Metropolitan Trajectories of HIV Epidemics, Drug Use, and Responses in US Key Populations

描述（由申请人提供）：30多年来，几乎所有关于艾滋病毒/艾滋病流行病和项目的研究都集中在一个与其他关键人群隔离的关键人群（KP）。这种孤立的做法极大地限制了对艾滋病毒/艾滋病流行病基本动态的科学了解，并导致我们错过了预防新感染的重要机会。该小组和其他人发表的初步分析表明，一个金伯利进程的艾滋病毒/艾滋病流行病和方案可能影响其他金伯利进程的流行病和方案。例如，我们对美国96个最大的大都市统计区（MSA）的分析表明，男男性行为者（MSM）中的艾滋病毒感染率预测了注射毒品者（PWID）中的艾滋病毒感染率，而PWID中的艾滋病毒感染率预测了异性恋者中的艾滋病发病率。对性网络的研究也表明，混合发生在KPs之间。同样，针对一个KP的计划可能会影响其他KP的流行病：我们发现，注射器交换计划的存在预示着这些MSA中异性恋者的艾滋病发病率和死亡率较低。支持这些研究结果的一个关键原则是，艾滋病毒/艾滋病病毒与许多传染病一样，影响到人口，而不仅仅是个人和网络。使用这种人口水平的方法，我们将开创一种新的高影响力的流行病学，方案和政策研究，关于艾滋病毒/艾滋病流行病和方案是否以及如何在三个关键点（即，男男性接触者，PWID和异性恋者）在美国。这项对美国96个最大的MSA进行的纵向（1992-2015）队列研究将（1）创建每个KP和KP亚组（根据种族/民族、年龄以及异性恋者和PWID的性别定义）的HIV/AIDS流行结局的MSA水平年度估计值，以及这些KP和KP亚组的HIV/AIDS相关项目存在和覆盖率。然后，它将描述这些流行病学和程序变量如何随时间和MSA而变化。使用这些流行病学和方案估计，它将（2）确定一个KP中的艾滋病毒/艾滋病流行病是否以及如何影响其他KP中的流行病，以及受其他KP中流行病的影响，包括整体和KP亚组;（3）发现每个KP和KP亚组的艾滋病毒/艾滋病相关方案存在和覆盖范围的决定因素。目标2将以疾病政治生态学和流行病辩证模式框架为指导;目标3将以相关的社区行动理论为指导。通过实现这些目标，并拥抱人口水平的角度来看，拟议的研究将推进一个新的研究范式，将发现和描述如何跨KP动态有助于推动艾滋病毒/艾滋病在美国的流行。调查结果还将开辟新的干预领域，包括旨在防止一个KP中的流行病影响其他KP中的流行病的干预措施，以及最大限度地发挥KPs干预措施的积极作用。一个对每个金伯利进程内的流行病和方案有深入了解的研究人员团队已经联合起来，整合他们的金伯利进程特定专业知识，以概念化和研究这些跨金伯利进程的相互作用。

DESCRIPTION (provided by applicant): For over 30 years, almost all studies of HIV/AIDS epidemics and programs have focused on one key population (KP) in isolation from other KPs. This siloed approach has significantly limited scientific understanding of the fundamental dynamics of HIV/AIDS epidemics, and has led us to miss vital opportunities to prevent new infections. Published and preliminary analyses by this team and others suggest that HIV/AIDS epidemics and programs in one KP may affect epidemics and programs in other KPs. For example, our analyses of the 96 largest US metropolitan statistical areas (MSAs) suggest that HIV prevalence among men who have sex with men (MSM) predicts HIV prevalence among people who inject drugs (PWID), and that HIV prevalence among PWID predicts AIDS incidence among heterosexuals. Studies of sexual networks also suggest that mixing occurs across KPs. Likewise, programs targeting one KP may affect epidemics in other KPs: we have found that the presence of syringe exchange programs predicts later lower AIDS incidence and mortality rates among heterosexuals in these MSAs. A key principle undergirding these findings has been that the HIV/AIDS virus, like many infectious diseases, affects populations, not just individuals and networks. Using this population-level approach, we will pioneer a novel line of high-impact epidemiologic, programmatic, and policy research on whether and how HIV/AIDS epidemics and programs affect one another across three KPs (i.e., MSM, PWID, and heterosexuals) in the US. This longitudinal (1992-2015) cohort study of the 96 largest MSAs in the US will (1) create MSA-level annual estimates of HIV/AIDS epidemic outcomes for each KP and KP subgroup (defined by race/ethnicity, age, and, for heterosexuals and PWID, gender), and of HIV/AIDS- related program presence and coverage for these KPs and KP subgroups. It will then describe how each of these epidemiologic and program variables varies across time and MSAs. Using these epidemiologic and programmatic estimates, it will (2) determine if and how HIV/AIDS epidemics in one KP affect and are affected by epidemics in other KPs, both overall and across KP subgroups; and (3) discover determinants of the presence and coverage of HIV/AIDS-related program presence and coverage for each KP and KP subgroup. Aim 2 will be guided by the Political Ecology of Disease and the Dialectical Model of Epidemics frameworks; Aim 3 will be guided by the related Theory of Community Action. By achieving these aims and embracing a population-level perspective, the proposed study will advance a new paradigm of research that will discover and describe how cross-KP dynamics help drive HIV/AIDS epidemics in the US. Findings will also open up new arenas for intervention, including interventions that seek to prevent epidemics in one KP from affecting epidemics in other KPs, and that maximize positive effects of interventions across KPs. A team of researchers with deep knowledge of epidemics and programs within each KP has joined forces to integrate their KP- specific expertise to conceptualize and study these cross-KP interactions.