Primary Care-Based Interventions to Reduce Alcohol Use Among HIV Patients

描述(由申请人提供)：本申请响应RFA-AA-12-009，改善艾滋病毒/艾滋病和酒精相关后果的干预措施(U01)。这项拟议的研究在艾滋病毒初级保健诊所进行，并使用健康计划的电子医疗记录(EMR)进行筛查；它有可能通过减少危险饮酒和相关并发症为艾滋病毒感染者带来重大好处。先前的研究已经确定，艾滋病毒和危险饮酒(定义为饮酒超过门槛，即男性每天5次或每周14次，女性每天4次或每周7次)并存的比率很高。这些水平的饮酒会影响抗逆转录病毒(ART)治疗，并增加抑郁症、不安全性行为和死亡率。这项拟议的随机试验考察了两种高度可实施的行为干预措施对减少危险饮酒的比较有效性，每种干预措施都具有适应性、分步护理成分：1)动机访谈(MI)，包括一次与研究临床医生的面对面会议和两次电话会议，另外三次电话会议针对那些在6个月时报告危险饮酒的人；以及2)使用集成到电子医疗记录(EMR)中的安全消息系统，关于危险饮酒风险的交互式电子邮件反馈，以及为那些在6个月后报告危险饮酒的人提供额外的电子邮件反馈。第三只胳膊将是通常的护理。我们还将评估这两种干预措施的成本效益，这两种干预措施有可能在其他类似的医疗保健环境中广泛采用。两种拟议的干预措施，MI和EF，是在行为健康和/或初级保健背景下减少危险饮酒的有前景的方法。EF还使用安全消息传递，这是一项新兴技术，已在其他健康、行为改变和心理健康治疗环境中进行了测试，用于解决包括饮酒在内的问题，但不适用于艾滋病毒感染者。在这项试验中，600名患者(每支手臂各200名)将从旧金山凯撒永久医院(KPNC)招募。研究人群和临床是检验这种干预措施的理想对象，因为基于NIAAA的筛查问题被记录在EMR中，并且有关于医疗保健利用、抗逆转录病毒治疗依从性和艾滋病毒临床结果的综合数据，包括退伍军人老龄化队列研究(VAS)指数，这是最近基于常规临床实验室措施验证的预后指数。研究团队在临床心理学、药物和酒精滥用治疗、艾滋病毒流行病学和生物统计学方面具有互补的专业知识。因此，团队和研究环境为测试MI和EF提供了理想的环境，这是减少该人群中危险酒精使用的两种创新方法，并可能为帮助感染艾滋病毒的个人提供强大的、可推广的工具。

DESCRIPTION (provided by applicant): This application responds to RFA-AA-12-009, Interventions to Improve HIV/AIDS and Alcohol-Related Outcomes (U01). The proposed study takes place in a HIV primary care clinic and uses the health plan's electronic medical record (EMR) for screening; it has the potential to provide a significant benefit to HIV- infected individuals by reducing hazardous drinking and the associated complications. Prior studies have identified high rates of co-occurrence of HIV and hazardous drinking (defined as drinking over threshold limits, i.e., 5+ daily or 14+ weekly drinks for men and 4+ daily or 7+ weekly drinks for women). Drinking at these levels can compromise antiretroviral (ART) treatment and increase rates of depression, unsafe sex, and mortality. The proposed randomized trial examines the comparative effectiveness of two highly implementable behavioral interventions for reducing hazardous drinking, each with an adaptive, stepped-care component: 1) Motivational Interviewing (MI), consisting of one in-person session with a study clinician and two phone sessions, with three additional phone sessions for those who report hazardous drinking at 6 months; and 2) interactive Emailed Feedback (EF) on hazardous drinking risks using a secure messaging system integrated into the Electronic Medical Record (EMR), with additional emailed feedback for those who report hazardous drinking at 6 months. A third arm will be usual care. We will also evaluate the cost-effectiveness of the two interventions which have the potential for wide adoption in other similar healthcare settings. The two proposed interventions, MI and EF, are promising approaches for reducing hazardous drinking in the setting of behavioral health and/or primary care. EF also uses secure messaging, an emerging technology that has been tested in other health, behavior change and mental health treatment settings, for problems including alcohol use but not among HIV-infected individuals. In this trial, 600 patients (200 in each arm) will be recruited from Kaiser Permanente Northern California (KPNC) San Francisco. The study population and clinic are ideal to examine such interventions since NIAAA-based screening questions are recorded in the EMR, and comprehensive data are available on health care utilization, ART adherence, and HIV clinical outcomes, including the Veterans Aging Cohort Study (VACS) index, a recently validated prognostic index based on routine clinical laboratory measures. The research team is well-qualified with complementary expertise in clinical psychology, drug and alcohol abuse treatment, HIV epidemiology, and biostatistics. Thus, the team and study setting provide the ideal environment to test MI and EF, two innovative approaches for reducing hazardous alcohol use in this population, and may provide powerful, generalizable tools for assisting individuals with HIV infection.