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Reducing Stigma in People Who Inject Drugs with HIV Using a Rapid Start Antiretroviral Therapy Intervention

使用快速启动抗逆转录病毒治疗干预措施减少艾滋病毒注射者的耻辱

基本信息

批准号：
10756389
负责人：
FREDERICK LEWIS ALTICE
金额：
$ 17.03万
依托单位：
YALE UNIVERSITY
依托单位国家：
美国
项目类别：
财政年份：
2023
资助国家：
美国
起止时间：
2023-07-15 至 2026-06-30
项目状态：
未结题

来源：
https://reporter.nih.gov/project-details/10756389
关键词：
Address Adherence Administrator Affect Africa South of the Sahara Anti-Retroviral Agents Architecture Asia Behavior Behavioral Clinical Cohort Studies Collaborations Consensus Country Data Decision Making Development Diagnosis Discrimination Drug usage Education Elements Eligibility Determination Epidemic Face Future Goals Guidelines HIV Health Health Personnel Healthcare Hepatitis C virus Hybrids Imprisonment Incidence Income Individual Infection Injecting drug user Intention Intervention Life Malaysia Mediating Medical Students Methods Needle-Exchange Programs Opportunistic Infections Pathway interactions Patients Perception Persons Physicians Policies Population Prejudice Prevalence Process Productivity Protocols documentation Provider Recommendation Research Research Methodology Resources Sexual Partners Social Class Social support Stereotyping System Techniques Testing Therapeutic Intervention Time Treatment outcome Trust Universities Viral Vitamins Work addiction antiretroviral therapy anxiety reduction clinically relevant comorbidity design evidence base experience future implementation implementation trial improved improved outcome intervention refinement low and middle-income countries medication for opioid use disorder mortality opioid use disorder peer pilot test rapid test sex social stigma systematic review therapy adherence therapy design therapy development tool transmission process treatment as prevention

项目摘要

HIV transmission continues in low- and middle-income countries (LMIC), especially among key affected populations (KAP) and in settings of high stigma and discrimination. In Malaysia, a LMIC in SE Asia, HIV incidence and mortality is increasing. HIV is concentrated among KAPs, especially people who inject drugs (PWID), a group that has substantially lower ART prescription and viral suppression (VS) levels relative to other KAPs, undermining HIV treatment as prevention (TasP) goals. PWID are especially vulnerable to overlapping and intersectional stigmas due to criminalization drug use and sex work, experiences with incarceration, social class and the presence of HIV itself. Our preliminary studies confirm high levels of negative stereotypes, prejudice and stigma toward PWID among medical students and HIV experts, with clear evidence of intention to discriminate against PWID by withholding ART prescription. Stigma-reducing interventions have mostly centered on educational and contact-based strategies. Such strategies, however, appear less effective where stereotypes and stigma are deeply entrenched, as in Malaysia, thus requiring the introduction and testing of alternative strategies. Behavioral design interventions are potentially effective ways to address stigma in such settings. Behavioral design interventions use tools like framing, nudges, and choice architecture, which can be used to re-design how physicians behave – or make non-discriminatory healthcare decisions. Rapid start antiretroviral (RS-ART) is an evidence-based strategy to initiate ART immediately, thereby supporting TasP goals by reducing time to VS, achieving VS and improving individual health. It has not been tested among PWID. It fits the criteria for behavioral design interventions by re-arranging clinician decision-making by first focusing on eligibility criteria (i.e., presence of opportunistic infections) rather than inaccurate perceptions of ART adherence or deservedness. Behavioral design interventions have not been tested in HIV stigma research, nor has they been assessed longitudinally or infusing clinically relevant dyads analyses of patients and clinicians. To guide the behavioral design of RS-ART among PWID, we will use the Delphi method to develop guidelines. Then we will use nominal group technique, a rank-ordering mixed method strategy to assess the multi-level barriers and facilitators to RS-ART for PWID, in order to adapt existing RS-ART protocols for PWID. Once the new guideline concordant RS-ART protocol is developed, we will pilot test it in 125 PWID over six months and conduct a longitudinal dyadic analysis of patients and clinicians of stigma, physician trust and social support. The RS-ART protocol will be refined further during pilot-testing to determine its utility as a stigma-reducing intervention that can be tested in a future implementation trial. This proposal brings over 17 years of productive collaboration between Yale and University of Malaya, with expertise in clinical HIV and addiction treatment, participation in clinical guidelines development, mixed methods research, intervention development and refinement, multi-level stigma assessment and intervention and dyadic analyses.

艾滋病毒在低收入和中等收入国家继续传播，特别是在主要受影响国家。在高羞耻度和高歧视的环境中，儿童和青少年受到的伤害更大。在马来西亚，东南亚的LMIC，艾滋病毒发病率和死亡率都在增加。艾滋病毒集中在Kap中，特别是注射毒品的人 (PWID)，与其他组相比，ART处方和病毒抑制(VS)水平显著较低 KAPS，破坏了艾滋病毒治疗作为预防(TasP)的目标。PWID特别容易重叠以及因毒品使用和性工作刑事化而产生的跨部门耻辱，监禁经历，社会班级和艾滋病毒本身的存在。我们的初步研究证实了高度的负面刻板印象，医学生和艾滋病毒专家对PWID的偏见和耻辱，并有明确的证据表明通过扣留ART处方来歧视PWID。减少耻辱的干预措施大多集中在关于教育和基于联系的战略。然而，在刻板印象的情况下，这种策略似乎不那么有效和耻辱是根深蒂固的，就像在马来西亚一样，因此需要引入和测试替代办法。战略。行为设计干预是解决此类环境中污名问题的潜在有效方法。行为设计干预使用框架、轻推和选择架构等工具，这些工具可用于重新设计医生的行为方式-或做出非歧视性的医疗决定。快速启动抗逆转录病毒 (RS-ART)是一种基于证据的策略，可立即启动ART，从而通过减少时间到VS，实现VS并改善个人健康。它还没有在PWID中进行测试。它符合标准对于行为设计干预，通过首先关注资格标准来重新安排临床医生的决策 (即机会性感染的存在)，而不是对ART坚持或罪有应得。行为设计干预措施还没有在艾滋病毒污名研究中得到测试，也没有得到测试对患者和临床医生进行纵向评估或注入临床相关的二联体分析。要引导 RS-ART在PWID中的行为设计，我们将使用Delphi方法来制定指南。那我们就会使用名义群技术、等级排序混合方法策略对多层壁垒进行评估促进者将RS-ART用于PWID，以便使现有的RS-ART协议适用于PWID。一旦新的指导方针制定了一致的RS-ART协议，我们将在六个月内用125个PWID进行试点测试，并进行患者和临床医生对污名、医生信任和社会支持的纵向二元分析。RS-ART 方案将在试点测试期间进一步完善，以确定其作为减少耻辱干预的效用，可以在未来的实施试验中进行测试。该提案带来了超过17年的富有成效的合作在耶鲁大学和马来亚大学之间，拥有临床艾滋病毒和成瘾治疗方面的专业知识，参与临床指南制定、混合方法研究、干预措施制定和完善、多层次污名评估和干预以及二元分析。