Improving HIV and Alcohol-Related Outcomes among HIV+ Persons in Clinic Settings

描述（由申请人提供）：在艾滋病毒阳性（艾滋病毒+）人群中，有害或危险水平的饮酒会加剧健康问题并加速艾滋病毒疾病的进展。抗逆转录病毒治疗（ART）一直是艾滋病毒感染者优化病毒抑制和减缓疾病进展的唯一最重要的治疗方法。坚持抗逆转录病毒治疗具有相当大的公共卫生影响，特别是考虑到最佳坚持治疗可降低发病率和死亡率，降低艾滋病毒耐药菌株发展的可能性，并降低艾滋病毒的传染性。PLUS项目（通过理解和支持积极生活）是第一个（据我们所知）基于理论的行为干预，它结合了动机访谈和认知行为技能培训，在一项随机对照试验中，在不同种族和民族的HIV阳性女性和男性样本中，展示了病毒载量、CD4细胞计数和自我报告依从性的显著改善。这是对危险饮酒者的第一次干预，以证明其效果显著。临床复制是研究艾滋病诊所提供者向患者提供干预措施在现实世界中的有效性的关键下一步。圣卢克罗斯福医院中心是纽约市最大的艾滋病毒医疗保健提供者，拥有5000多名活跃的艾滋病毒感染者，我们与该中心的综合护理中心（CCC）的医疗提供者合作，目标是更好地了解艾滋病毒感染者一生中与酒精相关的结果，并开展一项多地点比较有效性试验，包括三种强度的治疗：PLUS干预、常规强化治疗（eTAU）条件、在艾滋病毒阳性危险饮酒者中，测试PLUS干预在减少酒精使用和改善抗逆转录病毒治疗依从性、病毒载量和CD4计数方面的临床和成本效益。我们将通过以下四个具体目标实现我们的目标：1)调整PLUS干预措施，以便由精神卫生提供者在艾滋病毒诊所环境中提供服务，并纳入加强会议，以维持长期效果；2)在纽约市的一个艾滋病诊所联合体中，测试PLUS干预相对于单独使用eTAU和TAU对艾滋病毒阳性危险饮酒者的有效性；3)评估PLUS对eTAU条件和单独TAU的成本效益，估计超过5年和10年的窗口；4)通过CCC的电子病历分析回顾性队列数据和前瞻性自然病史数据。与CCC专家合作将有助于解决医疗服务提供一线的实际问题，为在艾滋病毒感染者中减少酒精使用和改善抗逆转录病毒治疗依从性和健康结果的综合规划铺平道路。我们的项目不仅有可能对有问题饮酒的HIV+患者的ART干预措施的有效性产生持续和强大的影响，而且还可能对有效利用EMR数据来检查大型城市和不同类型的HIV+临床患者中酒精和HIV相关结果之间的关系产生影响。

DESCRIPTION (provided by applicant): Alcohol consumption at harmful or hazardous levels among HIV-positive (HIV+) persons exacerbates health problems and accelerates HIV disease progression. Antiretroviral therapy (ART) has been the single most important treatment for people living with HIV to optimize viral suppression and slow disease progression. Adherence to ART has considerable public health implications, particularly given that optimal adherence decreases morbidity and mortality, decreases the potential for the development of drug resistant strains of HIV, and reduces HIV infectiousness. Project PLUS (Positive Living through Understanding and Support) was the first (and to our knowledge only) theory-based behavioral intervention, which integrates motivational interviewing and cognitive-behavioral skills training, to demonstrate significant improvements in viral load, CD4 cell count, and self-reported adherence among a racially and ethnically diverse sample of HIV+ women and men enrolled in a randomized controlled trial, and the first intervention for hazardous drinkers to demonstrate any significant effects. A clinic-based replication is the crucial next step in studying the intervention's effectiveness in the real world when delivered by HIV clinic providers to their patients. In collaboration with medical providers at the Center for Comprehensive Care (CCC) at St. Luke's-Roosevelt Hospital Center, the largest provider of HIV medical care in the New York City area with over 5000 active HIV+ patients, our goals are to better understand alcohol-related outcomes among HIV+ persons over the lifespan and to conduct a multisite comparative effectiveness trial with three intensities of treatment-the PLUS intervention, an enhanced treatment as usual (eTAU) condition, and treatment as usual (TAU) condition-to test the clinical and cost-effectiveness of the PLUS intervention in reducing alcohol use and improving ART adherence, viral load, and CD4 counts among HIV+ hazardous drinkers. We will achieve our goals through four specific aims: 1) adapt the PLUS intervention for delivery in HIV clinic settings by mental health providers, and incorporate booster sessions to sustain longer-term effects; 2) test the effectiveness of the PLUS intervention relative to eTAU and TAU alone for HIV+ hazardous drinkers when delivered in a consortium of HIV clinics in New York City; 3) assess the cost-effectiveness of PLUS to an eTAU condition and TAU alone as estimated over 5- and 10-year windows; and 4) analyze retrospective cohort data and prospective natural history data via CCC's Electronic Medical Records. Working together with CCC experts will help to address practical problems at the frontline of medical service provision to pave the way for a comprehensive program in reducing alcohol use and improving ART adherence and health outcomes among HIV+ persons. Our project has the potential to exert a sustained and powerful impact not only on the effectiveness of ART interventions for HIV+ persons with problematic drinking, but also on the effective use of EMR data to examine the relationship among alcohol and HIV-related outcomes in a large urban and diverse cohort of HIV+ clinic patients.