估第二代问题，即预防即治疗运动对社区水平血浆病毒载量、HAART耐药性和HIV发病率的影响。在这方面，将治疗作为预防进行评价是2012财政年度国家卫生研究院艾滋病毒相关研究跨计划的一个紧迫优先事项。除了“寻求，测试和治疗”活动，我们的研究设置的温哥华，加拿大，是非常适合我们的学习目标。全民保健系统免费提供所有医疗服务，包括高效抗逆转录病毒疗法。保密记录的连接使所有关键措施，包括保健服务利用和艾滋病毒临床结果，都能准确实现。该申请提出了一项严格和创新的研究计划，将汇集流行病学，地理和系统发育的方法，以批判性地告知努力应对注射吸毒者中的艾滋病毒传播和发病机制。 公共卫生相关性：注射毒品使用者中的高水平艾滋病毒感染是一个全球性的公共卫生紧急情况。作为回应，我们建议继续我们正在进行的对艾滋病毒阳性吸毒者的研究，以评估艾滋病毒治疗对抗逆转录病毒药物模式的影响。 加拿大温哥华艾滋病病毒的耐药性和传播模式。

DESCRIPTION (provided by applicant): The purpose of this application is to seek renewed funding for a long-running prospective cohort of HIV- infected individuals who use injection drugs (IDU) linked to comprehensive HIV clinical monitoring to examine the impacts of individual, social, policy, economic, and physical exposures on HIV treatment outcomes. We seek to analyse the effects of these contextual determinants, including incarceration, homelessness, and involvement in the sex trade, on HIV RNA plasma viral load at both the individual and community levels. We will augment our ongoing epidemiologic and clinical research activities with molecular genetics and geographic information systems (GIS) based methods to model the effect of these exposures on community-level plasma viral load, HIV incidence, and the generation of antiretroviral drug resistance. In recognition of the increasing international attention to the HIV "risk environment," a conceptual framework modeling the effect of exogenous and endogenous characteristics on the risk of HIV infection, we will employ this structure to integrate data from individual and community levels in analyses of HIV treatment outcomes. This proposal comes at a time of broad international consensus on the need to respond urgently to persistently elevated levels of HIV-related morbidity and mortality among IDU. Emerging evidence from mathematical modeling, observational cohorts and clinical trials has revealed the close link between the HIV RNA viral load within individuals and at the community level and the risk of HIV transmission between individuals, resulting in lower rates of infection in populations with higher levels of coverage of highly active antiretroviral therapy (HAART.) This observation has led to renewed HIV prevention efforts to seek out members of vulnerable populations, test them for HIV infection, and engage them in healthcare, including treatment for HIV infection, in order to reduce HIV-related morbidity and mortality and lower the incidence of HIV seroconversion. Our proposed study will be conducted during a province-wide "Seek, Test, and Treat" campaign. Given the study infrastructure established to date and our track record evaluating barriers to HAART access and adherence, we are uniquely well placed to prospectively assess second-generation questions regarding the treatment as prevention campaign's impacts on community-level plasma viral loads, HAART resistance, and HIV incidence. In this regard, evaluations of treatment as prevention are an urgent priority in the FY 2012 Trans-NIH Plan for HIV-Related Research. In addition to the "Seek, Test, and Treat" campaign, our study setting of Vancouver, Canada, is ideally suited to our study aims. The universal healthcare system provides all medical care, including HAART, free of charge. Confidential record linkages allow the accurate attainment of all key measures, including health service utilization and HIV clinical outcomes. This application proposes a program of rigorous and innovative study that will marshal epidemiologic, geographic, and phylogenetic approaches to critically inform efforts to respond to HIV transmission and pathogenesis among IDU. PUBLIC HEALTH RELEVANCE: High levels of HIV infection among people who use injection drugs is a global public health emergency. In response, we propose to renew our ongoing study of HIV-positive drug users to assess the effect of HIV treatment on patterns of antiretroviral drug resistance and patterns of HIV transmission in Vancouver, Canada.