Impact of Representative Payee Services on ART Adherence Among Marginalized People Living with HIV/AIDS

代表收款人服务对边缘化艾滋病毒/艾滋病感染者遵守抗逆转录病毒治疗的影响

• 批准号: 9905558
• 负责人: Mary Elizabeth Hawk
• 金额: $ 56.79万
• 依托单位: UNIVERSITY OF PITTSBURGH AT PITTSBURGH
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-05-05 至 2022-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9905558
• 关键词: AIDS/HIV problem; Address; Adherence; Anti-Retroviral Agents; Appointment; Attention; Behavioral; Biological; CD4 Lymphocyte Count; Caring; Chronic; Client; Clinical; Clinical Services; Computer Security; Cost Analysis; Data; Deposition; Economically Deprived Population; Economics; Financial Hardship; Funding; HIV; HIV Infections; Health; Health behavior; Housing; Incidence; Individual; Infection; Intervention; Interview; Investments; Measures; Mediation; Mediator of activation protein; Mental Health; Methods; Modeling; Occupational activity of managing finances; Outcome; Participant; Patient Self-Report; Patients; Pilot Projects; Policies; Politics; Population; Poverty; Prevention; Quality-Adjusted Life Years; Randomized Controlled Trials; Research; Resources; Self Efficacy; Services; Social Security; Stress; Structure; Substance Use Disorder; Testing; Time; Treatment outcome; United States Social Security Administration; Viral; Viral Load result; adherence rate; antiretroviral therapy; cognitive load; cost effectiveness; economic evaluation; follow-up; health disparity; housing instability; improved; innovation; medical appointment; medication compliance; mortality; payment; programs; public health relevance; remediation; social; standard of care; therapy adherence; transmission process; treatment adherence

Project Summary/Abstract There is a lack of structural interventions to improve antiretroviral therapy (ART) adherence, which represents missed opportunities to reduce HIV health disparities. Economic disadvantage can contribute to poor medication adherence and clinical outcomes through mediators such as limited social resources, repeated cycles of housing instability, high levels of stress caused by financial insecurity, and lack of resources to cope with these demands. Treatment as Prevention is an important method of improving clinical outcomes for people living with HIV/AIDS (PLWHA) and reducing secondary transmissions; however, for this approach to be optimized, rates of ART adherence must be improved and sustained. Client-Centered Representative Payee is a structural intervention that provides financial management support to PLWHA by modifying the implementation of a long-standing policy within the Social Security Administration, in which an organization is authorized to serve as the client's payee. The central hypothesis of this study is that by helping clients to pay rent and other bills on time, housing stability will improve and financial stress will decrease. By reducing the cognitive burden of living with chronic financial stress and frequent threats of housing loss, clients can devote more time and attention to medical appointments and medication adherence. It is further hypothesized that these changes will improve clients' self-efficacy for health behaviors, retention in care, medication adherence, and viral loads. These hypotheses will be tested via the following specific aims: (1) Conduct a randomized controlled trial (n=320) to test the effect of Client-Centered Rep Payee on ART adherence and viral load among PLWHA who are economically disadvantaged and unstably housed. Clinical adherence will be compared through behavioral and biological measures including prescription refill data, self-reported appointment adherence, and viral load for patients receiving the intervention versus those receiving standard of care. (2) Test underlying mechanisms associated with Client-Centered Rep Payee that contribute to changes in medication adherence and viral suppression rates. This will be accomplished via use of quantitative (mediation analysis) and qualitative (semi-structured interview) methods to test hypothesized mediators of medication adherence and viral suppression including financial and housing instability, financial stress, self- efficacy for health behaviors, and retention in care. (3) Assess the cost and cost-effectiveness of the Client- Centered Rep Payee model. An economic analysis will be conducted to model the impact of the intervention as compared with standard of care on quality adjusted life years as well as new infections averted. This approach is innovative because it offers a structural intervention to improve adherence by addressing the effects of economic insecurity, requires low financial investment, and can be layered with existing clinical services. Further, it is highly scalable as it builds on a current policy in practice within the Social Security system.

项目总结/摘要 缺乏结构性干预措施来提高抗逆转录病毒疗法的依从性， 错过了减少艾滋病毒健康差距的机会。经济上的不利条件会导致贫困 药物依从性和临床结果通过中介，如有限的社会资源，重复 住房不稳定、财政不安全造成的高度压力以及缺乏科普资源的周期 这些要求。治疗作为预防是改善临床结果的重要方法， 艾滋病毒/艾滋病感染者（PLWHA）和减少二次传播;然而， 因此，必须提高和维持抗逆转录病毒疗法的坚持率。以客户为中心的代表收款人是 结构性干预措施，通过修改 在社会保障管理局内执行一项长期政策，其中一个组织 被授权作为客户的收款人这项研究的中心假设是，通过帮助客户支付 租金和其他账单按时支付，住房稳定性将得到改善，财政压力将减少。通过减少 长期的经济压力和频繁的住房损失的威胁，客户可以投入 更多的时间和注意力到医疗预约和药物依从性。进一步假设， 这些变化将提高客户在健康行为、护理保留、药物依从性方面的自我效能， 和病毒载量。这些假设将通过以下具体目标进行检验：（1）进行随机化 对照试验（n=320），以测试以客户为中心的收款人对ART依从性和病毒载量的影响 在经济上处于不利地位和住房不稳定的艾滋病毒/艾滋病感染者/艾滋病患者中。临床依从性将 通过行为和生物学测量进行比较，包括处方续药数据，自我报告 接受干预的患者与接受标准治疗的患者的预约依从性和病毒载量 护理。(2)测试与以客户为中心的代表收款人相关的基本机制， 药物依从性和病毒抑制率的变化。这将通过使用定量 （中介分析）和定性（半结构化访谈）的方法来测试假设的调解人 药物依从性和病毒抑制，包括财务和住房不稳定，财务压力，自我 对健康行为的功效，以及保持护理。(3)评估客户的成本和成本效益- 中心代表收款人模型。将进行经济分析，以模拟干预的影响 与标准护理相比，质量调整生命年以及避免的新感染。这 这种方法是创新的，因为它提供了一种结构性干预，通过解决 经济不安全的影响，需要低的财政投资，并可以与现有的临床分层 服务此外，它是高度可扩展的，因为它建立在社会保障制度内的现行政策的基础上。 系统