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

描述(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局(NYCDOHMH)宣布了一项新政策，所有HIV血清阳性者都应该接受抗逆转录病毒治疗(ART)，无论CD4细胞数量如何。新政策的主要基础是“治疗即预防”，这不仅是改善提早开始抗逆转录病毒疗法的艾滋病毒携带者健康的一种方法，而且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：到艾滋病毒诊断后一年，80%的新艾滋病毒诊断病例将达到病毒抑制状态。纽约市每年发生3,400多例新的艾滋病毒感染；最近的数据表明，在2006-07年间，38%的人达到了持久的病毒抑制(即所有病毒载量为400拷贝/毫升)。这一政策目标雄心勃勃，但如果要实现这一目标，几乎可以肯定的是，它将在这座美国艾滋病疫情最严重的城市造就“无艾滋病一代”--这是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， 值得注意的是，该市艾滋病毒感染方面持续存在种族/族裔差异，特别是在非裔美国人中，以及与毒品有关的性传播。这项研究的主要目的是提供多系统数据，以评估政策的执行情况，并帮助确定最有效地利用现有资源来实现政策目标。设计和方法由生态系统模型提供信息，而RE-AIM模型指导对新政策实施的总体评估。这项研究的目标是：1)在确诊后12个月内评估持久的病毒抑制(即，连续两次病毒载量测试每毫升血浆400个艾滋病毒-1 RNA拷贝)，a)使用问题药物的性病诊所队列(N=300)，以及b)在项目资助期内在纽约市发生的所有新的艾滋病毒诊断(N=约3,400/年)；2)评估性病诊所队列中艾滋病毒治疗级联的关键指标，作为(A)与艾滋病毒护理有关的人的百分比；(B)收到启动抗逆转录病毒疗法的建议；(C)启动抗逆转录病毒疗法；以及(D)坚持抗逆转录病毒治疗；3)在纽约市所有新增艾滋病毒诊断病例的性病诊所队列和队列中评估持久病毒载量抑制和其他艾滋病毒治疗级联指标的多系统预测因素，以包括个人(例如种族/族裔、药物使用)和地理空间因素(例如社会经济条件、社会混乱、社会凝聚力和获得艾滋病毒相关医疗保健的空间机会)；4)使用STD队列定性数据描述和背景介绍目标1-3中的量化成果；以及5)描述艾滋病毒初级保健提供者采用、实施和维持艾滋病毒治疗政策的情况。持久病毒抑制的终点增加

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