Pathways contributing to racial disparities in HIV virologic response

 描述(由申请者提供)：非裔美国人(AA)目前在美国经历了与艾滋病毒相关的不利后果的不公平负担。这些不良后果包括感染、艾滋病诊断、病毒学失败和死亡。白宫2010年发布的美国国家艾滋病毒/艾滋病战略的三个目标之一是永久性地减少艾滋病毒疾病方面长期存在的健康差距，特别是种族/民族差距。查明调解艾滋病毒种族/族裔差异的主要途径至关重要，或确定有效干预措施的优先目标，以实现这一目标。种族对抗逆转录病毒疗法(ART)的不同使用(即，启动、修改和坚持)可能是美国AA和高加索人之间观察到的HIV相关不良结局的种族差异的主要中介因素。然而，仅仅和直接针对改善AA接受和坚持ART的频率低于高加索人的短期干预(例如教育计划)可能不足以永久减少HIV相关不良结果的种族差异。因此，为了实现国家艾滋病毒/艾滋病战略的目标，更多可能受种族影响的上游和远端因素可能直接或间接影响抗逆转录病毒药物的使用，进而与艾滋病毒相关的结果应被评估为艾滋病毒种族差异的重要调节因素。因此，这项拟议研究的目标是确定保险不足和食品不安全是否是重要的、更远端的中介，美国感染艾滋病毒的再生障碍性贫血和高加索成年人之间的病毒学反应差异有很大比例是通过这些中介作用的。拟议的研究将使用在艾滋病综合临床系统(CNICs)联合临床队列(R24 AI067039；M.Saag，Pi；www.uab.edu/CNICs/)中登记的大型、种族和地理多样化的艾滋病研究中心和高加索参与者的现有数据和将收集的数据。具体地说，这项研究的目的是：(1)检查和量化粮食不安全在艾滋病毒诊所就诊中调解种族差异的程度；(2)检查和量化保险不足和粮食不安全在病毒学反应中调解种族差异的程度；(3)检查和量化艾滋病毒诊所就诊是否和量化在食品不安全导致的病毒学反应中的不同程度。基于反事实框架的因果调解分析的新的量化方法将被用来估计总的、直接的和间接的影响，并反过来为所有拟议的调解分析估计调解的相关比例。我们预计，完成拟议的目标将确定粮食不安全和保险不足是否代表了艾滋病毒种族差距的重要、更远的调解人，在制定有效干预措施以实现2010年美国国家艾滋病毒/艾滋病战略的健康差距目标时，应优先考虑这些因素。

 DESCRIPTION (provided by applicant): African Americans (AAs) currently experience an inequitable burden of adverse HIV-related outcomes in the United States (U.S.). Such adverse outcomes include infection, AIDS diagnoses, virologic failure, and death. One of the three goals of the National HIV/AIDS Strategy for the U.S. issued by the White House in 2010 was to permanently reduce long-standing health disparities in HIV-disease, in particular racial/ethnic disparities. Identifying the major pathways that mediate HIV racial/ethnic disparities is critical or prioritizing targets for effective interventions to achieve this goal. Differential use (i.e., initation, modification, and adherence) of antiretroviral therapies (ARTs) by race may be a main mediator of observed racial disparities in adverse HIV- related outcomes between AAs and Caucasians in the U.S. However, short-term interventions (e.g., education programs) solely and directly targeted at improving ART initiation and adherence among AAs who have been observed to receive and adhere to ART less often than Caucasians may be insufficient to permanently reduce racial differences in adverse HIV-related outcomes. Therefore, to meet the goals of the National HIV/AIDS Strategy, more upstream, distal factors potentially influenced by race that likely directly or indirectly effect ART use and in turn HIV-related outcomes should be evaluated as important mediators of HIV racial disparities. As such, the goal of the proposed research is to establish whether inadequate insurance and food insecurity are important, more distal mediators through which a substantial proportion of differences in virologic response between HIV-infected AA and Caucasian adults in the U.S. operate. Existing and to be collected data from AA and Caucasian participants enrolled in the large, racially and geographically diverse Center for AIDS Research Network of Integrated Clinical Systems (CNICS) combined HIV clinic cohort (R24 AI067039; M. Saag, PI; www.uab.edu/cnics/) will be used for the proposed study. Specifically, this study aims to (1) examine if and quantify the degree to which food insecurity mediates racial differences in HIV clinic attendance, (2) examine if and quantify the degree to which inadequate insurance and food insecurity mediate racial differences in virologic response, and (3) examine if and quantify the degree to which HIV clinic attendance mediates differences in virologic response by food insecurity. Novel quantitative methods for causal mediation analysis based on the counterfactual framework will be used to estimate total, direct, and indirect effects and in turn the relevant proportion mediated for all proposed mediation analyses. We expect that completing the proposed aims will establish whether food insecurity and inadequate insurance represent important, more distal mediators of HIV racial disparities that should be prioritized as targets when developing effective interventions to achieve the health disparities goals of the 2010 U.S. National HIV/AIDS Strategy.