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/艾滋病流行病的研究和项目都集中在一个关键人群（KP）上，与其他KP隔离。这种孤立的做法严重限制了对艾滋病毒/艾滋病流行的基本动态的科学理解，并使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KP中的艾滋病毒/艾滋病流行病和方案可能影响其他KP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可以预测注射吸毒者（PWID）中的艾滋病毒感染率，而PWID中的艾滋病毒感染率可以预测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kp之间。同样，针对一个KP的项目可能会影响其他KP的流行病：我们发现，注射器交换项目的存在预示着这些msa中异性恋者的艾滋病发病率和死亡率会降低。支持这些发现的一个关键原则是，艾滋病毒/艾滋病与许多传染病一样，影响的是人群，而不仅仅是个人和网络。使用这种人口水平的方法，我们将在美国的三个KPs（即MSM， PWID和异性恋者）中开辟一条具有高影响力的流行病学，规划和政策研究的新路线。这项针对美国96个最大的msa的纵向（1992-2015）队列研究将(1)创建msa级别的HIV/AIDS流行结果年度估计，每个KP和KP亚组（按种族/民族、年龄定义，异性恋和PWID按性别定义），以及这些KP和KP亚组的HIV/AIDS相关项目的存在和覆盖范围。然后将描述这些流行病学和程序变量如何随时间和msa而变化。利用这些流行病学和规划估计，它将(2)确定一个KP的艾滋病毒/艾滋病流行病是否以及如何影响和受到其他KP的流行病的影响，无论是总体上还是KP的各个亚群；(3)发现每个KP和KP子组的HIV/ aids相关项目的存在和覆盖范围的决定因素。目标2将以疾病的政治生态学和流行病的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采用人口层面的观点，拟议的研究将推进一种新的研究范式，该范式将发现和描述跨kp动态如何帮助推动美国的艾滋病毒/艾滋病流行。研究结果还将为干预开辟新的领域，包括采取干预措施，设法防止某一KP的流行病影响到其他KP的流行病，并最大限度地提高各KP的干预措施的积极效果。一组对每个KP内的流行病和规划有深入了解的研究人员已联合起来，整合他们的KP特定专业知识，概念化和研究这些跨KP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.