The Impact of Incarceration and Substance Abuse on HIV-Infected Veterans

描述(申请人提供)：监禁和滥用药物对感染艾滋病毒的退伍军人的影响摘要：美国是世界上监禁率最高的国家，有1300多万人被监禁在监狱或监狱中。所有囚犯中有一半符合药物滥用或依赖的标准，每年感染艾滋病毒的人中就有一人被监禁。与从未被监禁的艾滋病毒感染者相比，现在和以前的囚犯对艾滋病毒疾病的控制更差，死亡率更高，尽管具体机制尚不清楚。艾滋病毒感染者在被释放到社区后病情恶化与再次滥用药物和更差地坚持抗逆转录病毒治疗有关。然而，大多数获释的艾滋病毒感染者在需要时没有接受药物滥用治疗，药物滥用对不良健康结果的独立影响尚不清楚。这使得很难设计出能够提供必要的药物滥用治疗和改善艾滋病毒结果的干预措施。要改善艾滋病毒携带者和药物滥用者的健康，就必须更好地了解监禁对吸毒和不健康饮酒的个人的艾滋病毒疾病控制的影响，以及在多个保健系统之间流动的影响。这项申请的拟议目的是：(1)确定监禁对退伍军人艾滋病毒疾病控制的独立影响，以及(2)确定监禁影响艾滋病毒疾病控制的可能的与药物滥用有关的机制。我们假设，在监禁频率和更糟糕的艾滋病毒结果之间存在剂量依赖关系，并且在报告使用毒品和不健康酒精的个人中，缺乏药物滥用治疗调解了这种联系。为了实证检验这些假设，我们将对退伍军人老龄化队列研究(VICS)的数据进行一般估计方程和潜在增长模型，该研究是一项正在进行的对2902名感染艾滋病毒的退伍军人进行的纵向多点队列研究，以研究监禁对艾滋病毒长期结果的影响以及观察到的潜在中介因素。退伍军人健康管理局是研究监禁对艾滋病毒疾病控制的影响的理想场所，因为它是美国最大的艾滋病毒感染者的单一医疗保健提供者，而且是一个封闭的保健系统。此外，由于Vacs包括潜在的与药物滥用相关的机制的广泛措施，我们将能够彻底检查监禁对艾滋病毒疾病控制的独立影响，并确定与药物滥用相关的可变机制。这些分析是确定这些媒介的必要的第一步，从而使我们能够有效地针对未来的干预研究来改善艾滋病毒感染者的健康。 退伍军人，一个独特和未得到充分研究的患者群体，并减少艾滋病毒疾病的传播。 公共卫生相关性：艾滋病毒感染者通常在被监禁期间健康状况有所改善；然而，由于再次吸毒和酗酒、不坚持药物治疗以及缺乏初级医疗保健，在释放到社区后，健康方面的成果就会消失。今天，惩教和社区卫生保健系统面临的最紧迫的问题之一是了解是什么特定于监禁的因素导致最近获释个人的健康状况下降。通过研究监禁和药物滥用对在退伍军人健康管理局接受护理的艾滋病毒感染者的影响，拟议的研究将提供关于可改变的风险因素和干预目标的宝贵信息，以减少有监禁病史的患者的艾滋病毒发病率。

DESCRIPTION (provided by applicant): The Impact of Incarceration and Substance Abuse on HIV-Infected Veterans Abstract: The United States has the highest rate of incarceration worldwide, such that more than 13 million individuals have been incarcerated in jail or prison. One half of all prisoners meet criteria for drug abuse or dependence and one in seven individuals infected with HIV is incarcerated each year. Compared with HIV- infected individuals never incarcerated, current and former inmates have worse HIV disease control and increased mortality, although the specific mechanisms for this are unknown. This worsening of HIV-infected patients' disease upon release to the community is associated with relapse to substance abuse and worse adherence to antiretroviral therapy. However, the majority of HIV-infected individuals released from incarceration do not receive substance abuse treatment when needed, and the independent impact of substance abuse on poor health outcomes is unclear. This makes it difficult to design interventions that provide needed substance abuse treatment and improve HIV outcomes. An improved understanding of the impact of incarceration on HIV disease control among individuals with drug and unhealthy alcohol use and the effects of moving between multiple health care systems is necessary for improving the health of individuals with HIV and substance abuse. The proposed aims for this application are: (1) to determine the independent impact of incarceration on HIV disease control in veterans and (2) to identify possible substance abuse-related mechanisms by which incarceration affects HIV disease control. We hypothesize that there is a dose dependent relationship between frequency of incarceration and worse HIV outcomes and that lack of substance abuse treatment, among individuals who report drug and unhealthy alcohol use, mediates this association. To empirically test these hypotheses, we will conduct general estimating equation and latent growth models on data from the Veterans Aging Cohort Study (VACS), an ongoing longitudinal, multisite cohort study of 2902 HIV-infected veterans, to study the impact of incarceration on long term HIV outcomes and potential mediators of observed observations. The Veterans Health Administration is an ideal setting to study the impact of incarceration on HIV disease control, as it is the single largest health care provider of HIV- infected individuals in the U.S. and is largey a closed system of care. Also, because VACS includes extensive measures of potential substance abuse-related mechanisms, we will be able to thoroughly examine the independent impact of incarceration on HIV disease control and identify mutable substance abuse-related mechanisms. These analyses are a necessary first step to identifying such mediators, thus allowing us to efficiently target future intervention studies to improve the health of HIV-infected veterans, a unique and understudied patient population, and reduce the spread of HIV disease. PUBLIC HEALTH RELEVANCE: HIV infected individuals typically have improved health while incarcerated; however, the gains in health are lost upon release to the community due to a relapse to drug and alcohol use, nonadherence with medications, and lack of primary medical care. One of the most pressing issues facing both the correctional and community health care systems today is understanding what incarceration-specific factors are driving this decline in health of recently released individuals. By studying the impact of incarceration and substance abuse among HIV-infected individuals who have received care in the Veterans Health Administration, the proposed studies will provide valuable information on modifiable risk factors and targets for intervention to reduce HIV disease morbidity in patients with a history of incarceration.