Missed visits and virologic failure among HIV infected African Americans receivin

描述（由申请人提供）：拟议研究的总体目标是使用丰富的前瞻性数据和最先进的定量方法来检查导致接受HIV医疗护理的非洲裔美国人（AA）错过预定门诊和病毒学失败的途径。现有数据来自于在综合临床系统艾滋病研究网络中心（CNICS）的三个地点登记的AA参与者（R24 AI 067039 -1; M。Saag，PI; http：//www.cnics.net/index.html）将用于拟定研究。CNICS是一个大型的、多样化的队列研究联盟，研究对象是1995年1月1日之后在诊所接受持续初级艾滋病毒护理的22，000多名艾滋病毒感染者。拟议工作的选定地点包括北卡罗来纳州大学艾滋病研究中心艾滋病毒临床队列（J. Eron，PI），亚拉巴马大学伯明翰分校（UAB）1917年临床队列（M。Saag，PI）和约翰霍普金斯艾滋病毒临床实践队列（R。摩尔，PI）。拟议的研究旨在（1）研究是否有和使用辅助服务（即，病例管理、酒精和药物滥用治疗）与随后的HIV病毒学失败的风险较低独立相关，并评估这种关联是否由预约就诊介导;（2）检查是否存在竞争性需求（即，因工作或资金有限而放弃医疗保健）与随后艾滋病毒病毒学失败的风险增加独立相关，并评估这种关联是否由预约就诊介导;以及（3）审查对保健提供者的不满是否-患者关系与随后HIV病毒学失败的风险增加独立相关，并评估这种相关性是否由预约介导出席情况.对于所有这三个目标，边际结构修正泊松回归模型将用于估计总的，自然的直接和自然的艾滋病毒辅助服务，竞争的需求，和医疗保健提供者-患者关系对病毒学失败的间接影响。将专门探讨通过预约出勤率介导的间接影响。拟议工作的结果将确定艾滋病毒感染的AA中的护理障碍，并为实施针对患者和环境的有针对性的干预措施提供信息（例如，诊所、社区、政策）级别，以最小化这些障碍。最大限度地减少AA之间的护理障碍，反过来又会减少艾滋病毒疾病中长期存在的巨大种族差异。 公共卫生相关声明：拟议的项目将确定艾滋病毒感染的非洲裔美国人中的护理障碍，并为实施针对患者和环境（例如，诊所、社区、政策）级别，以最小化这些障碍。最大限度地减少非裔美国人获得护理的障碍，反过来又会减少艾滋病毒疾病方面长期存在的巨大种族差异。

DESCRIPTION (provided by applicant): The overall goal of the proposed research is to use rich prospective data and state of the art quantitative methods to examine pathways contributing to missed scheduled clinic visits and virologic failure among African Americans (AAs) receiving HIV medical care. Existing data from AA participants enrolled in three sites of the Center for AIDS Research Network of Integrated Clinical Systems (CNICS) (R24 AI067039-1; M. Saag, PI; http://www.cnics.net/index.html) will be used for the proposed study. CNICS is a large and diverse consortium of cohort studies of over 22,000 HIV infected patients receiving ongoing primary HIV care in a clinic setting after 1 January 1995. Selected sites for the proposed work include the University of North Carolina Center for AIDS Research HIV Clinical Cohort (J. Eron, PI), the University of Alabama at Birmingham (UAB) 1917 Clinic Cohort (M. Saag, PI), and the Johns Hopkins HIV Clinical Practice Cohort (R. Moore, PI). The proposed study aims to (1) examine whether availability and use of ancillary services (i.e., case management, alcohol and drug abuse treatment) is associated independently with a lower risk of subsequent HIV virologic failure and assess whether this association is mediated by scheduled appointment attendance; (2) examine whether competing needs (i.e., forgoing medical care due to work or limited funds) are associated independently with an increased risk of subsequent HIV virologic failure and assess whether this association is mediated by scheduled appointment attendance; and (3) examine whether dissatisfaction with the healthcare provider-patient relationship is associated independently with an increased risk of subsequent HIV virologic failure and assess whether this association is mediated by scheduled appointment attendance. For all three aims, marginal structural modified Poisson regression models will be used to estimate total, natural direct, and natural indirect effects of ancillary HIV services, competing needs, and healthcare provider-patient relationships on virologic failure. Indirect effects mediated through scheduled appointment attendance will specifically be explored. Results from the proposed work will identify barriers to care among HIV-infected AAs and inform implementation of targeted interventions at the patient and contextual (e.g., clinic, neighborhood, policy) level to minimize such barriers. Minimizing barriers to care among AAs will in turn reduce substantial and longstanding racial disparities in HIV disease. PUBLIC HEALTH RELEVANCE STATEMENT: The proposed project will identify barriers to care among HIV-infected African Americans and inform implementation of targeted interventions at the patient and contextual (e.g., clinic, neighborhood, policy) level to minimize such barriers. Minimizing barriers to care among African Americans will in turn reduce substantial and longstanding racial disparities in HIV disease.