HIV Testing, Linkage and Retention in Care: Contextual Factors and Disparities

描述（由申请人提供）：本研究的目的是确定人们获得医疗保健的环境（即医疗保健环境）或生活环境（即居住环境）与五种结果（艾滋病毒检测、收到检测结果、与艾滋病毒/艾滋病护理的联系、艾滋病毒护理的保留和艾滋病毒载量）之间是否存在关联。艾滋病毒/艾滋病在种族/少数民族（特别是黑人和拉丁裔）和老年人（即50岁及以上）中的流行病学表明，他们可能会遇到障碍，导致早期发现艾滋病毒和预后的差异。因此，我们还将检查不同种族/民族和年龄（50岁至50岁）的结果差异。利用社会行为科学，这项研究将以促进不同群体、社区条件和成年阶段的护理公平的方式为临床实践提供信息。本研究的主要目的是：(1)基于初级保健患者的电子病历，采用随机效应的logistic回归多水平模型，考察医疗环境、居住环境与初级保健就诊期间HIV检测的关系；(2)采用随机效应的多水平logistic回归和Cox比例风险模型，分别检验新诊断为HIV阳性的管理医疗参保者的医疗环境、居住环境与接受HIV检测结果的关系，以及与HIV/AIDS护理的联系。第二个特定目的是确定这些关系中是否存在与种族/民族或年龄相关的差异（即年龄<50岁vs. 50岁）。以我们在艾滋病毒检测和护理方面的工作为基础

DESCRIPTION (provided by applicant): The purpose of this study is to determine if associations exist between the contexts in which people obtain healthcare (i.e., healthcare context) or live (i.e., residential context) and each of five outcomes (HIV testing, receipt of tes results, linkage to HIV/AIDS care, retention in HIV care and HIV viral load). The epidemiology of HIV/AIDS among racial/ethnic minorities (specifically, Blacks and Latinos) and older adults (i.e., 50 and older) suggests they may encounter barriers that contribute to disparities in early detection of HIV and in their prognoses. Hence, we will also examine disparities in the outcomes by race/ethnicity and older age (age >50). Drawing on the socio-behavioral sciences, the study will inform clinical practice in ways that promote equity in care across diverse groups, neighborhood conditions and stages of adulthood. The study's primary Specific Aims are to: (1) Examine relations between healthcare context, residential context and HIV testing during primary care visits using logistic regression multilevel models with random effects based on primary care patients' electronic medical records; and, (2) Examine relations between healthcare context, residential context and receipt of HIV test results and linkage to HIV/AIDS care, respectively, among managed care enrollees newly diagnosed as HIV-positive using multilevel logistic regression and Cox proportional hazards models with random effects. The secondary Specific Aim is to determine if racial/ethnic- or age-related (i.e., aged <50 vs. >50 years) disparities exist in these relationships. Building on our work on HIV testing and care, and guided by a model integrating the Public Health Critical Race Praxis and Behavioral Model of Healthcare Utilization, the four-year study based on the electronic medical records (EMRs) of adults enrolled in the largest managed care organization in the region. We will pool data over five years (2007-2011) to examine HIV testing among all patients presenting for primary care, and to examine receipt of HIV test results, linkage to and retention in HIV/AIDS care as well as HIV viral load among all patients newly diagnosed as HIV-positive. The study will comprise four multilevel analyses of patients' residential contexts (e.g., neighborhood HIV prevalence) and healthcare contexts (e.g., characteristics of the patient population) relative to HIV testing durin primary care visits (Aim 1), receipt of HIV test results and linkage to HIV/AIDS care among those diagnosed as HIV-positive (Aim 2), retention in HIV/AIDS care and HIV RNA viral load up to one-year post diagnosis. We will use personal and geospatial codes in the EMRs to link to: (1) files containing detailed information on each provider (e.g., demographics, specialty); (2) public data from the Centers for Disease Control and Prevention on HIV prevalence and HIV test sites in each zip code; (3) 2010 Census socioeconomic data (e.g., concentrated poverty) for each zip code; and, (4) global positioning system software to calculate the distance from a patient's home to their provider. This interdisciplinary, inter- institutional collaboration leveraes the expertise of a diverse team of new and seasoned investigators.