Identifying barriers to diabetes and HIV co-management in vulnerable populations

 描述(申请人提供)：艾滋病毒流行面临的一个重大挑战是包括糖尿病(DM)和心血管疾病在内的慢性疾病的负担日益加重，要求个人同时自我管理多种复杂的疾病。此外，社会和经济脆弱性可能会加剧糖尿病和艾滋病毒共同管理的障碍。然而，只有有限的证据来了解个人在共同管理艾滋病毒和糖尿病方面面临的挑战，以及社会和经济脆弱性(如经济匮乏、粮食不安全)对艾滋病毒/糖尿病共同管理和随后的健康结果产生影响的具体方式。特别是，感染艾滋病毒的妇女受到社会经济剥夺的影响不成比例，这表明她们在艾滋病毒/糖尿病共同管理方面可能面临更大的结构性障碍。应对这一挑战，需要领导人致力于并有能力开展连接社会/行为和临床科学以及艾滋病毒和糖尿病特定研究流的交叉研究。K01指导研究科学家发展奖将建立在我之前的卫生政策培训和之前关于艾滋病毒和经济脆弱性的研究的基础上，使我能够成为一名独立的调查者，解决糖尿病、艾滋病毒和健康的社会决定因素之间的相互作用。为了实现这一目标，我将获得以下方面的培训和指导：糖尿病的临床和人口健康方面；坚持和疾病自我管理的理论和措施；包括结构方程建模在内的高级统计方法；以及干预和试验设计。我将得到一个杰出的导师和顾问小组的支持，小组成员包括艾滋病毒临床医生、社会和行为研究人员、内分泌学家和统计学家，由Sheri Weiser博士领导，Sheri Weiser博士是解决脆弱人群健康的结构性障碍研究的领导者。我的指导研究计划将成为实现这些培训目标的工具，并将利用女性机构间艾滋病毒研究的基础设施，这是一项基于美国的多地点前瞻性研究，跟踪全球最大的艾滋病毒感染女性专门队列，反映了美国艾滋病毒在女性中流行的年龄、种族和抗逆转录病毒使用情况。我的研究目的是：(1)阐明促进或抑制糖尿病/艾滋病毒共同管理的个人和背景因素；(2)调查a)艾滋病毒共病对糖尿病管理的影响(初步分析)，以及(B)糖尿病合并疾病对抗逆转录病毒治疗依从性和艾滋病毒病毒载量的影响(二级分析)，考察社会和经济因素的中介或调节作用；(3)评估社会和经济因素对糖尿病/艾滋病毒共同管理的影响；(4)针对目标1-3中确定的因素，制定和测试改善糖尿病/艾滋病毒共同管理的干预措施的可行性。通过将我的培训目标与我提议的研究交织在一起，我将为长期研究议程奠定基础，调查和干预影响糖尿病和艾滋病毒共病和共同管理的社会和经济问题。我的最终目标是为跨越临床和社区背景的政策和计划提供信息，以改善感染艾滋病毒的弱势人群的慢性病结局。

 DESCRIPTION (provided by applicant): A significant challenge facing the HIV epidemic is the increasing burden of chronic diseases, including diabetes mellitus (DM) and cardiovascular disease, requiring individuals to self-manage multiple complex conditions simultaneously. Furthermore, social and economic vulnerability is likely to intensify barriers to DM and HIV co-management. Yet limited evidence exists to understand the challenges individuals face in co- managing HIV and DM, and the specific ways that social and economic vulnerability (e.g. financial deprivation, food insecurity) influence HIV/DM co-management and subsequent health outcomes. In particular, HIV- infected women are disproportionately impacted by socioeconomic deprivation, indicating they may face even greater structural barriers to HIV/DM co-management. Responding to this challenge calls for leaders committed to and capable of conducting cross-cutting research bridging social/behavioral and clinical sciences, and HIV and DM-specific research streams. This K01 Mentored Research Scientist Development Award will build upon my previous training in health policy and previous research on HIV and economic vulnerability to enable me to become an independent investigator addressing the interplay of diabetes, HIV and social determinants of health. To achieve this goal I will obtain training and mentoring in clinical and population health aspects of DM; theories and measures of adherence and disease self- management; advanced statistical approaches including structural equation modeling; and intervention and trial design. I will be supported by a distinguished panel of mentors and advisors including HIV clinicians, social and behavioral researchers, endocrinologists and statisticians, led by Dr. Sheri Weiser, a leader in research addressing structural barriers to health in vulnerable populations. My mentored research plan will be a vehicle for these training goals and will leverage the infrastructure of the Women's Interagency HIV Study, a multi-site prospective study based in the United States (US) following the largest dedicated cohort of HIV-infected women worldwide and reflecting the age, race, and antiretroviral use profile of the US HIV epidemic among women. My research aims are: (1) To elucidate individual and contextual factors that enable or inhibit DM/HIV co-management; (2) To investigate the impact of a) HIV comorbidity on DM management (primary analysis), and b) DM comorbidity on ART adherence and HIV viral load (secondary analysis), examining the mediating or modifying role of social and economic factors; (3) To evaluate the impact of social and economic factors on DM/HIV co-management; (4) To develop and test the feasibility an intervention to improve DM/HIV co-management, targeting the factors identified in Aims 1-3. By intertwining my training goals with my proposed research, I will lay the groundwork for a long-term research agenda investigating and intervening on social and economic issues affecting DM and HIV comorbidity and co-management. My ultimate goal is to inform policies and programs spanning the clinical and community context to improve chronic disease outcomes for vulnerable populations with HIV.