Community Vulnerability and Responses to Drug-User-Related HIV/AIDS

描述(由申请人提供)：这是社区脆弱性和对与吸毒者相关的艾滋病毒/艾滋病的反应研究的竞争性继续申请，研究为什么美国大城市地区在吸毒者中对艾滋病毒/艾滋病的易感性和他们的反应--即可能影响流行病的政策和计划--随着时间的推移而不同。毒品使用和艾滋病毒流行会随着时间的推移而变化。在上一次资助期间，我们显示美国96个最大的大都会地区的艾滋病毒流行率在1992年至2002年期间在注射吸毒者中下降，而在这些地区的注射吸毒者的人口流行率从1992年到2000年下降，但随后又开始上升。我们还表明，大都市地区在这些轨迹上存在差异，各种社会和政策力量影响了注射吸毒流行率、注射吸毒流行率中的种族差异、注射吸毒者中艾滋病毒流行率、注射吸毒者艾滋病流行率中的种族差异、药物滥用治疗覆盖范围以及注射器交换机会和覆盖率。不祥的是，我们最近的分析表明，青少年(15-29岁)中注射吸毒者的流行率已经开始上升。此外，正如其他人所表明的那样，艾滋病毒在一些大都市地区的死亡者(非注射海洛因、可卡因、可卡因、安非他明或甲基苯丙胺的使用者)中广泛传播。这些变化是在经济最近从缓慢下滑转向快速下滑的背景下发生的，这种转变将导致维持、更不用说扩大对吸毒者的服务的巨大困难。因此，拟议延续的具体目标是：1.描述1992-2012年美国96个大城市地区的趋势：(A)关键流行病学结果(注射吸毒者和死亡者的人口流行率，特别是其在年轻人中的流行率；以及注射吸毒者中艾滋病毒的流行率、后期诊断的艾滋病毒病例以及艾滋病的发病率和死亡率)以及(B)实施循证药物相关干预措施(药物滥用治疗、注射器交换、艾滋病毒咨询和检测)和(C)非循证药物相关干预措施(监禁和逮捕吸毒者)。2.了解宏观社会环境(例如，经济变化、社会融合、种族居住隔离)和流行病学需求如何影响干预措施；干预措施和宏观社会环境如何共同影响流行病学环境；一些干预措施(例如，逮捕、监禁)如何影响其他干预措施(例如，更换注射器的覆盖范围)；以及一些流行病学结果(例如，青少年注射吸毒者的流行情况)如何影响其他因素(例如，艾滋病毒流行)。3.使用基于代理的建模，开发一个综合理论，说明这些过程是如何相互作用的，因此各种干预组合在特定的社会背景下可能会产生什么影响。4.向公共卫生机构传播估计数、结果和理论上的理解，并继续就如何应对提出建议。 公共卫生相关性：该项目将估计在21年期间(1992-2012年)96个大都市地区注射和非注射毒品使用情况、注射吸毒者艾滋病毒/艾滋病和艾滋病死亡率以及吸毒者中与毒品和艾滋病毒有关的干预措施的变化。我们将调查这些流行病和干预措施是如何相互影响的，以及经济和社会条件等宏观背景因素如何塑造它们。我们将确定正在出现严重毒品使用、艾滋病毒或艾滋病流行的大都市地区，并向州和地方卫生部门和药品机构提供有关可能减少这些流行病的政策和计划的最佳信息。我们的发现还将帮助包括疾控中心和SAMHSA在内的国家公共卫生机构和其他研究人员计划一系列循证计划和政策，以减少导致高风险药物使用和相关的艾滋病毒和艾滋病流行的力量。

DESCRIPTION (provided by applicant): This is a competing continuation application for the Community Vulnerability and Responses to Drug-User- Related HIV/AIDS study of why large US metropolitan areas vary over time in their vulnerability to HIV/AIDS among drug users and in their responses-i.e., in policies and programs that may affect the epidemic. Drug use and HIV epidemics change over time. In the last funding period, we showed that HIV prevalence in the 96 largest US metropolitan areas declined among injection drug users (IDUs) from 1992 to 2002, and that the population prevalence of IDUs declined in these areas from 1992 to 2000, but then began to rise again. We also showed that metropolitan areas varied in these trajectories, and that a variety of social and policy forces shaped IDU prevalence, racial disparities in IDU prevalence, HIV prevalence among IDUs, racial disparities in AIDS prevalence among IDUs, drug abuse treatment coverage, and syringe exchange access and coverage. Ominously, our recent analyses indicate that the prevalence of IDUs among youth (aged 15 - 29) has begun to rise. Further, as others have shown, HIV has spread widely among NIDUs (non-injecting users of heroin, cocaine, crack, amphetamines or methamphetamine) in some metropolitan areas. These changes are occurring against the backdrop of an economy that has recently shifted from slow to rapid decline, a shift that will lead to great difficulty in maintaining, let alone expanding, services for drug users. Therefore, the Specific Aims of this proposed continuation are: 1. To describe trends, in the 96 largest US metropolitan areas from 1992 - 2012, in (a) critical epidemiologic outcomes (population prevalence of IDUs and NIDUs, and particularly their prevalence among youth; and, among IDUs, HIV prevalence, late-diagnosis HIV cases, and AIDS incidence and mortality) as well as in (b) the implementation of evidence-based drug- related interventions (drug abuse treatment, syringe exchange, HIV counseling and testing) and (c) non- evidence-based drug-related interventions (incarceration and arrests of drug users). 2. To understand how macro-social contexts (e.g., economic changes, social integration, racial residential segregation) and epidemiologic need affect interventions; how interventions and macro-social contexts together affect epidemiologic contexts; how some interventions (e.g., arrests, incarceration) affect others (e.g., syringe exchange coverage); and how some epidemiologic outcomes (e.g., prevalence of young IDUs) affect others (e.g., HIV prevalence). 3. To develop an integrated theory, using agent based modeling, of how these processes interact and thus what the impacts of various intervention mixes are likely to be in given social contexts. 4. To disseminate estimates, results and theoretical understandings to public health agencies and continue to advise them on how they might respond. PUBLIC HEALTH RELEVANCE: This project will estimate changes in injection and non-injection drug use, in HIV, AIDS and AIDS mortality rates among injection drug users, and in drug- and HIV-related interventions among drug users, in 96 large metropolitan areas over a 21-year period (1992 - 2012). We will investigate how these epidemics and interventions affect one another, and how macro-contextual factors like economic and social conditions shape them both. We will identify metropolitan areas in which serious drug use, HIV or AIDS epidemics are emerging, and offer state and local health departments and drug agencies the best information available on policies and programs that might reduce these epidemics. Our findings will also help national public health agencies, including the CDC and SAMHSA, and other researchers, plan a mixture of evidence-based programs and policies to reduce the forces that lead to high-risk drug use and the associated HIV and AIDS epidemics.