Comparative Effectiveness of Alcohol and Drug Treatment in HIV-Infected Veterans

描述（由申请人提供）：虽然酒精和物质使用障碍（ASUD）在HIV感染患者中很常见，但对ASUD治疗HIV感染人群的疗效和比较有效性知之甚少。此外，由于很少有ASUD患者接受任何类型的高质量ASUD治疗，因此了解与启动，参与和保留ASUD治疗相关的因素至少与特定类型的治疗一样重要。了解治疗启动，参与和保留的问题对于推进ASUD的比较有效性研究至关重要，特别是随着《平价医疗法案》（ACA）的实施。我们将使用退伍军人老龄化队列研究（VACS）来研究艾滋病毒感染的退伍军人中ASUD治疗的比较有效性和交付。VACS是一项大型的多地点、全国性的研究，有两个主要组成部分：1）一个由44,180名HIV感染的退伍军人和88360名未感染的对照者组成的“虚拟”队列，我们可以访问管理、药房、实验室、病理学、卫生服务利用率和相关的医疗补助/医疗保险数据;和2）VACS 8，一个由3631名艾滋病毒感染者和3693名匹配的艾滋病毒未感染退伍军人组成的前瞻性队列，它将年度自我报告调查信息添加到虚拟队列中可用的数据中。我们的具体目标是：1）比较不同类型的ASUD治疗的启动、参与和保留对HIV护理质量、病毒学抑制和患有ASUD的HIV感染退伍军人的成本的有效性; 2）确定HIV感染退伍军人中ASUD治疗的启动、参与和保留的预测因素;和3）评估ACA保险扩展对艾滋病毒感染退伍军人ASUD治疗的启动，参与和保留的影响。目标1和2将使用VACS虚拟队列，目标3将使用VACS 8前瞻性队列。对于目标1，我们将在VACS虚拟队列参与者中使用准实验性、倾向评分调整、差异中差异分析新ASUD治疗事件前后的结局。对于目标2，我们将进行时间更新的广义估计方程逻辑回归分析，以确定艾滋病毒感染的VACS虚拟队列参与者中ASUD治疗的启动，参与和保留的独立易感性，使能性和需求预测因子。对于目标3，我们将使用混合方法来前瞻性地评估艾滋病毒感染的VACS 8参与者与ASUD在几年的ACA保险扩展发生。实现这些目标将提供“真实的世界”的估计，其中ASUD战略与脆弱的艾滋病毒感染患者的国家样本中的最佳结果相关，并确定与增加参与和保留治疗相关的因素。

DESCRIPTION (provided by applicant): Although alcohol and substance use disorders (ASUDs) are common in HIV-infected patients, little is known about the efficacy and comparative effectiveness of ASUD treatments in HIV-infected populations. Further, because few individuals with ASUD receive high quality ASUD treatment of any type, understanding the factors associated with initiating, engaging, and remaining in ASUD treatment is at least as important as the specific type of treatment. Understanding issues of treatment initiation, engagement, and retention is critical to advancing comparative effectiveness research in ASUD, particularly as provisions of the Affordable Care Act (ACA) are implemented. We will use the Veterans Aging Cohort Study (VACS) to study the comparative effectiveness and delivery of ASUD treatment in HIV-infected Veterans. VACS is a large multisite, national study with 2 main components: 1) a "Virtual" Cohort of 44,180 HIV-infected Veterans and 88.360 uninfected comparators on which we have access to administrative, pharmacy, laboratory, pathology, health service utilization, and linked Medicaid/Medicare data; and 2) VACS 8, a prospective cohort of 3631 HIV-infected and 3693 matched HIV-uninfected Veterans that adds annual self-report survey information to data available in the Virtual Cohort. Our Specific Aims are to: 1) Compare the effectiveness of initiation, engagement, and retention in different types of ASUD treatment on quality of HIV care, virologic suppression, and costs in HIV-infected Veterans with ASUD; 2) Identify predictors of initiation, engagement, and retention in ASUD treatment in HIV- infected Veterans; and 3) Assess effects of ACA insurance expansion on initiation, engagement, and retention in ASUD treatment for HIV-infected Veterans. Aims 1 and 2 will use the VACS Virtual Cohort and Aim 3 will use the VACS 8 prospective cohort. For Aim 1, we will use a quasi-experimental, propensity-score adjusted, difference-in-differences analysis of outcomes before and after new ASUD treatment episodes in VACS Virtual Cohort participants. For Aim 2, we will conduct time-updated, generalized estimating equations logistic regression analyses to identify independent predisposing, enabling, and need predictors of initiation, engagement, and retention in ASUD treatment among HIV-infected VACS Virtual Cohort participants. For Aim 3, we will use a mixed-methods approach to prospectively assess HIV-infected VACS 8 participants with ASUD over several years as the ACA insurance expansion occurs. Achieving these aims will provide "real world" estimates of which ASUD strategies are associated with the best outcomes in a national sample of vulnerable HIV-infected patients and identify factors associated with increased engagement and retention in treatment.