Telemedicine to Improve Depression and Adherence in HIV+ Women in the Rural South

描述(由申请人提供)：抑郁已被认为是艾滋病毒护理不遵守的强烈预测因素，因此增加了发病率和死亡率。与感染艾滋病毒的男性相比，感染艾滋病毒的妇女不成比例地受到共病抑郁症的影响。然而，针对艾滋病毒感染妇女的心理社会需求的干预措施有限，特别是在艾滋病毒流行率仍然很高的美国南部农村地区。为了解决艾滋病毒感染妇女在艾滋病毒护理方面的这一根本差距，长期目标是开发一种有效的干预措施，通过降低抑郁症发病率并同时增加对抗逆转录病毒疗法(ART)的坚持和护理的保留，显著改善艾滋病毒感染妇女的临床结果。这项应用的目的是在文化上调整一种针对抑郁症和抗逆转录病毒治疗依从性(CBT-AD)的公认且有效的认知行为疗法，并测试其在居住在美国南部农村的艾滋病毒感染少数民族妇女中坚持艾滋病毒护理的可行性和可接受性。将利用电话会议/远程医疗技术，克服农村地区长期存在的获得保健服务的结构性障碍(例如，交通、获得精神卫生服务提供者的机会)。为实现这一目标，这项建议的具体目标是：1)在艾滋病毒感染妇女和艾滋病毒护理提供者中进行形成性研究(即焦点小组、关键信息提供人访谈)，以告知阿拉巴马州农村地区艾滋病毒感染妇女CBT-AD干预措施的文化适应情况；2)利用迭代开放标签非随机过程，系统地使CBT-AD干预措施适用于居住在阿拉巴马州农村的艾滋病毒感染抑郁症妇女和远程医疗技术；3)通过一项先导性随机对照试验(RCT)，评估改良的CBT-AD在减少HIV感染的抑郁症妇女中的抑郁、改善ART依从性和护理保留率方面的可行性、可接受性和初步疗效。参与者将从阿拉巴马州47个县的三个艾滋病毒护理组织招募，其中包括2010年感染艾滋病毒的668名妇女。在这项提议中，所有地点都通过远程医疗设备连接起来，以便利向农村地区提供精神卫生服务。这项拟议研究的贡献是巨大的。 因为这是一系列研究的第一步，预计这些研究将导致制定满足艾滋病毒感染妇女特定性别、心理和医疗需要的疗法，以改善对抗逆转录病毒疗法的坚持和护理的保持。本申请中建议的研究具有创新性，因为：1)它侧重于研究不足的弱势人口，即居住在南方腹地的感染艾滋病毒的妇女，她们已被证明在经济上处于不利地位，并因抑郁症发病率高而背负重担；2)它计划在文化上调整一种旨在降低抑郁症发病率的干预措施，同时增加对艾滋病毒护理的保留和坚持；3)它使用远程医疗技术，这将使获得护理和心理健康服务的障碍得以解决。 与公共卫生相关：拟议的研究与公共健康相关，因为它提供了创新的解决方案，解决了与抗逆转录病毒治疗相关的障碍，以及在患有高抑郁率的艾滋病毒感染妇女中坚持和保留护理。因此，拟议的研究直接符合NIH 2011财年艾滋病毒相关研究跨NIH计划和白宫国家艾滋病毒/艾滋病战略的目标，这些目标旨在通过研究影响艾滋病毒感染妇女和女孩遵守艾滋病毒治疗方案和医疗保健的干预措施来减少健康差距。此外，报告还确定有必要评估与艾滋病毒无关的治疗和包括精神健康障碍在内的共病对获得保健服务的影响。

DESCRIPTION (provided by applicant): Depression has been recognized as a strong predictor of HIV care non-adherence, and consequently of increased morbidity and mortality. HIV-infected women are disproportionally affected by co-morbid depression in comparison to HIV-infected men. However, interventions addressing the psychosocial needs of HIV-infected women, particularly in the rural Deep South of the United States where HIV prevalence remains high, are limited. To address this fundamental gap in HIV care of HIV-infected women, the long-term goal is to develop an effective intervention that significantly improves clinical outcomes in HIV-infected women by decreasing depression morbidity and simultaneously increasing both adherence to antiretroviral therapy (ART) and retention in care. The objective of this application is to culturally adapt an established and effective cognitive- behavioral therapy for depression and antiretroviral therapy adherence (CBT-AD) and test its feasibility and acceptability to HIV care adherence among HIV-infected minority women living in the rural South of the US. Teleconferencing/telemedicine technology will be used to overcome structural barriers to health care access (e.g. transportation, access to mental health service providers) persistent in rural areas. To accomplish this objective, the specific aims of this proposal are: 1) To conduct formative research (i.e. focus groups, individual key informant interviews) among HIV-infected women and HIV care providers to inform the cultural adaptation of the CBT-AD intervention for HIV-infected women in rural areas of Alabama; 2) To systematically adapt the CBT-AD intervention to HIV-infected depressed women residing in rural Alabama and telemedicine technology, using an iterative open-label - non-randomized process; and 3) To assess the feasibility, acceptability and preliminary efficacy of the adapted CBT-AD in reducing depression and improving ART adherence and retention in care among HIV-infected depressed women via a pilot randomized controlled trial (RCT). Participants will be recruited from three HIV care organizations serving 47 counties across Alabama, including 668 HIV-infected women in 2010. All sites are connected through telemedicine equipment facilitating the delivery of mental health service into rural areas in this proposal. The contribution of the proposed research is significant since it is the first step in a continuum of research that is expected to lead to the development o therapies that meet the gender-specific, psychological and medical needs of HIV-infected women to improve adherence to ART and retention in care. The research proposed in this application is innovative because of: 1) Its focus on an understudied vulnerable population, namely HIV-infected women residing in the Deep South who have been shown to be economically disadvantaged and burdened by high rates of depression; 2) Its plan to culturally adapt an intervention that aims at decreasing depression morbidity and simultaneously increases retention and adherence to HIV care and 3) Its use of telemedicine technology, which will allow for barriers of access to care and mental health services to be addressed. PUBLIC HEALTH RELEVANCE: The proposed research is relevant to public health because it provides innovative solutions to obstacles related to antiretroviral therapy adherence and retention in care among HIV-infected women experiencing high rates of depression. Thus the proposed research directly meets the goals of the NIH's FY 2011 Trans-NIH Plan for HIV-related Research and the White House's National HIV/AIDS Strategy, which aim at reducing health disparities by studying interventions that impact adherence to HIV therapeutic regimens and medical care among HIV-infected women and girls. Furthermore it identifies the need for evaluating the impact of HIV- unrelated therapies and co-morbidities, including mental health disorders, on access to health care.