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

描述(由申请人提供)：尽管酒精和物质使用障碍(ASUD)在艾滋病毒感染患者中很常见，但对ASUD治疗在艾滋病毒感染人群中的有效性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，了解与启动、参与和保持ASUD治疗相关的因素至少与特定类型的治疗同样重要。了解治疗开始、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，特别是在实施《平价医疗法案》(ACA)的规定时。我们将使用退伍军人老龄化队列研究(VAS)来研究ASUD治疗在感染艾滋病毒的退伍军人中的比较有效性和交付情况。Vacs是一项大型的多站点全国性研究，包括两个主要组成部分：1)44,180名感染艾滋病毒的退伍军人和88.360名未感染的参照者组成的“虚拟”队列，我们可以在该队列上获得行政、药房、实验室、病理、医疗服务利用情况以及相关的医疗补助/医疗保险数据；以及2)Vacs 8，一个预期队列，包括3,631名感染艾滋病毒的退伍军人和3,693名匹配的未感染艾滋病毒的退伍军人，它将年度自我报告调查信息添加到虚拟队列中的数据中。我们的具体目标是：1)比较不同类型ASUD治疗的启动、参与和保留对患有ASUD的艾滋病毒感染退伍军人的艾滋病毒护理质量、病毒学抑制和成本的有效性；2)确定艾滋病毒感染退伍军人ASUD治疗开始、参与和保留的预测因素；以及3)评估ACA保险扩展对艾滋病毒感染退伍军人ASUD治疗开始、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预期队列。对于目标1，我们将对VAS虚拟队列参与者在新的ASUD治疗前后的结果进行准实验、倾向分数调整、差异性分析。对于目标2，我们将进行时间更新的广义估计方程Logistic回归分析，以确定在HIV感染的VAS虚拟队列参与者中启动、参与和保留ASUD治疗的独立易感、使能和需求预测因素。对于目标3，随着ACA保险的扩展，我们将使用混合方法在几年内前瞻性地评估感染艾滋病毒的VISA 8名参与者患有ASUD。实现这些目标将提供ASUD战略与全国脆弱艾滋病毒感染患者样本的最佳结果相关的“现实世界”估计，并确定与更多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.