Impacts of universal access to HIV/AIDS care among HIV+ injection drug users

项目总结/摘要 自针对艾滋病毒感染的有效抗逆转录病毒疗法（ART）发展以来的二十年里，艾滋病毒阳性患者中， 使用非法药物的人（PWUD）在艾滋病毒治疗结果方面仍然存在持续的差异。 虽然高强度非法药物使用对获得和坚持抗逆转录病毒治疗的有害影响是显而易见的， 参与和保留艾滋病毒护理的社会、结构和经济障碍仍然不完全 描述，迫切需要确定艾滋病毒和成瘾治疗的各个方面， 最佳的艾滋病治疗效果。 与此同时，人们越来越认识到艾滋病毒相关合并症的重要性， 合并感染和并发症-特别是免疫功能障碍，慢性炎症和早产 年龄对艾滋病毒疾病的结果，即使是在艾滋病毒阳性的个人最佳从事抗逆转录病毒治疗。 一些合并症，如丙型肝炎病毒合并感染，对HIV阳性PWUD的影响很好 描述，我们不知道任何纵向研究使用一个有效的措施，包括艾滋病毒和非艾滋病毒感染者， HIV相关的临床生物标志物，以系统地研究HIV疾病的严重程度和非法药物的影响 艾滋病毒阳性的PWUD在免费环境中的使用情况以及相关的社会、结构和经济因素 普及医疗保健，包括所有抗逆转录病毒疗法和戒毒药物。 因此，在本申请中，我们提出了对个人，社会， 艾滋病毒治疗和疾病结果的结构和经济决定因素。具体地说， 通过延长对长期社区招募的1000多名潜在队列的资助， 与加拿大温哥华综合临床监测数据相关的艾滋病毒阳性PWUD，我们建议： 分析新的和新兴的艾滋病毒和成瘾治疗的实施，吸收和影响， 实现和维持最佳的艾滋病毒治疗和疾病结果;调查 已确定和新出现的非法药物使用模式以及不断演变的艾滋病毒成瘾治疗方法 治疗和疾病结果;探索社会，结构和经济力量之间的相互关系 和非法药物使用模式对艾滋病毒疾病的结果;并继续作为一个NIDA资助的队列， 一系列流行病学、系统发育/生物信息学和基础研究艾滋病毒感染的平台， 在使用非法药物的人中传播和发病。 更新我们的研究计划的建议利用了几个既定的和新兴的方面， 当地环境，包括：普遍获得免费医疗的集中计划，允许 完全确定临床数据，不受经济能力的混杂影响;正在进行的 为残疾人制定一系列创新的艾滋病毒和成瘾方案，包括在 艾滋病毒诊断、基于减少危害的艾滋病毒预防和治疗支持;以及 管理阿片类药物和兴奋剂使用障碍。我们的建议与最近关于高度优先 研究减少艾滋病毒阳性的残疾人在艾滋病毒治疗和疾病结果方面的差距， 证据，以促进参与和保留艾滋病毒护理，并减少合并症的影响， 并发症和合并感染。

PROJECT SUMMARY / ABSTRACT Two decades since the development of effective antiretroviral therapy (ART) for HIV infection, HIV-positive people who use illicit drugs (PWUD) continue to experience persistent disparities in HIV treatment outcomes. Although the deleterious impact of high-intensity illicit drug use on access and adherence to ART is clear, the social, structural and economic barriers to engagement and retention in HIV care remain incompletely described, and there is an urgent need to identify aspects of treatment for HIV and addiction that promote optimal HIV treatment outcomes. At the same time, there is an increasing appreciation of the importance of HIV-associated comorbidities, coinfections and complications—especially immunologic dysfunction, chronic inflammation and premature aging—on HIV disease outcomes, even among HIV-positive individuals optimally engaged in ART. Although the impact of some comorbidities, such as hepatitis C virus co-infection, on HIV-positive PWUD are well described, we are unaware of any longitudinal study using a validated measure incorporating HIV- and non- HIV-related clinical biomarkers to systematically investigate HIV disease severity, and the impact of illicit drug use and related social, structural and economic factors, among HIV-positive PWUD in a setting of no-cost universal medical care including all ART and medications for addiction treatment. Thus, in this application, we propose novel and significant investigations into the individual, social, structural and economic determinants of HIV treatment and disease outcomes among PWUD. Specifically, through the renewal of funding for a longstanding community-recruited prospective cohort of more than 1000 HIV-positive PWUD linked to comprehensive clinical monitoring data in Vancouver, Canada, we propose to: analyze the implementation, uptake and impact of new and emerging treatment for HIV and addiction on the achievement and maintenance of optimal HIV treatment and disease outcomes; investigate the impacts of established and emerging illicit drug use patterns and evolving approaches to addiction treatment on HIV treatment and disease outcomes; explore the interrelationships between social, structural and economic forces and illicit drug use patterns on HIV disease outcomes; and continue to serve as a NIDA-funded cohort that is a platform for a range of epidemiological, phylogenetic/bioinformatic and basic research into HIV acquisition, transmission and pathogenesis among people who use illicit drugs. This proposal to renew our research program exploits several established and emerging facets of the local environment, including: a centralized program of universal access to no-cost medical care, allowing for the complete ascertainment of clinical data free of the confounding influence of financial ability; the ongoing development of a range of innovative HIV and addiction programs for PWUD, including initiation of ART upon HIV diagnosis, harm-reduction-based HIV prevention and treatment supports; and novel approaches to manage opioid and stimulant use disorders. Our proposal is well aligned with recent calls for high-priority research to reduce disparities in HIV treatment and disease outcomes among HIV-positive PWUD through evidence to promote engagement and retention in HIV care and reduce the effect of comorbidities, complications and coinfections.