Comparative Effectiveness of Web-based vs. Traditional Adolescent HIV Prevention

描述（由申请人提供）：本申请涉及广泛的挑战领域（05）：比较有效性研究（CER）和特定的挑战主题，05- da -102*：使用基于web的技术治疗药物滥用和相关的健康后果。青年往往是艾滋病毒流行的中心，艾滋病毒在全世界被称为“青年驱动的疾病”。在美国，40%的新艾滋病毒感染发生在25岁以下的人群中，艾滋病毒是青少年死亡的第六大原因。与不吸毒的同龄人相比，吸毒青年感染艾滋病毒以及具有类似传播动力的其他传染病（如肝炎和性传播感染）的风险特别高。一些艾滋病毒预防干预措施已被证明对青少年有效，但它们很少提供给青少年，即使是在青少年药物滥用治疗方案等正式的护理系统中。此外，几乎没有青少年药物滥用治疗方案提供针对性传播感染或肝炎的循证干预措施。基于证据的预防干预措施的实施成本高昂，并且使现有资源紧张，因为平均药物滥用治疗方案的人员配备有限，病例量高。即使社区治疗项目的工作人员发起了以证据为基础的艾滋病毒预防干预措施，也可能难以确保其准确性。因此，基于研究的干预措施与治疗机构实际情况的有限兼容性可能会给在社区环境中转移循证实践带来许多操作障碍。我们之前开发了一个互动的、可定制的、基于网络的项目，重点是为青少年预防艾滋病毒、性传播感染和肝炎，该项目结合了预防科学和教育技术的有效组成部分，促进对关键技能和信息的掌握。该工具允许以高保真度和低成本交付复杂的干预，而不会增加对员工时间或培训需求的要求。我们证明，与单独提供教育工作者提供的预防干预相比，这种基于网络的工具作为教育工作者提供的艾滋病毒和传染病预防干预的辅助工具，可以提高预期的结果（例如，增加准确的艾滋病毒/疾病预防知识，增加减少风险行为的意愿）。然而，鉴于很少有青少年药物滥用治疗项目有资源提供传统的、基于证据的艾滋病、肝炎和性传播感染预防干预措施，了解这种自我导向的、网络提供的干预措施（作为一种独立的干预措施）的独立有效性是一个临床重要问题。在目前提出的试验中，我们将检查在门诊、社区药物滥用治疗中直接向青少年提供基于网络的艾滋病毒、肝炎和性传播感染预防干预与传统的（教育工作者提供的）艾滋病毒和传染病预防干预的比较效果和成本效益。我们将评估这些干预措施的相对有效性，主要是通过检查干预前和干预后在准确的艾滋病毒/疾病预防知识、从事更安全的性行为的意图和艾滋病毒风险行为方面的变化。此外，我们将研究干预措施对相关技能获取（如沟通技巧、谈判技巧和避孕套使用技巧）、对安全性行为的态度和自我报告的药物使用情况的影响程度。我们还将检查每种干预措施的可接受性（例如，通过要求青少年评价每种干预措施的有用性、趣味性等）。我们还计划在干预后1个月和3个月对青少年进行评估，以检查效果的持久性（包括干预条件下效果的任何差异持久性）。我们还将对基于网络的社区青少年药物滥用治疗项目进行经济分析。我们将从社会角度估计这种网络提供的干预相对于教育者提供的干预的增量成本效益比（以预防每例艾滋病毒感染的成本表示，根据艾滋病毒风险行为的变化估计）。我们还将从药物滥用治疗项目的角度和付款人的角度估计成本效益，以更好地了解影响在地方一级采用这种干预措施的因素。由于在治疗方案中存在相当大的成本限制，证明有效性不足以实施循证实践。相反，有必要展示成本效益。以技术为基础的艾滋病毒预防方法为与传统战略无关的干预工作创造了新的机会和途径。这种基于网络的工具和类似的基于技术的干预措施，如果发现有效和具有成本效益，可以通过显着提高在这种治疗环境中向个人提供的艾滋病毒预防干预措施的可得性和质量，大大推进药物滥用治疗系统。重要的是，这种基于网络的干预措施可以超越地理界限，从而使其在未来的应用中能够在各种各样的环境中使用，而在这些环境中，针对青年的艾滋病毒预防干预措施通常是有限的（例如，学校、保健提供者办公室、在线社交网络）。这一基于网络的系统还可以扩大，以解决其他问题，例如以证据为基础的技能培训（例如，自我控制培训）、药物滥用心理社会治疗/复发预防和精神卫生问题。因此，我们提出的项目有可能大大提高研究的速度和成就，以检查针对行为健康的基于技术的干预措施的有效性。我们建议在本项目中评估的计算机化干预措施，如果发现有效且具有成本效益，可以通过显着提高向此类环境中的青少年提供的艾滋病毒（和传染病）预防干预措施的可用性和质量，从而大大推进青少年药物滥用治疗系统。此外，这一干预措施是基于网络的，因此能够在青少年艾滋病毒预防干预措施通常有限的各种环境中使用（例如，学校、保健提供者办公室、在线社交网络）。拟议的项目可能产生关于利用技术促进为青少年提供基于科学的艾滋病毒预防的新模式的具有临床和经济意义的数据，有可能对改变青年中艾滋病毒流行的轨迹产生实质性影响。

DESCRIPTION (provided by applicant): This application addresses broad challenge Area (05): Comparative Effectiveness Research (CER) and specific Challenge Topic, 05-DA-102*: Treatment of Substance Abuse and Related Health Consequences Using Web-Based Technologies. Youth are frequently at the center of the HIV epidemic, and HIV has been referred to as a "youth-driven disease" worldwide. In the U.S., 40% of all new HIV infections occur in persons under age 25 years, and HIV is the 6th leading cause of death among adolescents. Youth who use drugs are at particularly high risk for HIV, as well as other infectious diseases with similar transmission dynamics, such as hepatitis and Sexually Transmitted Infections (STIs), relative to their non-drug using peers. Several HIV prevention interventions have been shown to be effective with adolescents, but they are infrequently provided to youth, even in formal systems of care such as adolescent substance abuse treatment programs. Additionally, virtually no adolescent substance abuse treatment programs offer evidence-based interventions targeting STIs or hepatitis. Evidence-based prevention interventions are expensive to implement and strain available resources, given the limited staffing and high caseloads at the average substance abuse treatment program. Even if evidence-based HIV prevention interventions are initiated by staff in community treatment programs, it may be difficult to ensure their fidelity. Thus, the limited compatibility of research-based interventions with treatment agency realities may present numerous operational barriers to the transfer of evidence-based practice in community-based settings. We previously developed an interactive, customizable, web-based program focused on the prevention of HIV, STIs and hepatitis for youth that incorporates effective components of both prevention science and educational technologies that promote mastery of key skills and information. This tool allows a complex intervention to be delivered with high fidelity and at low cost, without increasing demands on staff time or training needs. We demonstrated that this web-based tool, when provided as an adjunct to an educator- delivered HIV and infectious disease prevention intervention, enhanced desired outcomes (e.g., increased accurate HIV/disease prevention knowledge, increased intentions to reduce risk behavior) relative to the educator-delivered prevention intervention when provided alone. However, given that so few adolescent substance abuse treatment programs have the resources to offer traditionally-delivered, evidence-based HIV, hepatitis, and STI prevention interventions, understanding the independent effectiveness of this self-directed, web-delivered intervention (as a stand-alone intervention) is a clinically important question. In the presently proposed trial, we will examine the comparative effectiveness and cost-effectiveness of the web-based HIV, hepatitis and STI prevention intervention when offered to youth in outpatient, community- based substance abuse treatment when directly compared to a traditional (educator-delivered) HIV and infectious disease prevention intervention. We will assess the comparative effectiveness of these interventions by primarily examining changes from pre- to post-intervention in accurate HIV/disease prevention knowledge, intentions to engage in safer sex, and HIV risk behavior. Additionally, we will examine the extent to which the interventions impact relevant skills acquisition (e.g., communication skills, negotiation skills and condom use skills), attitudes toward safer sex, and self-reported substance use. We will also examine the acceptability of each intervention (e.g., by asking youth to rate how useful, interesting, etc. each intervention was). We also plan to evaluate youth at both 1 and 3 month post-intervention to examine the durability of effects (including any differential durability of effects across intervention conditions). We will also perform an economic analysis of the web-based program in community-based, adolescent substance abuse treatment programs. We will estimate the incremental cost-effectiveness ratio of this web- delivered intervention relative to the educator-delivered intervention from a societal perspective (presented as costs per HIV infections prevented, estimated from changes in HIV risk behavior). We will also estimate cost- effectiveness from the substance abuse treatment program's perspective and payer's perspective to better understand the factors impacting the adoption of this intervention at the local level. Because of the considerable cost constraints within treatment programs, demonstration of effectiveness is not sufficient for implementation of evidence-based practice. Rather, demonstration of cost-effectiveness is necessary. A technology-based approach to HIV prevention creates new opportunities and outlets for intervention efforts that are not tied to traditional strategies. This web-based tool, and similar technology-based interventions, if found effective and cost-effective, could substantially advance the substance abuse treatment system by markedly improving the availability and quality of HIV prevention interventions delivered to individuals in such treatment settings. Importantly, this web-based intervention can transcend geographic boundaries, thus enabling its use, in future applications, in a wide variety of settings where HIV prevention interventions for youth are typically limited (e.g., schools, health care providers' offices, online social networks). This web-based system can also be expanded to address other issues, such as evidence-based skills training (e.g., self-control training), substance abuse psychosocial treatment/relapse prevention and mental health issues. Thus, our proposed project has the potential to greatly increase the pace and achievement of research examining the effectiveness of technology-based interventions targeting behavioral health. Public Health Relevance Statement The computerized intervention we propose to evaluate in this project, if found effective and cost-effective, could substantially advance the adolescent substance abuse treatment system by markedly improving the availability and quality of HIV (and infectious disease) prevention interventions delivered to youth in such settings. Further, this intervention is web-based, thus enabling its use in a wide variety of settings where HIV prevention interventions for youth are typically limited (e.g., schools, health care providers' offices, online social networks). The proposed project may generate clinically and economically meaningful data regarding the use of technology in promoting new models of delivery of science-based HIV prevention for adolescents, with the potential to have a substantive impact in changing the trajectory of the HIV epidemic among youth.