Evaluating ART for All HIV Seropositives: Can it work with the hardest cases?

描述（由申请人提供）：在2011年12月1日世界艾滋病日，纽约市卫生和精神卫生部（NYCDOHMH）宣布了一项新政策，即所有HIV血清阳性患者都应接受抗逆转录病毒治疗（ART），无论CD4细胞计数如何。新政策的主要基础是“治疗即预防”，这不仅是改善早期开始抗逆转录病毒治疗的艾滋病毒感染者健康的一种方法，也是减少病毒传播的一种手段。NYCDOHMH为这项新政策设定了一个雄心勃勃的目标：在艾滋病毒诊断后一年内，80%的新艾滋病毒诊断将达到病毒抑制。纽约市每年有超过3400例新的艾滋病毒感染；最近的数据表明，2006-07年，38%的病毒达到了持久的病毒抑制（即所有病毒载量为400拷贝/mL）。这个政策目标是雄心勃勃的，但如果它得以实现，它几乎肯定会在美国当地艾滋病流行最严重的城市引领“无艾滋病一代”——2012年国际艾滋病大会的中心主题。实现这一政策目标存在严重困难，

DESCRIPTION (provided by applicant): On World AIDS Day, December 1, 2011, the NYC Department of Health and Mental Hygiene (NYCDOHMH) announced a new policy that all HIV seropositives should be offered antiretroviral treatment (ART) regardless of CD4 cell count. The new policy was based primarily on "treatment as prevention" as a method for not only improving the health of people living with HIV who initiate ART early, but also as a means of reducing transmission of the virus. The NYCDOHMH set an ambitious goal for this new policy: by one year post HIV diagnosis, 80% of new HIV diagnoses will have reached viral suppression. There are over 3,400 new HIV infections occurring annually in NYC; recent data indicate 38% reached durable viral suppression in 2006-07 (i.e., all viral loads 400 copies/mL). The policy goal is ambitious, but if it were to be achieved, it would almost certainly lead to an "AIDS-free generation" - the central theme of the 2012 International AIDS Conference - in the city with the largest local HIV epidemic in the US. There are serious difficulties in achieving this policy goal, notably the persistent racial/ethnic disparities in HIV infection in the city, especially among African-Americans, and drug-related sexual transmission. The overarching purpose of this research is to provide multisystem data to evaluate the implementation of the policy and help determine the most efficient use of available resources for achieving the policy goal. The design and methods are informed by the ecological systems model, while the RE-AIM model guides the overall assessment of the implementation of the new policy. The study aims are: 1) to assess durable viral suppression (i.e., two consecutive viral load tests 400 HIV-1 RNA copies per mL of plasma) within 12 months of diagnosis among a) STD clinic cohort (N = 300) with problem substance use, and b) all new HIV diagnoses in NYC occurring during the project funding period (N=approximately 3,400/year); 2) to assess key indicators along the HIV treatment cascade among the STD clinic cohort as the percentage who (a) link to HIV care; (b) receive a recommendation to initiate ART; (c) initiate ART treatment; and (d) adhere to ART treatment; 3) to assess multisystem predictors of durable viral load suppression and other HIV treatment cascade indicators among the STD clinic cohort and cohort of all new HIV diagnoses in NYC, to include individual (e.g., race/ethnicity, substance use) and geospatial factors (e.g., socioeconomic conditions, social disorder, social cohesion, and spatial access to HIV-related healthcare); 4) to describe and contextualize quantitative outcomes in Aims 1-3 using STD cohort qualitative data; and 5) to describe the adoption, implementation, and maintenance of HIV treatment policies among HIV primary care providers. The endpoint of durable viral suppression increases