Missed visits and virologic failure among HIV infected African Americans receivin

描述(申请人提供)：拟议研究的总体目标是使用丰富的前瞻性数据和最先进的量化方法来检查在接受艾滋病毒医疗护理的非裔美国人(AA)中导致错过预定门诊和病毒学失败的途径。综合临床系统(CNICS)艾滋病研究中心网络(R24AI067039-1；M.Saag，PI；http://www.cnics.net/index.html))三个站点注册的AA参与者的现有数据将用于拟议的研究。CNICs是一个大型和多样化的队列研究联盟，对1995年1月1日后在诊所接受持续初级艾滋病毒护理的22,000多名艾滋病毒感染者进行研究。拟议工作的选定地点包括北卡罗来纳大学艾滋病研究中心艾滋病毒临床队列(J.Eron，Pi)、阿拉巴马大学伯明翰分校(UAB)1917年临床队列(M.Saag，Pi)和约翰霍普金斯大学艾滋病毒临床实践队列(R.Moore，Pi)。这项拟议的研究旨在(1)研究提供和使用辅助服务(即病例管理、酒精和药物滥用治疗)是否与随后艾滋病毒病毒学失败的较低风险独立相关，并评估这种联系是否通过预约就诊人数来调节；(2)检查相互竞争的需要(即因工作或资金有限而放弃医疗护理)是否与随后艾滋病毒病毒学失败的风险增加独立相关，并评估这种联系是否通过预约就诊人数来调节；以及(3)检查对医疗保健提供者和患者关系的不满是否独立地与随后艾滋病毒病毒学失败的风险增加相关联，并评估这种关联是否通过预定的预约出席来调节。对于所有三个目标，边际结构修正泊松回归模型将被用来估计辅助艾滋病毒服务、竞争需求和医疗保健提供者-患者关系对病毒学失败的总体、自然直接和自然间接影响。还将专门探讨通过预约出席而产生的间接影响。拟议工作的结果将确定艾滋病毒感染的AA之间的护理障碍，并告知在患者和相关环境(例如，诊所、社区、政策)层面实施有针对性的干预措施，以最大限度地减少此类障碍。减少AAA之间的护理障碍将反过来减少艾滋病毒疾病方面存在的重大和长期的种族差异。 公共卫生相关性声明：拟议的项目将确定感染艾滋病毒的非裔美国人的护理障碍，并告知在患者和相关背景(例如，诊所、社区、政策)层面实施有针对性的干预措施，以最大限度地减少此类障碍。最大限度地减少非裔美国人的护理障碍将反过来减少艾滋病毒疾病方面存在的重大和长期的种族差异。

DESCRIPTION (provided by applicant): The overall goal of the proposed research is to use rich prospective data and state of the art quantitative methods to examine pathways contributing to missed scheduled clinic visits and virologic failure among African Americans (AAs) receiving HIV medical care. Existing data from AA participants enrolled in three sites of the Center for AIDS Research Network of Integrated Clinical Systems (CNICS) (R24 AI067039-1; M. Saag, PI; http://www.cnics.net/index.html) will be used for the proposed study. CNICS is a large and diverse consortium of cohort studies of over 22,000 HIV infected patients receiving ongoing primary HIV care in a clinic setting after 1 January 1995. Selected sites for the proposed work include the University of North Carolina Center for AIDS Research HIV Clinical Cohort (J. Eron, PI), the University of Alabama at Birmingham (UAB) 1917 Clinic Cohort (M. Saag, PI), and the Johns Hopkins HIV Clinical Practice Cohort (R. Moore, PI). The proposed study aims to (1) examine whether availability and use of ancillary services (i.e., case management, alcohol and drug abuse treatment) is associated independently with a lower risk of subsequent HIV virologic failure and assess whether this association is mediated by scheduled appointment attendance; (2) examine whether competing needs (i.e., forgoing medical care due to work or limited funds) are associated independently with an increased risk of subsequent HIV virologic failure and assess whether this association is mediated by scheduled appointment attendance; and (3) examine whether dissatisfaction with the healthcare provider-patient relationship is associated independently with an increased risk of subsequent HIV virologic failure and assess whether this association is mediated by scheduled appointment attendance. For all three aims, marginal structural modified Poisson regression models will be used to estimate total, natural direct, and natural indirect effects of ancillary HIV services, competing needs, and healthcare provider-patient relationships on virologic failure. Indirect effects mediated through scheduled appointment attendance will specifically be explored. Results from the proposed work will identify barriers to care among HIV-infected AAs and inform implementation of targeted interventions at the patient and contextual (e.g., clinic, neighborhood, policy) level to minimize such barriers. Minimizing barriers to care among AAs will in turn reduce substantial and longstanding racial disparities in HIV disease. PUBLIC HEALTH RELEVANCE STATEMENT: The proposed project will identify barriers to care among HIV-infected African Americans and inform implementation of targeted interventions at the patient and contextual (e.g., clinic, neighborhood, policy) level to minimize such barriers. Minimizing barriers to care among African Americans will in turn reduce substantial and longstanding racial disparities in HIV disease.