Quantifying health policy impacts on substance use and treatment among women with and at risk for HIV: a longitudinal multilevel analysis using the Women's Interagency HIV Study

项目摘要/摘要 物质使用(SU)，包括危险的酒精使用，在美国艾滋病毒携带者中很常见 州(美国)和比率超过一般女性人口。使用药物的艾滋病毒携带者是 不太可能开始和坚持使用抗逆转录病毒药物，这对发病率有重要影响， 死亡率和艾滋病毒传播。药物和酒精治疗可以减轻这些影响，但没有得到充分利用。在……里面 此外，大剂量阿片类止痛疗法在艾滋病毒携带者中很普遍，增加了他们服用处方的风险。 滥用药物。大麻可能是基于阿片类药物的疼痛控制的替代方案，但大麻的效果 对艾滋病毒临床结果的影响尚不清楚。几项政策举措有可能影响SU和毒品和 通过以下方式在美国进行酒精治疗：1)遏制用于疼痛管理的不适当的处方做法(例如， 处方药监测方案[PDMP])；2)增加获得药物和酒精治疗的机会(例如， 健康平等法[卫生平等法])；以及3)将用于医疗目的的大麻合法化(例如医用大麻法 [MML]))。然而，人们对这些卫生政策对艾滋病毒携带者妇女的影响知之甚少。研究表明， 这些政策有好处(例如，与药物治疗相关的HLP)。其他人发现负面的或非故意的 后果(例如，MML与更多的酒精有关，但较少使用阿片类药物)。这款K01利用参与者- NIH资助的女性机构间艾滋病毒研究的水平数据通过将队列数据与背景数据相结合 (例如，处方药滥用政策系统)捕获以下情况下的政策和医疗保健准入环境 这些女人活着。拟议的研究将使用纵向、多水平设计来生成证据，说明如何 卫生政策影响美国艾滋病毒携带者和非艾滋病毒女性的SU以及药物和酒精治疗，以及 阐明卫生政策如何在感染艾滋病毒的妇女中形成抑制艾滋病毒的途径。 具体目标是：目标1.评估方案管理计划与规定和非规定之间的关系 随着时间的推移，阿片类药物的使用，检查艾滋病毒状态和种族的调节作用。目标2.评估人际关系 在HPLS、获得药物和酒精治疗的机会以及随时间推移的治疗利用之间，检查 HIV状况、医疗保险和SU模式的调整作用。目标3：评估 MML，合法大麻的获取，大麻的使用和危险饮酒，审查修改 HIV状态的作用和SU的模式。目标4：在感染艾滋病毒的妇女中，评估PDMPs，HPLS， 和MML对HIV病毒的抑制，考察SU与药物和酒精的中介或修饰作用 治疗。为了实现这些目标，申请者将接受以下方面的培训：1)SU流行病学，2) 实证性政策分析，以及3)高级纵向多层次分析，由华盛顿大学指导 北卡罗来纳州教堂山的教员维维安·戈博士、阿多拉·阿迪莫拉博士、马克·霍姆斯博士和丹尼尔·鲍尔博士。这些 分析将为未来的政策和结构性干预提供信息，方法是生成政策如何 随着时间的推移，对感染艾滋病毒和有感染艾滋病毒风险的美国妇女的SU以及酒精和药物治疗的影响。

PROJECT SUMMARY/ABSTRACT Substance use (SU), including hazardous alcohol use, is common among women with HIV in the United States (US) and rates exceed those of the general female population. Substance-using women with HIV are less likely to initiate and adhere to antiretroviral medications, which has important implications for morbidity, mortality, and HIV transmission. Drug and alcohol treatment mitigates these effects, but is underutilized. In addition, high-dose opioid pain therapy is prevalent among people with HIV, increasing their risk of prescription drug misuse. Marijuana may serve as an alternative for opioid-based pain management, but marijuana's effect on HIV clinical outcomes is unclear. Several policy initiatives have the potential to influence SU and drug and alcohol treatment in the US by: 1) curbing inappropriate prescribing practices for pain management (e.g., prescription drug monitoring programs [PDMPs]); 2) increasing access to drug and alcohol treatment (e.g., health parity laws [HPLs]); and 3) legalizing marijuana use for medical purposes (e.g., medical marijuana laws [MMLs]). Yet, little is known about how these health policies impact women with HIV. Studies suggest that these policies have benefits (e.g., HPLs associated with drug treatment). Others found negative or unintended consequences (e.g., MMLs associated with more alcohol, but less opioid use). This K01 leverages participant- level data from the NIH-funded Women's Interagency HIV Study by integrating cohort data with contextual data (e.g., Prescription Drug Abuse Policy System) capturing the policy and health care access environments where these women live. The proposed study will use a longitudinal, multilevel design to generate evidence on how health policies impact SU and drug and alcohol treatment among women with and without HIV in the US, and elucidate the pathways through which health policies shape HIV viral suppression among women with HIV. The specific aims are: Aim 1. Assess relationships between PDMPs and prescribed and non-prescribed opioid use over time, examining the modifying role of HIV status and race. Aim 2. Assess relationships between HPLs, access to drug and alcohol treatment, and treatment utilization over time, examining the modifying role of HIV status, health insurance, and patterns of SU. Aim 3: Assess relationships between MMLs, access to legalized marijuana, and marijuana use and hazardous drinking, examining the modifying role of HIV status and patterns of SU. Aim 4: Among women with HIV, assess the impact of PDMPS, HPLs, and MMLs on HIV viral suppression, examining the mediating or modifying role of SU and drug and alcohol treatment. To accomplish these aims the applicant will receive training in: 1) the epidemiology of SU, 2) empirical policy analysis, and 3) advanced longitudinal multilevel analysis, under the direction of University of North Carolina at Chapel Hill faculty Drs. Vivian Go, Adaora Adimora, Mark Holmes, and Daniel Bauer. These analyses will to inform future policy and structural interventions by generating causal evidence on how policies influence SU and alcohol and drug treatment over time among US women with and at risk of HIV.